MedNexus
2020年 · 第06卷第02期
MedNexus
自2019年12月发现首例感染新型冠状病毒（新型冠状病毒）的患者以来，截至2020年4月17日，2019冠状病毒病（新冠肺炎）的累计确诊病例已超过210万例，并导致全球超过14万人死亡。疫情的发展可以分为两个阶段。第一阶段从2019年12月开始，到2020年2月结束，主要涉及抗击疫情的中国大陆。第二阶段，从2020年2月至今，涉及中国以外的国家，这些国家已成为病毒的主要战场，而中国大陆的疫情已基本得到遏制。回顾过去的经验和教训表明，早在2020年1月23日发布的《中国新型冠状病毒肺炎（COVID-19）诊疗指南》第一版试行版在很大程度上归功于中国政府的迅速反应和国家卫生健康委员会经验丰富的专家的聚集，在规范全国的诊断和治疗方面发挥了至关重要的作用。在一个多月的时间里，指南又发布了6个版本，纳入了最新的临床反馈和研究进展，其中最近的是第7版。
As a highly infectious respiratory tract disease, coronavirus disease 2019 (COVID-19) can cause respiratory, physical, and psychological dysfunction in patients. Therefore, pulmonary rehabilitation is crucial for both admitted and discharged patients of COVID-19. In this study, based on the newly released pulmonary rehabilitation guidelines for patients with COVID-19, as well as evidence from the pulmonary rehabilitation of patients with severe acute respiratory syndrome, we investigated pulmonary rehabilitation for patients with COVID-19 having complications, such as chronic pulmonary disease, and established an intelligent respiratory rehabilitation model for these patients.
Since December 2019, increasing attention has been paid to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic in Wuhan, China. SARS-CoV-2 primarily invades the respiratory tract and lungs, leading to pneumonia and other systemic disorders. The effect of SARS-CoV-2 in transplant recipients has raised significant concerns, especially because there is a large population of transplant recipients in China. Based on the current epidemic situation, this study reviewed publications on this virus and coronavirus disease 2019 (COVID-19), analyzed common features of respiratory viral pneumonias, and presented the currently reported clinical characteristics of COVID-19 in transplant recipients to improve strategies regarding the diagnosis and treatment of COVID-19 in this special population.
Coronavirus disease 2019 is a major threat to public health globally. Though its pathogenesis has not been fully elucidated, angiotensin-converting enzyme 2 (ACE2) has been recently identified as a receptor for the entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) into the cell. Here, we aimed to clarify the potential role of ACE2 in SARS-CoV-2-induced acute lung injury and its underlying mechanism. As a receptor for coronavirus, ACE2 mediates the entry of SARS-CoV-2 into cells in a similar way as for severe acute respiratory syndrome coronavirus (SARS-CoV). The high binding affinity of SARS-CoV-2 to ACE2 correlates with its efficient spread among humans. On the other hand, ACE2 negatively regulates the renin-angiotensin-aldosterone system (RAAS) primarily by converting angiotensin II to angiotensin 1-7, which exerts a beneficial effect on coronavirus-induced acute lung injury. Human recombinant ACE2 has been considered as a potential therapy for SARS-CoV-2 by blocking virus entry and redressing the imbalance of RAAS in SARS-CoV-2 infection. The level of ACE2 expression can be upregulated by treatment with an ACE inhibitor (ACEI) or angiotensin II type 1 receptor blocker (ARB). To date, no evidence shows that ACEIs or ARBs increase the susceptibility and mortality of patients infected with SARS-CoV-2, and hence, it is not advisable to discontinue such drugs in patients with cardiovascular disease.
Coronavirus disease (COVID-19) was first diagnosed in Wuhan in December 2019. The World Health Organization defined the subsequent outbreak of COVID-19 worldwide as a public health emergency of international concern. Epidemiological data indicate that at least 20% of COVID-19 patients have severe disease. In addition to impairment of the respiratory system, acute kidney injury (AKI) is a major complication. Immune damage mediated by cytokine storms and concomitant AKI is a key factor for poor prognosis. Based on previous experience of blood purification for patients with severe acute respiratory syndrome and Middle East respiratory syndrome combined with clinical front-line practice, we developed a blood purification protocol for patients with severe COVID-19. This protocol is divided into four major steps. The first step is to assess whether patients with severe COVID-19 require blood purification. The second step is to prescribe a blood purification treatment for patients with COVID-19. The third step is to monitor and adjust parameters of blood purification. The fourth step is to evaluate the timing of discontinuation of blood purification. It is expected that blood purification will play a key role in effectively reducing the mortality of patients with severe COVID-19 through the standardized implementation of the present protocol.
The World Health Organization characterized coronavirus disease (COVID-19) as a pandemic on March 11, 2020. Peritoneal dialysis patients have a weakened immune system that is associated with a high morbidity of infection. Thus, COVID-19 prevention measures and management for patients on peritoneal dialysis are urgent and critical. Based on published research on COVID-19 and previous clinical practices for similar coronavirus outbreaks, we aimed to make recommendations to manage patients undergoing peritoneal dialysis.
COVID-19 has become a pandemic and it has already spread to at least 171 countries/regions. Chronic kidney disease (CKD) is a global public health problem with a total of approximately 850 million patients with CKD worldwide and 119.5 million in China. Severe COVID-19 infection may damage the kidney and cause acute tubular necrosis, leading to proteinuria, hematuria and elevated serum creatinine. Since the SARS-CoV-2 enters the cells by binding to the angiotensin-converting enzyme 2 receptor, some doctors question its ability to increase the risk and severity of developing COVID-19. Neither clinical data nor basic scientific evidence supports this assumption. Therefore, patients who take angiotensin-converting enzyme inhibitor or angiotensin receptor blocker are not advised to change their therapy. Patients with CKD are generally the elderly population suffering from multiple comorbidities. Moreover, some patients with CKD might need to take glucocorticoids and immunosuppressants. Dialysis patients are recurrently exposed to a possible contaminated environment because their routine treatment usually requires three dialysis sessions per week. Considering all the above reasons, patients with CKD are more vulnerable to COVID-19 than the general population. The development of COVID-19 may worsen the impaired kidney function and further lead to rapid deterioration of kidney function and even death. Strict comprehensive protocols should be followed to prevent the spread of COVID-19 among patients with CKD. In this review, we provide some practical management recommendations for health care providers, patients with CKD, dialysis patients and dialysis facilities.
The incidence of idiopathic membranous nephropathy (IMN) has recently increased remarkably. Immune dysfunction caused by disordered intestinal flora might be an important factor affecting IMN. The Jian Pi Qu Shi Formula (JPQSF) shows promise in treating IMN. Here, we sequenced 16S rRNA genes to compare intestinal flora between patients with IMN and healthy persons. We also conducted a randomized controlled clinical trial to further compare the intestinal flora of patients with IMN treated with traditional Chinese medicine (TCM) and western medicine (WM).
Among 40 patients with IMN treated at Department of Nephrology in Xiyuan Hospital, Chinese Academy of Traditional Chinese Medicine between July 2016 and December 2018, we compared 30 of them with 10 healthy persons (controls). The IMN group was randomly assigned to receive JPQSF (TCM) or immunosuppressant WM therapy in (n = 15 per group) for 6 months. Intestinal microbiota diversity was analyzed using alpha diversity and beta diversity. Intestinal flora that significantly differed between the groups was analyzed using MetaStat. The effects and safety of the therapies were determined based on the values for plasma albumin, 24-h urine protein excretion, serum creatinine, urea nitrogen, estimate glomerular filtration rate (eGFR), complete blood count, and liver enzymes. All data were statistically analyzed using Statistical Package for the Social Sciences (SPSS) 20.0 statistical software.
Baseline characteristics did not significantly differ between the IMN and healthy groups, or the TCM and WM groups. After six months of treatment, 24-h urinary protein significantly declined in the TCM and WM groups (before and after treatment: 3.24 ± 1.74 vs. 1.73 ± 1.85 g, P < 0.05 and 3.94 ± 1.05 vs. 1.91 ± 1.18 g, P < 0.05, respectively). Plasma albumin was significantly increased in the TCM group (before vs. after treatment: 32.44 ± 9.04 vs. 39.99 ± 7.03 g/L, P < 0.05), but did not significantly change in the WM group (31.55 ± 4.23 vs. 34.83 ± 9.14 g/L, P > 0.05). Values for urea nitrogen, serum creatinine, and eGFR did not significantly change in either group. The alpha diversity index for intestinal flora differed between the IMN and healthy groups, and the TCM and WM groups. Comparisons of multiple samples (beta diversity) revealed differences in intestinal flora between the IMN and healthy groups, and the TCM and WM groups. The Metastat analysis findings showed that the main genera that differed between the IMN group before treatment and the healthy group were Christensenellaceae_R-7_group, Bifidobacterium (77), Dorea, Escherichia-Shigella, Parabacteroides, Bifidobacterium, and Coprococcus_3. After TCM therapy, the main differential genera were Butyricimonas, Bacteroides, Alistipes, and Lachnospira, and after WM therapy, these were Ruminococcus_2, Lachnospiraceae_ND3007_group, Lachnospira, Bifidobacterium, Alistipes, and [Eubacterium]_ventriosum_group.
Patients with IMN might have disordered intestinal flora, and JPQSF can regulate intestinal flora in patients with IMN.
Clinical practice guidelines can improve healthcare processes and patient outcomes; however, the quality of these guidelines varies greatly in China. The aim of this study was to construct a comprehensive instrument for the appraisal of clinical practice guidelines in China (AGREE-CHINA), and to validate its reliability as a tool for helping potential guideline users in assessing guideline quality.
First, an interdisciplinary working group was established for developing the methods. They also created a checklist as a tool according to the Appraisal of Guidelines, Research and Evaluation II (AGREE II) standards, considering the particularity of Chinese clinical practice. Next, the first draft of AGREE-China was developed by vote, modification, preliminary trial, and cross-verification. To ensure the objectivity, credibility, and reproducibility of the draft assessment, all of the checklists and standards were cross-reviewed fairly widely. Finally, AGREE-CHINA and AGREE II were used to assess the Chinese guidelines published in the past five years, and the results were compared.
The presented AGREE-CHINA covered five main checkpoints (science and rigor, effectiveness and safety, economy, usability and feasibility, and conflicts of interest) with each point divided into several more specific checkpoints. Definitions and rationales for each main checkpoint appear in the Appendix. The quality ratings based on the total scores of AGREE-China and AGREE II were consistent (r = 0.508, P = 0.020). Compared with AGREE II, the study showed a higher level of interrater-reliability for AGREE-CHINA overall (ICC = 0.957, P < 0.001). The mean time required for AGREE-CHINA was less than that for AGREE II; this was approximately 30 minutes for every assessment. User satisfaction was generally high.
This paper has presented the first edition of the AGREE-CHINA appraisal tool for clinical guidelines. It is quick and easy to use; it assesses and performs well in comparison to AGREE II. This first version of AGREE-CHINA will require further development and validation.
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