Transgender(跨性別)病人

DOCTORS
Transgender at the Cancer Clinic
http://nyti.ms/1VcTNdJ via @nytimeswell
By MIKKAEL A. SEKERES, M.D.  SEPTEMBER 24, 2015 11:44 AM September 24, 2015

Transgender 
前文：https://zh.wikipedia.org/zh-tw/跨性別
在最初，英文的Transgender這個字是美國的維吉妮亞·普林斯（Virginia Prince）在1970年代創造的，用來與Transsexual（變性者）這個名詞作對照，指稱那些並不希望進行手術來「改變生理性別（Sex）」以及／或那些認為他們是位在兩個社會性別（Gender）中間的人，他們並不將自己嚴格界定為任何一種性別，而是將自己界定為既非完全的男性，也不是完全的女性。

看到The New York Times這篇文章讓人感興趣，我們怎麼面對或是處理一位Transgender(跨性別)病人呢？

作者是一位血腫科醫師，有一天fellow正在向他報一位病人病史時，只提到「這是一位46歲病人...」, 主治醫師問，「是男或是女呢？」因為男女生病是有別的。

fellow說，那就看你怎麼決定了？一頭霧水的主治醫師說，「你經過多年的醫師訓練，應該能判斷是男或是女病人吧？」fellow還是搖搖頭，然後說「這病人是Transgender」

下班後，當作者問他的14歲兒子有關Transgender的事時，兒子聳聳肩，若無其事的說，

“It’s no big deal. A couple of kids in my school are transgender, too.”

I wondered if, in medicine, we are equally as nonplussed as my public-high-school-attending teenager.

主治醫師和fellow一起去看病人，她穿著光鮮亮麗並帶著香水味，作者試著如往常一樣閱讀著病歷。當作者開始幫病人做身體檢查時，他想著，是否去詢問患者Transgender的事？藉以表達出他的開放豁達或是只是表示出自己的好奇？甚至作者心裡想，這患者的父母知道他們小孩transgender的事嗎？

最後，這位主治醫師並沒有問transgender相關的問題，因為這些問題和她的白血病治療是沒有相關的，過度關心這個議題，只是讓患者覺得這醫師會因transgender而給予不同的治療。

---
Dr. Mikkael Sekeres is director of the leukemia program at the Cleveland Clinic.

---
半年前的新聞，我想有一天我們也會遇到這樣的Transgender(跨性別)病人的

作者： 聯合新聞網／記者喻文玟 2015-04-08 聯合新聞網

「我心裡住著女生」年過半百的台中一中生物老師曾愷芯，前年妻子病逝後，決定從「心」出發，接受醫師諮詢，服用女性賀爾蒙改變性特徵，從胖大叔變成美熟女，今年六月要動手術摘除男性器官，「她」的這一步已走了數十年。

曾愷芯是家中四兄弟姊妹的長子，他說，「幼時經常夢見自己是女生」，早期社會環境保守，他一直壓抑自己的性向，也走入結婚禮堂，婚後更不忍心讓愛妻知道「真相」，常陪太太逛街，百般呵護，在師生眼中是「愛妻好男人」。

2015 諾貝爾生理學或醫學獎

Nobel Prize in Medicine Awarded to 3 Scientists for Parasite-Fighting Therapies http://nyti.ms/1L1fhpj

2015 諾貝爾生理學或醫學獎

這次諾貝爾生理學或醫學獎令我注意的是這個藥「Ivermectin」，因為日前一位scabies患者被高雄長庚皮膚科醫師開了這個自費口服藥，效果神奇，紅疹和癢幾乎消除，不像之前用BB solution一樣，似有效似無效。查了文獻，才了解這個人畜共通治療藥物，「Ivermectin」。

這三位獲獎者都是利用現代實驗室科學方法來找出長久以來就存在於藥草或是土壤中對抗寄生蟲藥物，因而獲得諾貝爾獎。

Dr. Campbell and Dr. Omura developed Avermectin, the parent of Ivermectin, a medicine that has nearly eradicated river blindness and radically reduced the incidence of filariasis, which can cause the disfiguring swelling of the lymph system in the legs and lower body known as elephantiasis.

看到這段描述，讓我想起醫學院生活中，大一二的寄生蟲學，絲蟲病，會破壞人類的淋巴腺，造成象腿病水腫。Dr. Campbell和 Dr. Omura就是發現了Avermectin這個成份，後來進化成患者現在用的Ivermectin。

另一位是女性的Dr. Tu Youyou，是第一位以大陸籍獲諾貝爾科學獎項的公民（之前也許獲獎者都已不是大陸籍了） became the first citizen of the People’s Republic of China to win a Nobel Prize in the sciences, for discovering Artemisinin, a drug that is now part of standard antimalarial regimens.

“These two discoveries have provided humankind with powerful new means to combat these debilitating diseases that affect hundreds of millions of people annually,” the Nobel Committee said in a statement. “The consequences in terms of improved human health and reduced suffering are immeasurable” because parasitic diseases “represent a huge barrier to improving human health and well-being.”

Parasitic diseases are a threat to an estimated one-third of the world’s population, particularly among the poor in sub-Saharan Africa, South Asia and Latin America. Insects transmit both river blindness (black flies) and malaria (mosquitoes).

沒錯，絲蟲病或是瘧疾都是落後國家才有的傳染病，而且造成相當大的死亡，有了以上兩個藥物的發現「Artemisinin」和「Avermectin」，大大減少了這些拉丁美洲、南非和南亞洲國家人民的痛苦。

In 1987 Merck, which had profited handsomely from use of Ivermectin in domestic and farm animals, began distributing the drug free to people because those who needed it the most could not afford it.

這是個有良心的藥廠（Merck），生產以上這二種藥，免費的供給落後國家人民。

Dr. Omura applied what the Nobel Committee said were “extraordinary skills in developing unique methods” for scientifically characterizing natural products in Streptomyces 鏈黴菌屬 bacteria found in soil. Bacterial cousins have yielded antibiotics like streptomycin.

Dr. Omura carries a plastic bag to collect soil samples. From several thousand cultures of Streptomyces he focused on the 50 he thought showed the most promise against dangerous microbes.

After obtaining cultures from Dr. Omura, Dr. Campbell documented one that yielded a substance that was remarkably effective against parasites in domestic and farm animals. The sample came from a golf course near Tokyo. He named the purified substance Avermectin. Further chemical tests produced Ivermectin that killed parasites in infected humans. 

數十年磨一劍，這二位發現Avermectin的獲獎者，從數千個含鏈黴菌屬的土壤樣本中，慢慢縮小範圍，利用實驗室方法，提練出「Avermectin」。

另一位是大陸本產的諾貝爾獎得主，有中國傳統醫學相關背景，
Dr. Tu, born in 1930, is chief professor at the China Academy of Traditional Chinese Medicine and the first Chinese scientist to win a Nobel science award.

以下這句話看了真是令人會心一笑，諾貝爾獎單位強調這不是頒獎給中國傳統醫學，而是 ...
The Nobel Committee emphasized that it was not giving the award to traditional Chinese medicine but to a scientist who, inspired by it, went on to use sophisticated research methods to find a new therapy for malaria. The discovery came at a time when the parasites became resistant to more traditional drugs like quinine and chloroquine and as the number of infections surged.

文中報導，Dr. Tu篩選了瘧疾區的動物，想辦法找出治療瘧疾的藥物，但是一直沒有一個一致性的結果。後來，她看了古代中國醫書，發現藥草經過高溫煮沸後，雖然會釋放出裡面的成份，但是也會破壞其中活性成份，所以她改以其他方法來萃取純化，就成功找出可以治療瘧疾的「Artemisinin」（註：傳統quinine或是chloroquine，因為抗藥性的問題，效果已經大不如前了）

NEW ICD-10 AND ICD-9 BYE BYE!

NEW ICD-10 AND ICD-9 BYE BYE!

之前在 The New York Times 就有看到美國醫師，也是對2015/10/1要改用ICD-10的焦慮，
One Symptom in New Medical Codes: Doctor Anxiety
By ROBERT PEARSEPT. 13, 2015

國內的醫界因為明年就要停用已經用了30年，舊的ICD-9，改用新的ICD-10, 反彈的聲音一定會有。因為人性是習慣舊的，要強迫學新的，一定會遇到阻力。因應健保局推動的鼓勵提早ICD-10編碼實作獎勵方案，我也去醫療資訊公司上課，原來就是編碼的詳細度更高，更精確，不過以往記的日後就不能用了，要重新記憶，這一定會有陣痛期。

Dr. Marks, a former president of the Connecticut Orthopaedic Society, gave an example: A doctor will be asked to specify whether a fractured thigh bone is in the right or left leg; whether the bone protrudes through the skin; whether healing is routine or delayed; and whether the bone fragments rejoin at the wrong angle, leaving the patient with a deformed limb.

“The number of codes is exploding,” Dr. Marks said. “On Oct. 1, we will be speaking a new language. It’s like switching to German, after speaking English for 30 years.”

以上最後一句話，最傳神能表達ICD-9轉換至ICD-10的差異。

抗拒改變是可以預期的，近日剛好看到以下這文章，回應一下大多數醫師對於ICD-10的反彈，也許可以平衡一下我們的想法，然而，他用了"myopic perspectives" 來回應大多數醫師的反彈，真是令人刺目和刺耳啊！(OS: 這也是一位醫界大老寫的吧？)

The Opinion Pages | LETTER
Improving Health Data
SEPT. 22, 2015
To the Editor:

“One Symptom in New Codes: Doctor Anxiety” (front page, Sept. 14) focused a great deal on myopic perspectives of what will happen when the health care community implements a new set of medical billing codes (known as ICD-10) by Oct. 1. Despite years of preparation time and support from private industry, nonprofit organizations and the government, some are afraid of change.

But with change comes opportunity. The greater detail in ICD-10 codes will tell a more accurate and complete patient story and reverse the trend of deteriorating health data. The richer data will increase the ability to measure quality, safety and efficacy of care; reduce fraud and waste; and ensure that health care dollars are used most efficiently. This is a point that everyone can agree on.

LYNNE THOMAS GORDON

Chief Executive, American Health Information Management Association
Chicago