新型冠状病毒肺炎防控中的热点和难点问题

新型冠状病毒肺炎(COVID-19)疫情已持续1年余,目前全球的感染人数仍在上升,疫情走向不明确。COVID-19疫情后续会如何发展？目前新冠肺炎治疗药物的研究现状,应用于临床的疫苗是否会改变目前疫情流行的格局？在疫情常态化的背景下,其他呼吸道病毒的流行病学是否会发生变化？本文将围绕这些热点和难点问题进行讨论和分析。     

新型冠状病毒肺炎疫情形势下原发性肝癌破裂出血的诊治策略

在新型冠状病毒肺炎(简称:新冠肺炎;WHO定名:COVID-19)疫情下,如何处理危及患者生命的原发性肝癌(简称肝癌)破裂出血是目前临床上亟需解决的问题之一。笔者认为,该病的临床处置应在筛查新冠肺炎的前提下,遵循操作流程,做好充分防护。对于疑似或确诊新冠肺炎患者,需综合考虑新冠肺炎分型、肝癌破裂出血的程度、肿瘤情况、肝功能情况等因素,慎重制定具体治疗方案,开展个体化治疗。遵从既保证患者的安全及疗效,又要降低医护人员感染风险的诊治原则。     

新冠疫情下的心脏外科：改变与应对之策

新型冠状病毒（新冠）疫情自2019年12月爆发以来已对世界各国产生了巨大的影响。2022年12月，随着国内疫情管控政策松绑，全国各地相继进入新冠疫情高峰期，医疗挤兑现象常见。我国心外科对新冠大流行背景下的工作开展缺乏经验。本文通过回顾既往相关文献，对新冠疫情中心外科开展手术可能面临的主要问题进行总结，包括心外科手术量的可能变化趋势、新冠对心外科手术预后的影响、新冠流行期间的心外科诊疗策略选择和手术时机选择以及新冠期间对医院管理者的建议等，以期为国内心外科同行在新冠大流行背景下开展工作提供参考。     

新型冠状病毒肺炎隔离病房的紧急筹建与管理

目的总结新型冠状病毒肺炎(下称新冠肺炎)隔离病房改建及管理经验,为应对突发公共卫生事件提供参考。方法将感染科5个病区紧急改建为符合收治新冠肺炎的隔离病区,收治新冠肺炎患者338例,严格按国家诊治隔离标准进行培训及管理。结果经治疗327例患者好转出院,11例死亡。结论紧急改建新冠肺炎隔离病区有效缓解了疫情初期患者入院难的问题,严格规范化培训与管理使新建隔离病区发挥了较好的作用。     

新冠肺炎非疫区复工复产下中西医结合医院普外科诊疗策略

新型冠状病毒感染的肺炎目前在世界范围内流行,给人民生产生活和身体健康构成严重威胁,各中西医结合医院普外科为防控需要原有诊疗模式发生改变,如何做好疫情防控前提下,让普外科疾病患者得到合理诊治。本文就新冠肺炎非疫区复工复产下患者门诊就诊、住院流程的建立、医护人员防护、病房的合理化分配、患者术后发热处理流程、确诊及疑似新冠肺炎患者的术中及围手术期处理等方面探讨诊疗策略,并在疾病围手术期使用中医药治疗促进患者快速恢复,体现中西医结合对普外科疾病的治疗优势。     

新型冠状病毒肺炎大流行形势下疝和腹壁外科疾病诊疗思考

目前,新型冠状病毒肺炎(新冠肺炎)疫情仍在持续,其病原体近日被命名为2019新型冠状病毒(SARS-CoV-2)。疝和腹壁外科疾病,是人群的高发疾病,有急诊手术可能。在新冠肺炎流行的形势下,疝和腹壁外科医生应该按照指南和诊疗常规,顺应新形势下新冠肺炎的诊疗指南,做好疝和腹壁外科疾病的分类诊疗,合理选择手术方式;做好诊治、护理流程优化的同时,根据不同的风险等级,做好自身的防护措施。疝和腹壁外科疾病患者,也应该积极配合医务人员,按照流程做好就诊、配合住院手术治疗等工作。     

新型冠状病毒肺炎患者围手术期处理及防护的认识与思考

新近在中国武汉集中暴发的新型冠状病毒(SARS-CoV-2)所致肺炎(新冠肺炎,WHO定名:COVID-19)疫情严重威胁人民健康,目前已累及25个国家和地区。截至2020年2月13日,中国累计确诊病例63 946例,疑似病例10 109例,病死率2.06%。目前认为SARS-CoV-2传播途径主要是飞沫传播和密切接触,尚不能排除气溶胶和粪-口传播的可能。最新研究表明,新冠肺炎具有非常高的传播效率(R0为3.77)。按照国家卫生健康委员会的要求,疫情暴发期间外科手术的开展限于急诊手术和限期手术。对于疑似或确诊感染新冠肺炎患者外科手术时如何进行围手术期的防护,目前国内外尚无相关指南和共识,缺乏可借鉴的成熟经验。据不完全统计武汉大学中南医院与武汉大学人民医院在疫情期间共收治50例围手术期新冠肺炎患者,其中2例为术后确诊新冠肺炎,围手术期导致16名医务等相关人员感染;48例为术前新冠肺炎疑似或确诊患者,围手术期采取针对性的防护措施后未出现医务相关人员的感染。笔者根据中南大学湘雅医院在新冠肺炎流行期间制定的隔离措施和防护经验,结合上述武汉市两所医院的病例资料,探讨在新冠肺炎流行期间医务人员如何进行围手术期规范操作,制定有效的防护措施。     

显微外科医护人员在抗击新冠肺炎疫情中的角色转换与作用浅析

新型冠状病毒肺炎(简称新冠肺炎,COVID-19)疫情在全球爆发,确诊病例超过200万例,多个国家出现医疗资源挤兑,医护人员严重短缺.在武汉抗击新冠肺炎疫情的阻击战中,全国众多显微外科医护人员投入到新冠肺炎患者救治工作中.本文通过回顾作者抗击新冠肺炎疫情的亲身经历,分析显微外科医护人员支援前线、救治新冠肺炎患者时所面临的挑战,探讨如何转换角色,同时发挥自身专业优势,为抗击疫情作贡献.以期为今后在应对重大急性传染病疫情时如何更好的发挥显微外科医护人员力量提供参考.     

新型冠状病毒肺炎疫情下实施血管外科诊疗的思考和建议

目前,新型冠状病毒肺炎(简称:新冠肺炎,WHO命名为COVID-19)疫情对我国人民的生命健康造成了巨大的威胁。在新冠肺炎疫情下,如何应对血管外科门诊患者;如何应对血管外科的危急重症患者;如何安全的实施血管外科手术;如何做好血管外科患者的术后管理和随访,这些都对血管外科医师提出了新的挑战。结合最新的文献报道和笔者所在医院的防控经验,本文对以上问题作出思考并提出个人建议,希望能起到抛砖引玉之作用,能够引发血管外科医师对新冠肺炎疫情下如何实施血管外科诊疗进行思考,以期更好地为临床服务。     

新型冠状病毒肺炎疫情期间开展显微外科手术专家共识

目前,国内新型冠状病毒肺炎(简称新冠肺炎,COVID-19)疫情防控形势持续向好,各地生产、生活秩序加速恢复.然而,复工、复产带来的人员聚集和流动可能增加疫情反复的风险,境外疫情爆发带来的病例输入压力与日俱增.在“内防反弹,外防输入”的疫情防控要求下,如何开展显微外科手术,做到既满足患者日常诊治需求,又避免疫情扩散,亟待一份专家指导意见.中华医学会显微外科学分会和《中华显微外科杂志》编辑部组织部分显微外科专家,总结、讨论在新冠肺炎疫情期间进行疫情防控及开展显微外科手术的经验,形成专家共识:①根据患者新冠病毒感染风险的级别选择治疗方案,对于高风险患者,可选择非手术治疗或延迟手术,不影响预后者应暂缓进行手术,必须实施急诊手术者,应在Ⅲ级防护下进行手术;对于低风险患者,可在Ⅰ级防护下开展各类显微外科手术.院前急救或需进行紧急手术而未完成新冠肺炎排查,未能确定风险级别者,需在Ⅱ级以上(含Ⅱ级)防护条件下进行手术.②设置过渡病房(病区),集中收治中、高风险患者.③医务人员实施分级防护,正确使用防护用品.④中、高风险患者围术期处置应统一指挥,严格遵守疫情防控指引,有序落实人员、物品及环境准备.⑤需加强医护人员新冠肺炎知识及院感培训,以及手术人员在防护条件下进行显微外科操作的培训.     

新型冠状病毒肺炎疫情期间乳腺外科运行情况分析

背景与目的:尽管目前国内新型冠状病毒肺炎(COVID-19)疫情得到了有效的控制,但国外病例仍在持续增加,防控形势依然严峻。本研究以陆军军医大学第一附属医院乳腺外科为例,分析总结新型冠状病毒肺炎疫情期间综合性三甲医院乳腺外科运行情况,为疫情期间及后疫情时期安全、高效地开展乳腺外科工作提供有效参考和经验做法。方法:选取自2020年1月31日—2020年2月20日COVID-19流行期间陆军军医大学第一附属医院乳腺甲状腺外科收治的37例乳腺癌患者,对其临床特征、防护手段及治疗效果等病例资料进行回顾性分析。对患者的入院和术前准备、术中防护、术后康复等关键环节,以及医护人员自我防护及心理疏导进行方法总结。对专科治疗及疫情防控的效果进行随访研究。分析在后疫情时期如何提升对潜在传染病风险的认知,结合乳腺外科的诊治特点,从手术指征把握、气溶胶管理和诊室防护等多方面加强疫情防控和职业防护工作。结果:37例乳腺癌患者经排除COVID-19风险后均接受手术治疗,平均手术时间为(152.23±46.19)min,平均术中出血量为(85.23±23.47)mL,无术中输血病例。在37例乳腺癌患者中,有19例患者接受术前6～8周期新辅助治疗,其中7例术后证实为病理学完全缓解。术后2例出现持续发热,经过隔离、监测体温及对症支持治疗后恢复正常,新型冠状病毒核酸检测排除COVID-19感染可能。经跟踪随访,患者及陪护人员均无发热、咳嗽、乏力等COVID-19疑似表现,相关医护人员同样未出现疑似病例,总体防控效果较好。结论:在COVID-19疫情流行期间,在科学防控、竭力避免医患双方感染COVID-19的前提下,可结合当地疫情情况全力为乳腺癌患者提供有效治疗。应继续遵从"科学决策、人文服务"的精神,严格遵循上级下发的各类防控指南和管理规范,并依据实际完成乳腺癌患者的院前排查、术前准备、术中防护、术后康复等必要环节。严格在患者入院前及围手术期各环节遵循疫情防护规范、协调好疫情防控与专科诊治的关系,有利于最大限度地确保乳腺外科手术安全地完成,守护患者及医务人员的健康。     

新型冠状病毒肺炎疫情形势下肿瘤专科医院头颈部恶性肿瘤诊治体会：附38例报告

背景与目的:2019年12月开始出现的新型冠状病毒肺炎(COVID-19)正在全球呈流行态势。有研究发现,肿瘤患者罹患COVID-19的风险较高,且更易出现重症及病情恶化。头颈肿瘤作为肿瘤专科医院接诊的重要病种,病例基数庞大,疾病复杂,部分肿瘤恶性程度极高,往往进展迅速,经不起拖延,而开展头颈肿瘤诊疗活动需要进行口腔、喉及气道等部位的操作本身又可能增加COVID-19医患感染风险。因此,本研究着重探讨COVID-19疫情形势下肿瘤专科医院头颈肿瘤的诊治和防控策略。方法:回顾性分析2020年2月1日—2020年2月22日在中国科学院大学附属肿瘤医院(浙江省肿瘤医院)头颈外科预约收治的38例头颈部恶性肿瘤患者的临床资料。本中心实行分时段预约就诊,基于诊疗指南和临床实践合理分流患者,严格把握住院指征。所有收住患者均需进行详细的流行病学调查、核酸检测和胸部CT扫描,排除COVID-19后方能接受手术或化疗。诊疗期间严格执行疫情防控措施,仔细观察诊疗经过,关注体温监测和管理,出院后跟踪随访患者恢复情况并通过互联网医院或其他网络途径实施医学指导和后续治疗。结果:头颈部恶性肿瘤38例患者中,男17例,女21例,平均49岁;其中甲状腺癌21例,口腔恶性肿瘤6例,唾液腺癌3例,喉癌2例,下咽癌2例,颈段食管癌1例,淋巴瘤1例,鼻咽癌1例,血管肉瘤1例。31例接受手术治疗,7例接受化疗,诊疗过程中3例出现发热,其中1例为粒缺性发热,1例为肿瘤坏死感染发热,1例因切口感染而发热,患者总体经过顺利,恢复良好,住院期间及出院后随访2周未发现患者和医务人员COVID-19感染。结论:COVID-19疫情形势下,基于诊疗指南和临床实践,合理分流、科学防控,充分利用"互联网+医疗"的优势,在积极投身抗击疫情同时,保护肿瘤患者免受病毒感染,并做好患者的心理支持,将疫情对治疗的影响降到最低并保证治疗的延续性是头颈肿瘤临床诊疗工作的可行策略。     

Characteristics and outcomes of COVID-19 infection in 45 patients with breast cancer: A multi-center retrospective study in Hubei,China

BackgroundThe COVID-19 pandemic is a significant worldwide health crisis. Breast cancer patients with COVID-19 are fragile and require particular clinical care. This study aimed to identify the clinical characteristics of breast cancer patients with COVID-19 and the risks associated with anti-cancer treatment.MethodsThe medical records of breast cancer patients with laboratory-confirmed COVID-19 were collected among 9559 COVID-19 patients from seven designated hospitals from 13th January to 18th March 2020 in Hubei, China. Univariate and multivariate analyses were performed to assess risk factors for COVID-19 severity.ResultsOf the 45 breast cancer patients with COVID-19, 33 (73.3%) developed non-severe COVID-19, while 12 (26.7%) developed severe COVID-19, of which 3 (6.7%) patients died. The median age was 62 years, and 3 (6.7%) patients had stage IV breast cancer. Univariate analysis showed that age over 75 and the Eastern Cooperative Oncology Group (ECOG) score were associated with COVID-19 disease severity (P < 0.05). Multivariate analysis showed that patients who received chemotherapy within 7 days had a significantly higher risk for severe COVID-19 (logistic regression model: RR = 13.886, 95% CI 1.014–190.243, P = 0.049; Cox proportional hazards model: HR = 13.909, 95% CI 1.086–178.150, P = 0.043), with more pronounced neutropenia and higher LDH, CRP and procalcitonin levels than other patients (P < 0.05).ConclusionsIn our breast cancer cohort, the severity of COVID-19 could be associated with baseline factors such as age over 75 and ECOG scores. Chemotherapy within 7 days before symptom onset could be a risk factor for severe COVID-19, reflected by neutropenia and elevated LDH, CRP and procalcitonin levels.     

新型冠状病毒肺炎疫情期间糖尿病足病多学科诊疗策略

新型冠状病毒肺炎(COVID-19)疫情正处于暴发和相持相交替的关键阶段。糖尿病足病(以下简称糖尿病足)是常见的严重糖尿病慢性并发症,诊治难度大且常需要多学科协作,在COVID-19疫情背景下,糖尿病足诊治面临着新的严峻形势。糖尿病足患者比一般人群更容易患COVID-19,而对于合并糖尿病足的COVID-19患者在糖尿病足处理和COVID-19处理上都更为困难。此外,COVID-19疫情期间糖尿病足诊疗的医疗资源相对减少,而多数糖尿病足患者需要长期门诊随访,部分患者需要限期手术或急诊手术。医护人员需要依据新形势对糖尿病足患者采取新的诊疗流程和措施。本文结合武汉等地多家医院的一线COVID-19和糖尿病足患者诊治经验,参考相关诊疗方案和专家共识,对COVID-19疫情下糖尿病足的多学科诊疗策略进行归纳总结。     

新型冠状病毒肺炎疫情下急诊创伤骨科诊疗行为的建议和策略

目的探讨新型冠状病毒肺炎(COVID-19)疫情下急诊创伤骨科诊疗行为的建议和策略。方法回顾性分析2020年1月21日至2月15日期间武汉大学人民医院骨外科收治的128例急诊创伤骨科患者资料,男71例,女57例;年龄为5~88岁,平均48.7岁。门诊处置107例;住院手术21例,其中急诊手术4例,择期手术17例。记录患者和医务人员感染COVID-19的情况,总结疫情暴发以来实施的一些措施和经验。结果107例接受门诊处置的患者中,3例确诊COVID-19,3例疑似COVID-19。4例接受急诊手术的患者中,1例疑似COVID-19;17例接受择期手术的患者中,1例确诊COVID-19,2例疑似COVID-19。医务人员感染COVID-19的情况:2名护士确诊COVID-19,但均为轻症患者;1名医生和1名护士均疑似COVID-19。医务人员感染COVID-19均发生在疫情防控措施执行之前,不排除社区感染的可能。结论各级医疗机构在做好COVID-19防控的同时,保证安全、有效的医疗行为正常运转尤为重要。在COVID-19疫情期间,参与急诊创伤骨科的一线医务人员的接诊过程均面临诸多挑战。通过健全急诊创伤分诊流程、住院患者分类管理、住院病房优化管理、围手术期标准预防、完善落实医护防护制度、患者及陪护宣教配合等措施,可降低院内COVID-19感染发生率,在疫情期间依然可以为急诊创伤骨科患者提供优质、安全的医疗服务。     

Breast cancer survivorship care during the COVID-19 pandemic within an urban New York Hospital System

PurposeTo examine clinicodemographic determinants associated with breast cancer survivorship follow-up during COVID-19.MethodsWe performed a retrospective, population-based cohort study including early stage (Stage I-II) breast cancer patients who underwent resection between 2006 and 2018 in a New York City hospital system. The primary outcome was oncologic follow-up prior to and during the COVID-19 pandemic. Secondary analyses compared differences in follow-up by COVID-19 case rates stratified by ZIP code.ResultsA total of 2942 patients with early-stage breast cancer were available for analysis. 1588 (54%) of patients had attended follow-up in the year prior to the COVID-19 period but failed to continue to follow-up during the pandemic, either in-person or via telemedicine. 1242 (42%) patients attended a follow-up appointment during the COVID-19 pandemic.Compared with patients who did not present for follow-up during COVID-19, patients who continued their oncologic follow-up during the pandemic were younger (p = 0.049) more likely to have received adjuvant radiation therapy (p = 0.025), and have lower household income (p = 0.031) on multivariate modeling. When patients who live in Bronx, New York, were stratified by ZIP code, there was a modest negative association (r = −0.56) between COVID-19 cases and proportion of patients who continued to follow-up during the COVID-19 period.ConclusionWe observed a dramatic disruption in routine breast cancer follow-up during the COVID-19 pandemic. Providers and health systems should emphasize reintegrating patients who missed appointments during COVID-19 back into regular surveillance programs to avoid significant morbidity and mortality from missed breast cancer recurrences.     

新型冠状病毒肺炎疫情期间创伤骨科患者处理要点

新型冠状病毒肺炎疫情严峻,虽一定程度上限制了人员流动,但仍不可避免骨折患者、尤其是低能量损伤老年患者来医院就诊。在此特殊时期,创伤骨科医师应如何在常规的诊疗方式中结合新型冠状病毒肺炎的防控,做好创伤患者围手术期管理,选择合理的术式及麻醉方式,对于患者的预后及疫情的防控至关重要。在做好诊断、治疗、护理、康复等流程的同时,医务人员如何做好自身的防护,避免出现聚集性传播,也是必须要面对的问题。该文从创伤骨科医、护、患三者出发,结合多学科综合干预模式,对当前疫情期间如何做好创伤骨科患者的防治工作进行简要阐述。     

Guideline for diagnosis and treatment of spine trauma in the epidemic of COVID-19

Outbreak of COVID-19 is ongoing all over the world. Spine trauma is one of the most common types of trauma and will probably be encountered during the fight against COVID-19 and resumption of work and production. Patients with unstable spine fractures or continuous deterioration of neurological function require emergency surgery. The COVID-19 epidemic has brought tremendous challenges to the diagnosis and treatment of such patients. To coordinate the diagnosis and treatment of infectious disease prevention and spine trauma so as to formulate a rigorous diagnosis and treatment plan and to reduce the disability and mortality of the disease, multidisciplinary collaboration is needed. This expert consensus is formulated in order to (1) prevent and control the epidemic, (2) diagnose and treat patients with spine trauma reasonably, and (3) reduce the risk of cross-infection between patients and medical personnel during the treatment.     

Changes in breast cancer management during the Corona Virus Disease 19 pandemic: An international survey of the European Breast Cancer Research Association of Surgical Trialists (EUBREAST)

BackgroundCorona Virus Disease 19 (COVID-19) had a worldwide negative impact on healthcare systems, which were not used to coping with such pandemic. Adaptation strategies prioritizing COVID-19 patients included triage of patients and reduction or re-allocation of other services. The aim of our survey was to provide a real time international snapshot of modifications of breast cancer management during the COVID-19 pandemic.MethodsA survey was developed by a multidisciplinary group on behalf of European Breast Cancer Research Association of Surgical Trialists and distributed via breast cancer societies. One reply per breast unit was requested.ResultsIn ten days, 377 breast centres from 41 countries completed the questionnaire. RT-PCR testing for SARS-CoV-2 prior to treatment was reported by 44.8% of the institutions. The estimated time interval between diagnosis and treatment initiation increased for about 20% of institutions. Indications for primary systemic therapy were modified in 56% (211/377), with upfront surgery increasing from 39.8% to 50.7% (p < 0.002) and from 33.7% to 42.2% (p < 0.016) in T1cN0 triple-negative and ER-negative/HER2-positive cases, respectively. Sixty-seven percent considered that chemotherapy increases risks for developing COVID-19 complications. Fifty-one percent of the responders reported modifications in chemotherapy protocols. Gene-expression profile used to evaluate the need for adjuvant chemotherapy increased in 18.8%. In luminal-A tumours, a large majority (68%) recommended endocrine treatment to postpone surgery. Postoperative radiation therapy was postponed in 20% of the cases.ConclusionsBreast cancer management was considerably modified during the COVID-19 pandemic. Our data provide a base to investigate whether these changes impact oncologic outcomes.