新型冠状病毒感染相关心脏损害的机制探讨

2019年12月以来,爆发于湖北省武汉市、流行于全国乃至全球的新型冠状病毒肺炎(COVID-19)引起广泛关注。其病原体被判定为一种名为SARS-CoV-2的新型冠状病毒,具有较高的传染性和致病力。SARS-CoV-2感染者除典型呼吸系统表现外,相当一部分出现心悸、胸闷等症状与心电图、心肌酶谱、心功能等改变,病毒相关心肌损伤、ACE2表达下调、炎症反应、缺氧及代谢障碍等因素与其发生发展密切相关。本文综合以往冠状病毒研究和现有COVID-19报道,对此心脏损害可能机制进行综述。     

201例新型冠状病毒肺炎患者肝损害临床特征分析

目的了解新型冠状病毒肺炎(COVID-19)患者肝损害特征,为临床诊治工作提供参考。方法收集2020年1月19日-3月5日湖北省襄阳市中心医院三院区收治的201例COVID-19患者的病历资料,分为非危重组(轻型/普通型,n=173)、危重组(重型/危重型,n=28) 2组,收集ALT、AST、TBil、DBil及Alb等指标。计量资料组间比较采用t检验;计数资料组间比较采用χ2检验;等级资料组间比较采用Wilcoxon秩和检验。结果 201例患者中37例(18. 4%)出现肝损害,危重组19例,非危重组18例,2组间肝损害发生率比较差异有统计学意义(67. 9%vs 10. 4%,χ2=52. 963,P 0. 05)。危重组肝损害患者与非危重组肝损害患者ALT和(或) AST水平异常时间(入院时和住院期间)情况比较差异有统计学意义(χ2=11. 906,P 0. 05); 2组肝损害患者ALT和(或) AST水平升高情况比较差异有统计学意义(Z=-2. 869,P 0. 05),大部分患者为轻中度肝损害。201例患者中胆红素升高者1例(TBil 2倍正常值上限,且以IBil为主),为非危重肝损害患者。危重组肝损害患者Alb水平明显低于非危重组(t=-8. 002,P 0. 05); 201例患者中Alb水平下降者有75例,其中入院时50例(24. 9%),住院期间25例(12. 4%),2时间段患者Alb水平(t=-4. 967,P 0. 05)和低白蛋白血症情况(χ2=26. 645,P 0. 05)比较差异均有统计学意义。结论 COVID-19患者肝损害比较常见,以轻中度肝损害为主,胆红素异常发生率较低,Alb浓度下降发生率高,危重患者与非危重患者在肝损害发病率及严重程度具有显著差异,白蛋白水平能可作为评估及预测COVID-19患者病情严重程度指标之一。     

新型冠状病毒肺炎死亡患者80例的临床特征分析

目的:分析新型冠状病毒肺炎(COVID-19)死亡病例的临床特征和死亡原因,为降低患者病死率提供借鉴。方法:对2020年1月11日至2月11日武汉大学人民医院收治的80例COVID-19死亡患者的临床资料进行回顾性分析。并对患者入院后第1次与死亡前最后一次的白细胞计数、淋巴细胞计数、降钙素原、乳酸、D-二聚体、纤维蛋白降解产物、N末端脑钠肽前体、超敏肌钙蛋白I、乳酸脱氢酶、CD4+T淋巴细胞计数进行比较。统计学分析采用配对t检验或威尔科克森符号秩检验。结果:80例死亡患者的中位年龄为72岁,年龄≥60岁者占78.75%(63/80)。入院时重型患者36例(45.00%),危重型44例(55.00%);58例(72.50%)合并有基础疾病,主要为高血压、糖尿病、冠状动脉粥样硬化性心脏病、慢性阻塞性肺疾病等。患者入院后第1次与死亡前最后一次实验室检查结果比较,白细胞计数升高[8.01(4.86,12.29)×109/L比12.55(8.25,17.66)×109/L],淋巴细胞计数降低[0.70(0.46,0.88)×109/L比0.54(0.39,0.75)×109/L],降钙素原升高[0.20(0.11,0.74)μg/L比1.00(0.20,1.99)μg/L],乳酸水平升高[2.10(1.40,3.10)mmol/L比3.10(2.60,4.10)mmol/L],D-二聚体升高[4.33(0.97,18.98)mg/L比15.29(5.17,53.44)mg/L],纤维蛋白降解产物升高[15.90(3.58,76.60)mg/L比63.14(21.23,110.67)mg/L],N末端脑钠肽前体升高[1078.00(347.35,2996.50)ng/L比3439.50(1576.00,9281.50)ng/L],超敏肌钙蛋白I升高[0.08(0.03,0.17)μg/L比0.33(0.14,2.47)μg/L],乳酸脱氢酶升高[397.00(327.00,523.50)U/L比624.00(481.00,854.00)U/L],CD4+T淋巴细胞计数降低[137.00(104.00,168.00)/μL比97.00(67.00,128.00)/μL];差异均有统计学意义(W=238.00、1053.50、150.00、152.00、192.00、190.00、108.00、57.00、53.00、40.00,均P<0.05)。80例患者均接受了抗病毒治疗和呼吸支持等综合治疗,然而病情迅速恶化,入院后1 d内死亡7例,7 d内死亡66例,主要死亡原因是顽固性低氧血症引起的呼吸衰竭及其不可逆的多器官功能衰竭。结论:合并有慢性基础疾病的老年COVID-19患者的预后较差,在病程早期加以重视并予对症治疗,对改善其预后至关重要。     

新型冠状病毒肺炎累及心脏的表现和治疗建议

由于新型冠状病毒具有传播能力强、临床表现多样、潜伏期长、可隐性传染等特征,目前全球累计已有超过480万人被感染,新型冠状病毒肺炎患者除了典型的呼吸系统表现外,心脏受累亦不少见,本文通过目前可获得的文献和临床资料,对新型冠状病毒肺炎患者心脏受累的流行病学特征、可能机制、临床表现进行了总结,并结合自身一线抗疫临床经验对新型冠状病毒肺炎合并心脏受累的治疗进行了讨论,以供临床一线医师参考。     

2019新型冠状病毒肺炎29例临床特征分析

目的 分析2019新型冠状病毒(2019-nCoV)肺炎患者的临床特征,研究患者血清中炎症相关细胞因子与病情严重程度的相关性.方法 选取2020年1月在华中科技大学同济医学院附属同济医院隔离病房收治的29例2019-nCoV患者为研究对象,收集临床资料,分析一般情况、临床症状、血液检验及CT影像学的特征.根据相关诊断标准将患者分为普通型(15例)、重型(9例)和危重型(5例)3组.检测各组患者血清中炎症相关细胞因子及其他反映病情变化标志物的表达水平,比较和分析3组患者血清中上述各指标变化的规律及其与疾病临床分型的关系.结果 (1)2019-nCoV肺炎患者的主要临床症状为发热(28/29),伴或不伴有呼吸道及其他系统症状;2例死亡患者分别合并基础疾病和混合细菌感染.(2)患者外周血一般表现为白细胞总数正常或减低(23/29),淋巴细胞计数减少(20/29),超敏C反应蛋白(hs-CRP)增高(27/29),降钙素原正常.多数患者血清中乳酸脱氢酶(LDH)表达水平明显增高(20/29),白蛋白减低(15/29);而丙氨酸氨基转移酶(ALT),天冬氨酸氨基转移酶(AST),总胆红素(Tbil),血肌酐(Scr)等指标无明显变化.(3)典型病例的CT表现为单发或多发的斑片状磨玻璃影,伴有小叶间隔增厚;疾病进展时病灶增多、范围扩大,磨玻璃影与实变影或条索影共存,部分重症患者表现为双肺弥漫性病变.(4)3组患者血清中白细胞介素-2受体(IL-2R)、IL-6表达水平差异均具有统计学意义(P<0.05),其中危重型高于重型、重型高于普通型.而3组研究对象血清中的肿瘤坏死因子-α(TNF-α)、IL-1β、IL-8、IL-10、hs-CRP、淋巴细胞计数、LDH表达水平差异均无统计学意义(P>0.05).结论2019新型冠状病毒肺炎的临床特征与一般病毒性肺炎类似;高分辨率CT有助于鉴别诊断;患者血清中IL-2R、IL-6表达水平有助于疾病临床分型,可能有助于预测新冠肺炎的严重程度和预后.     

老年人新型冠状病毒肺炎死亡病例1例分析

自2019年12月湖北省武汉市发现了多例新型冠状病毒(2019 novel coronavirus,2019-nCoV)[1]感染的肺炎(corona virus disease 2019,COVID-19)病例以来,疫情快速传播蔓延,截止撰稿之日,湖北省已累计确诊病例62031例[2]。在众多病例中,老年人发病症状不典型,感染后病情进展快,死亡率高。老年患者感染COVID-19后以心血管疾病为首发症状就诊比例较高[3]。笔者现就1例合并多种心血管基础疾病的COVID-19老年死亡病例进行分析讨论。     

北京65例新型冠状病毒肺炎患者临床特征分析

目的分析新型冠状病毒肺炎(COVID-19)确诊病例的流行病学、临床症状及实验室检查指标,为全面总结COVID-19的临床特征与正确评价患者预后提供依据。方法采用回顾性研究方法,以2020年1月20日—2月29日期间本中心收治的65例COVID-19患者为研究对象,根据临床症状将患者分为轻型组(18例),普通型组(31例)和重/危重型组(16例)3组,对所有患者流行病学、临床症状及实验室检查指标进行分析。结果 65例COVID-19患者中男37例(57%),女28例(43%);年龄3～85岁,平均(46.63±18.63)岁。从出现症状到入院平均时长为(7.00±5.02)d,住院时间为(17.07±10.51)d。3组间及两两分组之间年龄比较差异均具有统计学意义(P均0.05),即年龄越大的患者病情越重。相较于轻型组和普通型组患者,重/危重型组患者合并有更多的基础疾病。COVID-19患者临床症状以发热(75%)、咳嗽(57%)、肌痛或乏力(43%)为主,其余症状还包括咳痰,头痛,胸闷、气短及腹泻等。24例(37%)有武汉暴露史,19例(29%)有家族聚集性接触史。实验室检查结果显示:3组患者WBC和淋巴细胞绝对计数降低;D-二聚体,CRP,IL-6及ESR水平升高。在重/危重型组患者中,8例(50%)出现淋巴细胞绝对计数下降,9例(9/14,64%)出现D-二聚体水平升高。此外,重/危重型组患者中,CRP、IL-6、降钙素原和ESR水平都显著升高。COVID-19患者住院时间与淋巴细胞绝对计数呈负相关。结论 COVID-19患者的临床特点复杂,一般以发热、咳嗽、肌痛或乏力为主要症状。与轻型组和普通型组患者相比,重/危重型组患者淋巴细胞绝对计数减少和炎症相关的指标上升更显著,免疫平衡失调,可能影响患者的疾病进展、恢复和预后。     

广西儿童新型冠状病毒肺炎11例临床分析

［摘要］　目的　探讨新型冠状病毒肺炎患儿的临床特征及预后。方法　回顾性分析2020-01-19～2020-03-11期间诊断为新型冠状病毒肺炎并集中收治于广西壮族自治区人民医院的11例住院患儿的临床资料。结果　共纳入4例无症状患儿和7例普通型患儿,均为聚集性发病。肺部典型CT影像表现为磨玻璃阴影,经治疗后全部吸收。5例<3岁患儿均发现大便病毒核酸持续阳性,最长持续41 d;4例血清肌酸激酶同工酶水平升高2倍以上。新型冠状病毒肺炎母亲乳汁中病毒核酸阴性。结论　新型冠状病毒肺炎患儿临床表现较轻,但对3岁以下儿童需警惕心肌损伤及粪口传播的可能。     

57例新型冠状病毒肺炎患者临床特点分析

目的　分析南宁市第四人民医院收治的新型冠状病毒肺炎（coronavirus disease-2019, COVID-19）患者临床特征及流行病学特点,为COVID-19疫情防控提供借鉴。方法　选取2020年1月22日—2月17日在南宁市第四人民医院隔离病房收治的57例COVID-19患者为研究对象,收集患者的临床资料,分析其一般情况、流行病学、临床症状、实验室检查结果及CT影像学特征。根据《新型冠状病毒感染的肺炎诊疗方案（试行第五版）》的临床分型方法,对比分析轻型/普通型与重型/危重型患者的临床特征。结果　57例确诊COVID-19患者中,男28例（49%）,女29例（51%）,平均年龄45岁,武汉相关病例36例（63.16%）。37例患者来自聚集性感染（64.91%）,有10起家庭聚集性感染。临床症状以发热（52.63%）、咳嗽（42.10%）、咽喉不适（22.81%）、乏力（19.30%）为主,7例无症状。轻型/普通型50例（87.72%）,重型/危重型7例（12.28%）。17例（29.82%）合并基础疾病,1例合并乙型流感病毒感染,1例合并肺部支原体感染。17例粪便核酸检测阳性,且咽拭子核酸转阴快于粪便核酸检测,13例（32.50%）咽拭子核酸检测转阴后粪便核酸检测仍为阳性。典型病例CT表现为多发斑片状磨玻璃影,外周胸膜下分布为主,下肺多见,重症患者病灶广泛。病灶吸收好转表现形式可不一致。结论　南宁市COVID-19病例以输入性及轻型/普通型病例为主,有粪便传播途径可能;临床特征与病毒性肺炎类似,高分辨率CT有助于诊断。     

重症新型冠状病毒肺炎患者心血管疾病相关危险因素分析

目的探讨重症新型冠状病毒肺炎患者的心血管疾病相关危险因素,并进行分析。方法2020年2月10日至3月4日,纳入杭州市第三批援鄂医疗队接管的华中科技大学同济医院光谷院区E1-3重症病区重症新型冠状病毒肺炎(novel coronavirus pneumonia,NCP)患者61例,记录分析患者的入院基线资料、心血管危险因素和入院初期心血管相关实验室指标。结果 61例重症NCP患者中,发展至危重症8例(13.1%),男7例(87.5%),女1例(12.5%),其中转至ICU治疗6例(75%),死亡5例(62.5%),仍为重症组53例(86.9%)。61例NCP患者心血管相关危险因素包括高血压(34.4%)、糖尿病(14.8%)、吸烟(21.3%)以及心血管疾病史(13.1%),其中高血压、糖尿病患病率均高于一般人群。此外,分析所有重症患者入院初期心血管相关的实验室指标,平均C反应蛋白(CRP)水平(35.9±52.9)mg/L、D-二聚体(D-D)水平(1.65±3.73)μg/m L、脑钠肽(BNP)水平(153.1±219.5)pg/m L、高敏肌钙蛋白I(hs-TNI)水平(15.8±78.8)pg/m L、肌酸激酶同工酶(CK-MB)水平(0.8±0.9)ng/mL,其中CRP及D-D水平均高于正常值,而进展至危重症的8例NCP患者上述所有指标均高于正常值。结论 61例重症NCP患者高血压、糖尿病患病率明显高于一般人群。入院初期心血管相关临床指标中平均CRP、D-D水平均高于正常值,进展至危重症的患者中hs-TnI、BNP升高明显,尤其是hs-TnI显著升高可能与心肌损伤相关,死亡风险更高。     

Clinical Features and Outcomes of Coronavirus Disease 2019 in Patients with Inflammatory Bowel Disease and Spondyloarthropathies

Background:We aimed to determine the clinical features, predictive factors associated with severe disease, and outcomes of coronavirus disease 2019 in patients with immune-mediated inflammatory diseases and report data on the comparison of coronavirus disease 2019 between patients with inflammatory bowel disease and spondyloarthropathies.Methods:A total of 101 patients with inflammatory bowel disease and spondyloarthropathies who had confirmed diagnosis of coronavirus disease 2019 were retrospectively analyzed. Demographics, comorbidities, immunosuppressive treatments, and the impact of immunosuppression on negative outcomes were assessed.Results:The median age of the patients was 47 (38-57) years. The most common rheumatologic diagnosis was ankylosing spondylitis (n = 24), psoriatic arthritis (n = 17), and reactive arthritis (n = 1). In the inflammatory bowel disease group, 47 patients had ulcerative colitis, 11 Crohn’s disease, and 1 unclassified. The most commonly used treatments were biologics (55%) in the spondyloarthropathies group and aminosalicylates (66.1%) in the inflammatory bowel disease group. Overall, 18.8% of the patients required hospitalization, 5% developed severe complications, and 2% died. There were no significant differences in coronavirus disease 2019-related negative outcomes between spondyloarthropathies and inflammatory bowel disease patients. The median age was higher in the patients who required hospitalization [57 (46-66) vs 47 (38-57) years, P = .008]. Bilateral opacities on chest radiographs were more common in the patients who required hospitalization in the spondyloarthropathies group [88.9% vs 14.3%, P = .016]. Comorbidity was significantly associated with hospitalization in the inflammatory bowel disease group (P ≤ .05). Baseline therapy with biologics or immunosuppressives was not associated with severe coronavirus disease 2019 outcomes.Conclusion:Older age, comorbidities, and bilateral ground-glass opacities were associated with adverse outcomes, whereas specific immune-mediated inflammatory disease diagnoses or immunosuppressive treatments were not.     

Effect of the Coronavirus Disease 2019 Lockdown on Lifestyle Factors in Japanese Patients with Inflammatory Bowel Disease

Objective To examine the effect of the coronavirus disease 2019 (COVID-19) lockdown on lifestyle factors and psychological stress in patients with inflammatory bowel disease (IBD). Methods A retrospective study was conducted on patients with IBD in Japan 2 months after the initiation of the first state of emergency (June 16 to August 21, 2020). A self-reported questionnaire was used to collect data, and lifestyle factors and psychological stress levels before and after the state of emergency were compared. Patients Patients with IBD who were followed up regularly at Osaka City University Hospital from June 16 to August 21, 2020, were included and were classified into elderly (≥65 years old) and non-elderly groups (<65 years old). Results The study sample comprised 451 responders (241, ulcerative colitis; 210, Crohn''s disease; 0, COVID-19). The sleep duration increased, whereas the exercise, working, and walking durations decreased during the COVID-19 lockdown. The proportion of patients with psychological stress due to COVID-19, those with an inability to exercise, and those staying indoors increased significantly during COVID-19 lockdown. Lifestyle factors changed more markedly in non-elderly patients, those who were more stressed due to COVID-19, those with the inability to exercise, and those staying indoors during COVID-19 lockdown. Among elderly patients, no significant changes were identified in stress-causing factors. Conclusion The COVID-19 lockdown affected lifestyle factors and psychological stress in patients with IBD, particularly non-elderly patients. These findings may be helpful in suggesting favorable lifestyle changes for patients with IBD.     

Home-Based Medical Care: High-Value Health Care During Coronavirus Disease 2019 and Beyond

Ms. H is a 78-year-old woman with a history of congestive heart failure, chronic obstructive pulmonary disease, and recent stroke who was discharged 1 month ago from a subacute rehabilitation facility. She moved in with her son because she now requires a walker and cannot return to her third-floor apartment. One evening, Ms. H develops a low-grade fever and mild shortness of breath intermittently relieved by her albuterol inhaler. Her son is worried, but knows that his mom does not want to return to the hospital.     

Four Cases of Coronavirus Disease 2019 Transferred from a Cruise Ship

An outbreak of coronavirus disease 2019 (COVID-19) that began in Wuhan, China, has spread rapidly to many countries. We herein report four cases of COVID-19 confirmed in Japan among passengers of the cruise ship Diamond Princess and describe the clinical features, clinical course, and progression of chest computed tomographic images, chest radiographs, and treatment. Although these four patients had symptoms that included a fever, malaise, runny nose, and cough, one patient had no symptoms on admission. Two of the four patients needed mechanical ventilation due to respiratory deterioration. One of the patients who required mechanical ventilation was transferred to a higher-level medical institution. Except for that patient, the other three patients were able to return home under their own power. Every patient took lopinavir/ritonavir, which was considered the most effective treatment at the time. We used it after receiving approval from the ethics committee in our hospital. In this case report, we emphasize that some patients need to be carefully monitored, even if their respiratory condition is stable at the initial presentation, as their respiratory status may deteriorate rapidly within a few days after oxygen administration begins.     

新冠肺炎疫情期间胃食管反流病患者的临床诊疗管理

目前新型冠状病毒已经在短时间内蔓延至全国大部分省市且感染人数进行性增多,已正式明确有人传人的传染特点,现已被国家卫生健康委员会纳入到《中华人民共和国传染病防治法》规定的乙类传染病并采取甲类传染病的预防、控制措施。由于病毒的未知型,传染性强,暂无特效药物及长期的居家隔离等原因导致相当一部分人出现不同程度的焦虑、抑郁甚至暴躁的心理状态,这些可以引起反酸、烧心、腹胀甚至恶心、呕吐等消化道症状,并可能加重胃食管反流病（GERD）患者的症状,进一步困扰其日常生活。为有效让GERD患者顺利度过新型冠状病毒流行期,本文做一阐述,供广大临床同道借鉴。     

新型冠状病毒肺炎疫情对急性心肌梗死诊治的影响

新型冠状病毒肺炎成为世界卫生体系的严峻挑战,国内外均采取了前所未有的严格防控措施,肺炎疫情对急性心肌梗死的急诊救治流程产生了深刻的影响,国内外制定了一系列的相关文件以指导疫情期间急性心肌梗死的救治工作,本文对此进行综述。     

Anxiety,Depression, and Resilience of Healthcare Workers in Japan During the Coronavirus Disease 2019 Outbreak

Objective Coronavirus disease 2019 (COVID-19) is spreading around the world. The aim of this study was to assess the degree of anxiety, depression, resilience, and other psychiatric symptoms among healthcare workers in Japan during the COVID-19 pandemic. Methods This survey involved medical healthcare workers at the Japanese Red Cross Medical Center (Tokyo, Japan) between April 22 and May 15, 2020. The degree of symptoms of anxiety, depression, and resilience was assessed using the Japanese versions of the 7-item Generalized Anxiety Disorder Scale (GAD-7), Center for Epidemiologic Studies Depression Scale (CES-D), and 10-item Connor-Davidson Resilience Scale. Furthermore, we added original questionnaires comprising three factors: (i) anxiety and fear of infection and death; (ii) isolation and unreasonable treatment; and (iii) motivation and escape behavior at work. Results In total, 848 healthcare workers participated in this survey: 104 doctors, 461 nurses, 184 other co-medical staff, and 99 office workers. Among all participants, 85 (10.0%) developed moderate-to-severe anxiety disorder, and 237 (27.9%) developed depression. Problems with anxiety and fear of infection and death, isolation and unreasonable treatment, and motivation and escape from work were higher in the depression group than in the non-depression group (total CES-D score ≥ 16 points). Being a nurse and high total GAD-7 scores were risk factors of depression. Older workers and those with higher resilience were less likely to develop depression than others. Conclusion During the COVID-19 epidemic, many healthcare workers suffered from psychiatric symptoms. Psychological support and interventions for protecting the mental health of them are needed.     

Progress in the Clinical Features and Pathogenesis of Abnormal Liver Enzymes in Coronavirus Disease 2019

With the rapid development of research on coronavirus disease 2019 (COVID-19), more and more attention has been drawn to its damage to extrapulmonary organs. There are increasing lines of evidence showing that liver injury is closely related to the severity of COVID-19, which may have an adverse impact on the progression and prognosis of the patients. What is more, severe acute respiratory syndrome coronavirus-2 infection, cytokine storm, ischemia/hypoxia reperfusion injury, aggravation of the primary liver disease and drug-induced liver injury may all contribute to the hepatic damage in COVID-19 patients; although, the drug-induced liver injury, especially idiosyncratic drug-induced liver injury, requires further causality confirmation by the updated Roussel Uclaf Causality Assessment Method published in 2016. Up to now, there is no specific regimen for COVID-19, and COVID-19-related liver injury is mainly controlled by symptomatic and supportive treatment. Here, we review the clinical features of abnormal liver enzymes in COVID-19 and pathogenesis of COVID-19-related liver injury based on the current evidence, which may provide help for clinicians and researchers in exploring the pathogenesis and developing treatment strategies.