新型冠状病毒与脑血管病的关系

自2019年12月起,2019冠状病毒病(COVID-19,又称新型冠状病毒肺炎)首先在武汉被发现,随后该病迅速蔓延至全国乃至其他国家。该病具有传播广、死亡及重症率高的特点,影响深远,引起国内外的广泛重视。而脑血管病同样为我国人群主要的慢性疾病,每年也可造成一定的死亡及致残风险。COVID-19的发病机制与脑血管病的危险因素以及脑血管病本身都有很密切的关系,易合并存在,引发院内感染。笔者根据COVID-19现有的资料结合以往相关疾病的临床经验对新型冠状病毒与脑血管疾病的关系做一归纳,以求更好地指导临床个体化诊疗。     

Structural variations and expression profiles of the SARS-CoV-2 host invasion genes in lung cancer

Recent days have seen growing evidence of cancer's susceptibility to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and of the effect of genomic differences on the virus' entrance genes in lung cancer. Genetic confirmation of the hypotheses regarding gene expression and mutation pattern of target genes, including angiotensin-converting enzyme-2 (ACE2), transmembrane serine protease 2 (TMPRSS2), basigin (CD147/BSG) and paired basic amino acid cleaving enzyme (FURIN/PCSK3), as well as correlation analysis, was done in relation to lung adenocarcinoma (LUAD) and lung squamous carcinoma (LUSC) using in silico analysis. Not only were gene expression and mutation patterns detected, but also there were correlation and survival analysis between ACE2 and other target genes expression levels. The total genetic anomaly carrying rate of target genes, including ACE2, TMPRSS2, CD147/BSG, and FURIN/PCSK3, was determined as 8.1% and 21 mutations were detected, with 7 of these mutations having pathogenic features. p.H34N on the RBD binding residues for SARS-CoV-2 was determined in our LUAD patient group. According to gene expression analysis results, though the TMPRSS2 level was statistically significantly decreased in the LUSC patient group compared to healthy control, the ACE2 level was determined to be high in LUAD and LUSC groups. There were no meaningful differences in the expression of CD147 and FURIN genes. The challenge for today is building the assessment of genomic susceptibility to COVID-19 in lung cancer, requiring detailed experimental laboratory studies, in addition to in silico analyses, as a way of assessing the mechanism of novel virus invasion that can be used in the development of effective SARS-CoV-2 therapy.     

改良脐动静脉双管同步换血治疗重症新生儿高胆红素血症疗效观察

目的观察改良脐动静脉双管进行同步换血治疗重症新生儿高胆红素血症的疗效和安全性。方法将我院收治的64例确诊为新生儿高胆红素血症患儿随机分为两组,对照组32例持续24小时蓝光照射配合静滴白蛋白等综合治疗,治疗组32例在对照组综合治疗的基础上,通过改良后脐动静脉双管进行同步换血治疗后。对两组患儿治疗前后的血清胆红素、血糖、电解质以及血常规进行观察和比较。结果治疗组与对照组对比治疗组血清胆红素较观察组下降明显,治疗前后差异明显,有统计学意义,P0.05。血红蛋白轻微下降,血钾、血氯、血钙、血钠水平没有明显变化,差异不明显,无统计学意义,P0.05。结论改良后脐动静脉双管进行同步换血治疗新生儿高胆红素血症安全、快速降低重症新生儿高胆红素血症患儿的胆红素水平,值得有条件的医院推广。     

儿童COVID-19的临床特征：一项关于SARS、MERS及COVID-19的系统评价

目的 系统总结新型冠状病毒肺炎（COVID-19）儿童病例的临床特征。方法 计算机检索PubMed、Embase、Web of Science、The Cochrane Library、中国知网、重庆维普和万方数据库，搜集关于儿童COVID-19的临床研究，检索时限均为建库至2020年5月21日。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后，对纳入研究进行描述性分析。并与严重呼吸窘迫综合征（SARS）、中东呼吸综合征（MERS）儿童病例相关指标进行比较。结果 共纳入75个研究，包括COVID-19儿童病例806例。研究结果显示：患儿年龄在生后36?h到18岁不等，男女比例为1.21?：?1。与SARS、MERS病例类似，COVID-19病例最常见感染方式为家庭聚集感染，占74.6%（601/806）。COVID-19、SARS及MERS病例临床症状相似，以发热、咳嗽为主。部分患儿出现消化道症状。上述三者无症状感染儿童比例分别为17.9%（144/806）、2.5%（2/81）及57.1%（12/21）。COVID-19、MERS病例胸部影像学病变以双侧为主，病变阳性率分别为63.4%（421/664）及26.3%（5/19），均低于其病毒核酸检测阳性率（分别为99.8%及100%）。而SARS病例胸部影像学以单侧病变为主，其影像学阳性率为88.9%（72/81），高于病毒核酸检测阳性率（29.2%）。COVID-19及SARS患儿粪便中均检测到病毒核酸，检测阳性率分别为60.2%（56/93）、71.4%（5/7）。COVID-19患儿重症率及病死率分别为4.5%（31/686）、0.1%（1/806）；SARS儿童重症率及病死率分别为1.5%（1/68）、0%；MERS儿童重症率及病死率分别为14.3%（3/21）、9.5%（2/21）。结论 儿童COVID-19临床症状与儿童SARS、MERS相似，以发热、咳嗽为主，均存在无症状感染者，但COVID-19和SARS儿童的病情较MERS轻。家庭聚集感染为COVID-19儿童重要的感染方式。流行病学接触史、影像学检查及病毒核酸检测结果是诊断COVID-19的重要依据。     

床旁多普勒超声引导下经皮气管切开术在重症脑出血患者中的应用

目的探讨床旁多普勒超声引导下经皮气管切开术（PDT）在重症脑出血患者中的应用价值。方法选取2014年1月—2019年4月南方医科大学附属小榄医院重症医学科监护治疗的重症脑出血患者126例，在ICU床旁采用超声引导下行PDT。术前采用超声进行检查，明确气管位置、周围组织及血管情况，确定穿刺部位及深度，指导术前气管导管退管。术中实时超声引导，确保手术安全。术后超声确认气管切开套管位置，筛查排除气胸等相关并发症。观察操作时间（从皮肤穿刺到成功置入气管套管时间）、一针穿刺成功率、置管成功率、气管插管意外脱管率；观察术中及术后并发症：出血量、血管/甲状腺损伤、气管后壁损伤、皮下气肿、气胸、低氧血症发生率等。结果126例患者手术均一次操作成功，一针穿刺成功率及置管成功率均为100%，未发生气管插管意外脱管。操作时间5~12 min，平均操作时间7.5 min。术中及术后未发生难以控制的大出血、严重低氧血症、血管/甲状腺损伤、气管后壁损伤、皮下气肿及气胸等并发症。结论对重症脑出血患者行床旁实时超声引导下行PDT，提高了手术的可视性、操作性和安全性，提高PDT成功率，降低相关并发症，具有良好的临床价值。     

Prevalence and clinical characteristics of children with medical complexity in Tottori Prefecture,Japan: A population-based longitudinal study

ObjectivesTo investigate the prevalence and background of children with medical complexity (CMC) and its secular trend in Japan.MethodsCMC were defined as patients under the age of 20 years requiring medical care and devices. The patients were enrolled using the national health insurance claims data of three hospitals and two rehabilitation centers in Tottori Prefecture. The study period was divided into three periods: Period 1, 2007–2010; Period 2, 2011–2014; and Period 3, 2015–2018.ResultsA total of 378 CMC were enrolled. The prevalence of CMC was 1.88 per 1000 population among subjects aged <20 years in 2018, and it increased by approximately 1.9 times during the study period. The number of CMC who presented with severe motor and intellectual disabilities did not change from Period 1 to Period 3. Meanwhile, the number of CMC who had relatively preserved motor and intellectual abilities increased from 58 to 98. The proportion of CMC who required respiratory management and oxygen therapy increased by 1.3 and 1.8 times, respectively. By contrast, the proportion of CMC who need tube feeding decreased significantly between periods 1 and 3 (P < 0.05).ConclusionsThe prevalence of CMC increased almost twice during the 12-year study period; however, the increase in the number of patients with relatively preserved motor and intellectual abilities was pronounced. This study showed that the need for medical care and devices differed based on the underlying disorders and severity of CMC; therefore, individualized medical, welfare, and administrative services and education about the various types of CMC must be provided.     

临床护理路径用于ICU重症颅脑损伤患者护理中的价值

目的 探讨临床护理路径用于ICU重症颅脑损伤患者护理中的价值。方法 选择2017年11月～2018年10月进行ICU重症颅脑损伤治疗的患者100例作为对象,随机数字表法分为对照组(n=50)和观察组(n=50)。对照组给予常规护理,观察组在其基础上应用临床护理路径,15 d护理后比较患者依从性情况、对患者护理前后心理状态进行评分,对不良并发症产生情况进行比较。结果 观察组康复锻炼依从、按时用药依从及饮食依从高于对照组(P0.05)。护理前两组SDS与SAS评分比较差异无统计学意义(P0.05),护理后,观察组SDS与SAS评分低于对照组(P0.05)。观察组出现压疮、泌尿感染、以及发热的发生率显著低于对照组(P0.05)。结论 将临床护理路径用于ICU重症颅脑损伤患者的护理中,提高了患者的护理依从性,减少了不良情绪以及不良并发症的产生,有助于患者整体治疗,值得推广应用。