新型冠状病毒肺炎诊断研究进展

新型冠状病毒肺炎(COVID-19)疫情以来,疾病的高传染性使确诊人数剧增,同时死亡人数也在日益增加。现全球已有200余个国家或地区出现感染病例。疾病的早诊可以有效控制疾病传播,同时使感染者得到有效的隔离和救治,提高生存率。目前,中国COVID-19的控制取得了阶段性胜利。本文对COVID-19的临床表现、实验室检查、...     

Lack of association of antihypertensive drugs with the risk and severity of COVID-19: A meta-analysis

BackgroundThe association of antihypertensive drugs with the risk and severity of COVID-19 remains unknown.Methods and ResultsWe systematically searched PubMed, MEDLINE, The Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and medRxiv for publications before July 13, 2020. Cohort studies and case-control studies that contain information on the association of antihypertensive agents including angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), calcium-channel blockers (CCBs), β-blockers, and diuretics with the risk and severity of COVID-19 were selected. The random or fixed-effects models were used to pool the odds ratio (OR) with 95% confidence interval (CI) for the outcomes.The literature search yielded 53 studies that satisfied our inclusion criteria, which comprised 39 cohort studies and 14 case-control studies. These studies included a total of 2,100,587 participants. We observed no association between prior usage of antihypertensive medications including ACEIs/ARBs, CCBs, β-blockers, or diuretics and the risk and severity of COVID-19. Additionally, when only hypertensive patients were included, the severity and mortality were lower with prior usage of ACEIs/ARBs (overall OR of 0.81, 95% CI 0.66?0.99, p < 0.05 and overall OR of 0.77, 95% CI 0.66?0.91, p < 0.01).ConclusionsTaken together, usage of antihypertensive drugs is not associated with the risk and severity of COVID-19. Based on the current available literature, it is not recommended to abstain from the usage of these drugs in COVID-19 patients.RegistrationThe meta-analysis was registered on OSF (https://osf.io/ynd5g).     

Hydroxychloroquine with azithromycin in patients hospitalized for mild and moderate COVID-19

ObjectivesTo assess the efficacy of hydroxychloroquine in combination with azithromycin in terms of clinical and biochemical outcomes in adult patients with COVID-19 hospitalized for acute respiratory distress syndrome (ARDS), and to describe the occurrence of adverse events.MethodRetrospective comparative study, based in a quaternary private hospital in Rio de Janeiro, Brazil, involving 193 adult patients hospitalized for mild and moderate COVID-19 related ARSD, analyzing treatment efficacy based on clinical and biochemical outcomes.ResultsThe active group comprised 101 (52.3%) patients using hydroxychloroquine associated with azithromycin and the control group 92 (47.7%) patients who did not take these medications. Median age was 59 (47–70) in the active group and 65 (47−77) in the control group (p < 0.05). Patients in the control group had greater extent of pulmonary involvement on baseline chest CT scans (p < 0.05). All other baseline variables (BMI, comorbidities, previous use of medications and biochemical assessments) were similar between groups. In the medication group, 25% (25 out of 101) were admitted to the ICU, compared to 21% (19 out of 92) in the control group (p > 0.05). No difference in mortality, duration of non-invasive oxygen use or duration of hospitalization was seen between groups. The therapeutic regimen was well tolerated, with only eight (7.9%) patients presenting gastrointestinal symptoms and eight (7.9%) patients withdrawn treatment due to QTc prolongation.ConclusionsPatients treated with hydroxychloroquine combined with azithromycin and the control group had similar clinical outcomes. This therapeutic regimen was considered ineffective in hospitalized patients with mild to moderate COVID-19 related ARDS and was associated with few non-severe adverse events.     

Cardiovascular Manifestations of COVID-19

Coronavirus disease 2019 (COVID-19) first emerged in a group of patients who presented with severe pneumonia in Wuhan, China, in December 2019. A novel virus, now called SARS- CoV-2 (Severe Acute Respiratory Syndrome Coronavirus-2), was isolated from lower respiratory tract samples. The current outbreak of infection has spread to over 100 countries and killed more than 340,000 people as of 25^th May, 2020.The predominant clinical manifestation of COVID-19 is a respiratory disease- ranging from mild flu-like symptoms to  fulminant  pneumonia and  Acute Respiratory Distress Syndrome  (ARDS). Patients with pre-existing cardiovascular risk factors are considered more susceptible to the virus, and these conditions are often worsened by the infection. Furthermore, COVID-19 infection has led to de novo cardiac complications, like acute myocardial injury and arrhythmias.In this review, we have focused on the cardiovascular manifestations of COVID-19 infection that have been reported in the literature so far. We have also outlined the effect of pre-existing cardiovascular disease as well as risk factors on the clinical course and outcomes of COVID-19 infection.     

Acute upper limb ischemia in a patient with COVID-19

Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection mainly present with upper and lower respiratory tract symptoms, with complications related to cytokine storm syndrome and acute respiratory distress syndrome. It has also been described to predispose to venous and arterial thromboembolism; however, limited published data is available regarding thrombosis in coronavirus disease 2019 (COVID-19). Here we are presenting a case of arterial thrombosis in a patient with COVID-19 and a systematic review on coagulopathy associated with COVID-19.     

Clinical and Microbiological Features of Asymptomatic SARS-CoV-2 Infection and Mild COVID-19 in Seven Crewmembers of a Cruise Ship

Objective To describe the clinical features and clinical course of individuals diagnosed with asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or mild coronavirus disease (COVID)-19. Patients The study participants consisted of 7 crewmembers of the passenger cruise-liner, Diamond Princess, who were admitted to our hospital after becoming infected with SARS-CoV-2 aboard the ship. Methods The data on patient background and biochemical test results were obtained from the patients'' medical records. All patients had a chest X-ray, and a throat swab and sputum samples were sent for culture on admission. Results The median age of the 7 patients, of whom 4 were male and 3 were female, was 39 years (range: 23-47 years). On admission, none of them had fever, but 4 (57%) had a cough. None of them showed any signs of organ damage on laboratory testing. Chest X-ray showed pneumonia in one individual, which resolved spontaneously, while the other 6 had normal chest X-ray findings. Culture of throat swabs and sputum samples revealed that 4 patients (57%) had bacterial upper respiratory infections (Haemophilus influenzae, Klebsiella pneumoniae, and Staphylococcus aureus). The period from a positive polymerase chain reaction (PCR) test to negative conversion ranged from 5 to 13 days, with a median of 8 days. Conclusion Healthy young adults without risk factors who acquire SARS-CoV-2 infection may have an asymptomatic infection or may experience mild COVID-19. In addition to obesity, an older age, underlying illness, and being overweight can lead to a risk of exacerbation; thus, hospital management for such individuals may be desirable. Culturing respiratory samples may be useful for diagnosing secondary bacterial pneumonia.     

Patient and Clinical Factors at Admission Affect the Levels of Neutralizing Antibodies Six Months after Recovering from COVID-19

The rate of decline in the levels of neutralizing antibodies (NAbs) greatly varies among patients who recover from Coronavirus disease 2019 (COVID-19). However, little is known about factors associated with this phenomenon. The objective of this study is to investigate early factors at admission that can influence long-term NAb levels in patients who recovered from COVID-19. A total of 306 individuals who recovered from COVID-19 at the Tongji Hospital, Wuhan, China, were included in this study. The patients were classified into two groups with high (NAb^high, n = 153) and low (NAb^low, n = 153) levels of NAb, respectively based on the median NAb levels six months after discharge. The majority (300/306, 98.0%) of the COVID-19 convalescents had detected NAbs. The median NAb concentration was 63.1 (34.7, 108.9) AU/mL. Compared with the NAb^low group, a larger proportion of the NAb^high group received corticosteroids (38.8% vs. 22.4%, p = 0.002) and IVIG therapy (26.5% vs. 16.3%, p = 0.033), and presented with diabetes comorbidity (25.2% vs. 12.2%, p = 0.004); high blood urea (median (IQR): 4.8 (3.7, 6.1) vs. 3.9 (3.5, 5.4) mmol/L; p = 0.017); CRP (31.6 (4.0, 93.7) vs. 16.3 (2.7, 51.4) mg/L; p = 0.027); PCT (0.08 (0.05, 0.17) vs. 0.05 (0.03, 0.09) ng/mL; p = 0.001); SF (838.5 (378.2, 1533.4) vs. 478.5 (222.0, 1133.4) μg/L; p = 0.035); and fibrinogen (5.1 (3.8, 6.4) vs. 4.5 (3.5, 5.7) g/L; p = 0.014) levels, but low SpO₂ levels (96.0 (92.0, 98.0) vs. 97.0 (94.0, 98.0)%; p = 0.009). The predictive model based on Gaussian mixture models, displayed an average accuracy of 0.7117 in one of the 8191 formulas, and ROC analysis showed an AUC value of 0.715 (0.657–0.772), and specificity and sensitivity were 72.5% and 67.3%, respectively. In conclusion, we found that several factors at admission can contribute to the high level of NAbs in patients after discharge, and constructed a predictive model for long-term NAb levels, which can provide guidance for clinical treatment and monitoring.     

2019新型冠状病毒肺炎的挑战和机遇——对新型冠状病毒肺炎的认识及防治思考

新型冠状病毒(severe acute respiratory syndrome coronavirus 2,SARS-CoV-2)引发的新型冠状病毒肺炎(coronavirus disease 2019,COVID-19)的持续爆发于2019年12月底在湖北武汉被首次报道,确诊病例每天都在增加,造成的死亡人数已超过2002/2003在我国爆发的SARS病毒,成为受全球关注的突发公共卫生事件,所有政府和医疗机构都处于高度戒备状态.在此,我们根据目前掌握的数据,大体对COVID-19的基因组学、流行病学、临床表现、诊断、治疗等方面进行了概述.     

Comparison of clinical characteristics between patients with coronavirus disease 2019 (COVID-19) who retested RT-PCR positive versus negative: a retrospective study of data from Nanjing

BackgroundThe epidemiological and clinical characteristics of patients with coronavirus disease 2019 (COVID-19) have been reported. However, the prevalence of retesting positive by RT-PCR for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the associated patient characteristics, remain unclear.MethodsWe included 90 confirmed cases of COVID-19 treated in the Nanjing Public Health Center from January 20, 2020 to February 16, 2020 in this retrospective study. All patients completed treatment for COVID-19 and were retested by RT-PCR for SARS-CoV-2 4–20 days after completion of therapy. The clinical characteristics between patients with who retested positive versus negative by RT-PCR were compared, and the factors predictive of positive retesting were analyzed. Positive retesting was modeled with the area under the receiver operating characteristic curve (AUC).ResultsThe age range of the study population was 0.8–97 years, and all patients were cured or showed improvement. A total of 10 (11%) patients retested positive by RT-PCR 4–20 days after completion of therapy. As compared with patients who retested negative, those who retested positive had a lower percentage of pre-admission fever, a higher percentage of post-admission fever, a lower percentage of bilateral lung infection, higher white blood cell (WBC) count and creatine phosphokinase, and lower hypersensitive c-reactive protein (hs-CRP), interleukin-6 and erythrocyte sedimentation rates (all P<0.05). Logistic regression analysis of the above eight key variables showed that lower hs-CRP and higher WBC were independently associated with positive retesting by RT-PCR. A combination of hs-CRP and WBC were predictive of positive retesting, with an AUC of 0.859.ConclusionsPatients with COVID-19 who retested positive by RT-PCR for SARS-CoV-2 had mild symptoms and better blood testing results. A combination of hs-CRP and WBC may predict positive retesting by RT-PCR; however, the sensitivity and specificity should be studied further.     

Tracheostomy for COVID-19 respiratory failure: timing,ventilatory characteristics,and outcomes

BackgroundWhereas data from the pre-pandemic era have demonstrated that tracheostomy can accelerate liberation from the ventilator, reduce need for sedation, and facilitate rehabilitation, concerns for healthcare worker safety have led to disagreement on tracheostomy placement in COVID-19 patients. Data on COVID-19 patients undergoing tracheostomy may inform best practices. Thus, we report a retrospective institutional cohort experience with tracheostomy in ventilated patients with COVID-19, examining associations between time to tracheostomy and duration of mechanical ventilation in relation to patient characteristics, clinical course, and survival.MethodsClinical data were extracted for all COVID-19 tracheostomies performed at a quaternary referral center from April-July 2020. Outcomes studied included mortality, adverse events, duration of mechanical ventilation, and time to decannulation.ResultsAmong 64 COVID-19 tracheostomies (13% of COVID-19 hospitalizations), patients were 64% male and 42% African American, with a median age of 54 (range, 20–89). Median time to tracheostomy was 22 (range, 7–60) days and median duration of mechanical ventilation was 39.4 (range, 20–113) days. Earlier tracheostomy was associated with shortened mechanical ventilation (R²=0.4, P<0.01). Median decannulation time was 35.3 (range, 7–79) days. There was 19% mortality and adverse events in 45%, mostly from bleeding in therapeutically anticoagulated patients.ConclusionsTracheostomy was associated with swifter liberation from the ventilator and acceptable safety for physicians in this series of critically ill COVID-19 patients. Patient mortality was not increased relative to historical data on acute respiratory distress syndrome (ARDS). Future studies are required to establish conclusions of causality regarding tracheostomy timing with mechanical ventilation, complications, or mortality in COVID-19 patients.     

The Potential Role of COVID-19 in the Pathogenesis of Multiple Sclerosis—A Preliminary Report

Coronavirus 2019 (COVID-19) is an infectious respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that mainly affects the lungs. COVID-19 symptoms include the presence of fevers, dry coughs, fatigue, sore throat, headaches, diarrhea, and a loss of taste or smell. However, it is understood that SARS-CoV-2 is neurotoxic and neuro-invasive and could enter the central nervous system (CNS) via the hematogenous route or via the peripheral nerve route and causes encephalitis, encephalopathy, and acute disseminated encephalomyelitis (ADEM) in COVID-19 patients. This review discusses the possibility of SARS-CoV-2-mediated Multiple Sclerosis (MS) development in the future, comparable to the surge in Parkinson’s disease cases following the Spanish Flu in 1918. Moreover, the SARS-CoV-2 infection is associated with a cytokine storm. This review highlights the impact of these modulated cytokines on glial cell interactions within the CNS and their role in potentially prompting MS development as a secondary disease by SARS-CoV-2. SARS-CoV-2 is neurotropic and could interfere with various functions of neurons leading to MS development. The influence of neuroinflammation, microglia phagocytotic capabilities, as well as hypoxia-mediated mitochondrial dysfunction and neurodegeneration, are mechanisms that may ultimately trigger MS development.     

Successful Use of Certolizumab Pegol for Refractory Psoriatic Arthritis Triggered by COVID-19 Infection

Recently, the coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, has spread worldwide. Although nearly all patients incur mild-to-moderate disease from this viral infection, some develop severe manifestations with a poor prognosis. COVID-19 can also induce autoimmune disease; several cases of arthritis following COVID-19 have been documented in the literature, such as reactive arthritis and chronic arthritis. We herein report a case of psoriatic arthritis triggered by COVID-19. Although the arthritis had been refractory to glucocorticoids and methotrexate, certolizumab pegol subsequently led to remission.     

Application of artificial intelligence in COVID-19 medical area: a systematic review

BackgroundCoronavirus disease 2019 (COVID-19) has caused a large-scale global epidemic, impacting international politics and the economy. At present, there is no particularly effective medicine and treatment plan. Therefore, it is urgent and significant to find new technologies to diagnose early, isolate early, and treat early. Multimodal data drove artificial intelligence (AI) can potentially be the option. During the COVID-19 Pandemic, AI provided cutting-edge applications in disease, medicine, treatment, and target recognition. This paper reviewed the literature on the intersection of AI and medicine to analyze and compare different AI model applications in the COVID-19 Pandemic, evaluate their effectiveness, show their advantages and differences, and introduce the main models and their characteristics.MethodsWe searched PubMed, arXiv, medRxiv, and Google Scholar through February 2020 to identify studies on AI applications in the medical areas for the COVID-19 Pandemic.ResultsWe summarize the main AI applications in six areas: (I) epidemiology, (II) diagnosis, (III) progression, (IV) treatment, (V) psychological health impact, and (VI) data security. The ongoing development in AI has significantly improved prediction, contact tracing, screening, diagnosis, treatment, medication, and vaccine development for the COVID-19 Pandemic and reducing human intervention in medical practice.DiscussionThis paper provides strong advice for using AI-based auxiliary tools for related applications of human diseases. We also discuss the clinicians’ role in the further development of AI. They and AI researchers can integrate AI technology with current clinical processes and information systems into applications. In the future, AI personnel and medical workers will further cooperate closely.     

新型冠状病毒肺炎普通型病例40例临床研究

背景新型冠状病毒肺炎自2019年12月开始暴发流行,面对这一疫情,防控及诊治方面的措施还在摸索中。长沙市第一医院是湖南省及长沙市新型冠状病毒肺炎患者定点收治单位,回顾性分析患者的临床资料对新型冠状病毒肺炎的进一步认识具有重要意义。目的总结分析长沙市第一医院感染隔离病房收治的新型冠状病毒肺炎普通型患者40例的临床资料。方法选取2020-01-17至2020-02-05长沙市第一医院感染隔离病房收治的新型冠状病毒肺炎普通型患者40例,分析总结其一般资料、流行病学史、发病情况、临床表现、实验室检查、影像学检查及治疗情况。结果本组40例患者年龄为1~77岁,中位年龄为45岁;男23例(57.5%),女17例(42.5%);有基础疾病患者10例(25.0%);有家族聚集史者8例(20.0%);疫情时期路过武汉及周边地区5例(12.5%);居住在武汉地区来长沙探亲患者4例(10.0%);无流行病学史3例(7.5%)。2例多次行新型冠状病毒(2019-nCoV)核酸检测均为阴性,5~7 d后行2019-nCoV核酸检测阳性。40例患者中发热32例(80.0%),咳嗽、咳痰20例(50.0%);主要体征包括肺部听诊呼吸音粗36例(90.0%),肺部闻及干湿性啰音20例(50.0%)。CT影像学检查特点为:磨玻璃影与实变影或条索影共存,一般为节段性,可累及多个肺叶。主要行抗病毒+支持治疗,合并细菌感染者加用抗生素。结论新型冠状病毒肺炎人群普遍易感,多发生在中老年,以男性居多。家族聚集性发病占20%。临床上以发热、咳嗽、乏力为主要表现,血化验提示白细胞计数正常或降低,淋巴细胞计数降低为主,C反应蛋白早期升高,影像学表现对发病判断及治疗效果具有指导性意义。对于2019-nCoV核酸检测为阴性的情况,需要特别关注患者临床表现,结合肺部CT分析,可采取单独隔离以避免漏诊。一旦确诊就应该收住入院并尽早治疗。治疗上以抗病毒治疗为主,注意营养支持及胃肠道功能保护,联合中药治疗,必要时在疾病进展期加用短期甲泼尼龙治疗,避免细胞因子炎性损伤,进展为重症或危重症。     

糖皮质激素辅助治疗重型新型冠状病毒肺炎的回顾性分析

目的探讨糖皮质激素辅助治疗对重型新型冠状病毒肺炎(COVID-19)患者的影响,为进一步优化COVID-19的治疗策略提供参考。 方法纳入某医院普通病区2020年2月28日在院且被确诊为重型COVID-19的195例患者,根据有无糖皮质激素用药史分为激素组和非激素组。回顾性分析各组患者一般资料、激素用药情况、病程中不同阶段的体温、当日最佳指氧饱和度、血常规相关信息、C反应蛋白(CRP)、降钙素原(PCT)及相关不良反应发生情况、咽拭子SARS-CoV-2核酸转阴时间和转归。 结果激素组和非激素组患者均以男性为主,平均年龄相近(63.01±11.93 vs. 62.20±14.26)岁,临床症状、合并基础疾病、病程、抗病毒治疗、体温等情况基本一致(P>0.05)。激素组指氧饱和度低于非激素组[96(92～98)vs. 97(95～98),P<0.05]。激素组白细胞计数和中性粒细胞绝对值在正常范围但明显高于非激素组(P<0.05),淋巴细胞绝对值明显低于非激素组[0.90(0.68～1.10)vs. 1.29(0.93～1.62),P<0.05],CRP明显高于非激素组[34.56(9.69～62.27)vs. 7.60(2.19～37.28),P<0.05]。经治疗,激素组(激素干预后)指氧饱和度较非激素组(入院后1周)更优[99(98～99)vs. 98(97～99),P<0.05],白细胞计数和中性粒细胞绝对值有所增加且明显高于非激素组(入院1周后)(P<0.05)但仍在正常范围内,淋巴细胞计数明显回升且与非激素组(入院后1周)相近[1.39(1.08～2.18)vs. 1.36(1.05～1.82),P>0.05];CRP值回落且与非激素组(入院后1周)相近(P>0.05)。对激素组按激素累积剂量行亚组分析无阳性发现。各组患者咽拭子SARS-CoV-2核酸转阴时间中位数相近[20.00(15.00～26.00)d vs. 19.00(13.00～23.00)d],组间无差异(P>0.05)。激素组共报告6例、8人次不良反应,男性为主,年龄多在70岁以上,均报告血糖较基线水平明显升高,其中2例还出现血压较基线水平明显升高。非激素组无不良反应报告。各组患者均好转出院,无病情恶化和死亡报告。因数据缺失较多,为避免偏倚,PCT未予纳入分析。 结论在缺乏高级别循证医学证据支持的抗病毒药物情况下,在强化治疗的基础上给予重症COVID-19患者适当剂量和疗程的激素治疗,可能改善氧合,使患者更多临床获益,且用药风险可控,转归预期好。但本项目存在一定局限性,开展激素辅助治疗COVID-19的随机对照研究是必要的。     

COVID-19 and Older Adults: What We Know

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel virus that causes COVID-19 infection, has recently emerged and caused a deadly pandemic. Studies have shown that this virus causes worse outcomes and a higher mortality rate in older adults and those with comorbidities such as hypertension, cardiovascular disease, diabetes, chronic respiratory disease, and chronic kidney disease (CKD). A significant percentage of older American adults have these diseases, putting them at a higher risk of infection. Additionally, many adults with hypertension, diabetes, and CKD are placed on angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers. Studies have shown that these medications upregulate the ACE-2 receptor, the very receptor that the SARS-CoV-2 virus uses to enter host cells. Although it has been hypothesized that this may cause a further increased risk of infection, more studies on the role of these medications in COVID-19 infections are necessary. In this review, we discuss the transmission, symptomatology, and mortality of COVID-19 as they relate to older adults, and possible treatments that are currently under investigation. J Am Geriatr Soc 68:926–929, 2020