Contribution of Traditional Chinese Medicine Combined with Conventional Medicine Treatment for a Long-Term Survivor of Heart Transplant with Severe COVID-19： A Case Report / 中医杂志

We report a case of a long-term survivor of heart transplant who developed severe COVID-19 and was treated with a traditional Chinese medicine combined with conventional medicine. Throughout the treatment， the patient received active conventional medical treatment， and traditional Chinese medicine interventions included tonifying qi， invigorating the spleen and transforming phlegm， promoting yang and eliminating stagnation， resolving dampness and dissipating phlegm， and promoting blood circulation and eliminating stasis. The main therapeutic principles adopted were to recuperating depleted yang and rescuing the patient from collapse and to resolve phlegm and promote water. Pogezilong Xuanbai Chengqi Decoction （破格子龙宣白承气汤） with modifications was administered. In summary， it is crucial to the timely adjust the immunosuppressive regimen， combine use of various anti-infective agents with a focus on COVID-19， to protect of cardiac and renal function， and to integrate traditional Chinese medicine in the entire treatment process. As this case is rare， the diagnostic and therapeutic methods in traditional Chinese medicine， the use of immunosuppressive agents， and follow-up monitoring strategies can be a valuable reference.

Characteristics of myocardial injury in severe and critical coronavirus disease 2019 patients and its effect on prognosis / 第二军医大学学报

Objective To analyze the characteristics and related risk factors of myocardial injury in severe and critical coronavirus disease 2019 (COVID-19) patients and their relationship with the prognosis. Methods The clinical data of severe and critical COVID-19 patients treated in General Hospital of Central Theater Command of PLA from Jan. 2020 to Mar. 2020 were collected. The patients were divided into non-myocardial injury group and myocardial injury group. The baseline data, clinical characteristics, auxiliary examination, treatment and prognosis were compared between the two groups, and the risk factors of myocardial injury and the effect on the prognosis of the severe and critical COVID-19 patients were analyzed. Results A total of 56 patients were included, with 22 in the non-myocardial injury group and 34 in the myocardial injury group. Patients were mostly male in both groups, and there was no significant difference in gender composition between the two groups (P>0.05). Compared with the non-myocardial injury group, the age of onset was significantly higher in the myocardial injury group (78.5[ 70.8, 89.0] years vs 56.5[ 50.3, 68.3] years, P0.05). For the CT findings of the lungs, the proportion of patients having patch-like/plaque-like shadows and ground-glass opacities was significantly greater in the non-myocardial injury group versus the myocardial injury group (72.7%[ 16/22] vs 38.2%[ 13/34], χ2=6.364, P0.05). Compared with the non-myocardial injury group, the levels of N-terminal pro-B-type natriuretic peptide, D-dimer, procalcitonin and IL-6 were significantly higher in the myocardial injury group (4 939.5[ 1 817.0, 9 450.3] pg/mL vs 612.5[ 301.0, 1 029.5] pg/mL, 4 386.5 [2 309.5, 9 635.3] ng/mL vs 850.5 [343.5, 2 333.8] ng/mL, 0.46 [0.23, 3.79] ng/mL vs 0.18 [0.13, 0.39] ng/mL, and 138.6 [41.9, 464.8] pg/mL vs 65.1[ 34.7, 99.3] pg/mL, respectively), and the differences were significant (all P0.05). The mortality rate was significantly higher in the myocardial injury than that in the non-myocardial injury group (58.8% [20/34] vs 9.1% [2/22], P<0.01). Patients who received tracheal intubation, extracorporeal membrane oxygenation, continuous renal replacement therapy (CRRT) and other invasive life support measures were all in the myocardial injury group. Conclusion Older age, male gender, coronary heart disease and (or) cardiac insufficiency, and elevated D-dimer, procalcitonin and IL-6 are the risk factors of myocardial injury in severe and critical COVID-19 patients. Myocardial injury can aggravate the condition and some patients need invasive circulating breathing support, with poor prognosis and high mortality. Therefore, the above indicators need to be observed more closely and dynamically and active treatment should be given according to related factors.

Clinical characteristics and chest computed tomography findings of severe and critical coronavirus disease 2019 in Shanghai, China / 第二军医大学学报

Objective To sum up the clinical characteristics and chest computed tomography (CT) findings of severe and critical coronavirus disease 2019 (COVID-19) patients, and to explore the factors affecting the outcomes, so as to provide experience for the clinical diagnosis and treatment of severe and critical COVID-19. Methods The data of 25 severe and critical COVID-19 patients, who were treated in our hospital from Jan. 23, 2020 to Mar. 5, 2020, were collected. The clinical characteristics were retrospectively analyzed, and the clinical and laboratory indexes were compared between cured patients and uncured patients. The laboratory indicators of cured patients were further compared between the progressive and recovery stages. The chest CT findings of the patients were observed, and the lesion volume was quantified to assess the evolution of lung lesions using the CT image-based intelligent pneumonia lesion quantitative analysis software. Results There were 19 male and six female COVID-19 patients, and there were three deaths. The median age of 25 patients was 65 (63, 75) years old, and the body mass index (BMI) was 25.60 (23.51, 28.65) kg/m2. Twenty-two patients had a clear epidemiological history. Fever (22 cases) and cough (14 cases) were the most common first symptoms, and 18 patients had underlying diseases. Twelve patients were cured and discharged (median hospital stay was 25.5 d), and 13 patients were not cured, including three deaths and 10 cases with hospital stay>25 d with no remission. Compared with the uncured patients, the cured patients had significantly lower BMI, longer time from onset to progression to severe or critical illness, and higher CD4+T lymphocyte counts (all P<0.05). Multivariate logistic regression analysis showed that high CD4+T lymphocyte count was an independent protective factor for the cure and discharge of severe and critical COVID-19 patients (P=0.031). Compared with those in the progressive stage, the lymphocyte count and CD4+T lymphocyte count of 12 cured patients were significantly higher in the progression stage, and the C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR) and procalcitonin level were significantly lower (all P<0.01). Twenty-one patients received chest CT examination in the progressive stage; and all of them had multiple ground-glass opacities and consolidation shadows of the multiple-lobe lateral band and the dorsal side of bilateral lungs, 20 cases had pleural thickening, 9 cases had a small amount of bilateral pleural effusion, and 8 cases had mediastinal lymphadenopathy. The 12 cured patients received CT examination during the recovery period, and their lesions were all improved to different extents; some patients had irregular fiber grid shadows and stripe shadows; and the pleural thickening and pleural effusion were reduced to different extents. The quantitative analysis curves showed that lesion volume in the 12 cured patients obviously increased in the progressive stage and reduced in the absorption stage, showing an inverted V shape; and lesion volume in the uncured patients (nine cases received CT examination for two or more times) showed a rapid increase in the progressive stage. Conclusion Most severe and critical COVID-19 patients in Shanghai are older, with higher BMI and underlying diseases. Low BMI, slow disease progression, and high CD4+T lymphocyte count are beneficial to the improvement of COVID-19. The main findings of chest CT include multiple ground-glass opacities and consolidation shadows, mainly distributing in the lateral band and the dorsal side of lungs and mostly involving the pleura. The laboratory indexes, including the lymphocyte, CRP, CD4+T lymphocyte, ESR and procalcitonin, and chest CT examination play an important role in the diagnosis, disease monitoring and prognosis assessment of COVID-19

Clinical manifestation and management of acute cholangitis severe type with different types of obstruction / 中华消化外科杂志

Objective To investigate the clinical manifestation and management of acute cholangitis severe type (ACST) with different typos of obstruction. Methods From January 1997 to December 2006, 164 consecutive patients with ACST had been admitted to Chengdu First People's Hospital. All patients were divided into extrahepatic type group (n=122), intrahepatic type group (n=18) and mixed type group (n=24) accord-ing to the types of obstruction. Clinical manifestation and therapeutic outcome of the 3 groups were analyzed using chi-square test, continuity correction test or Fisher exact test. Results There was no significant difference in clinical manifestation between patients with extrahepatic type and those with mixed type (P>0.05). The incidence of jaundice and abdominal pain in patients with intrahepatic type is significantly lower than those with extrahepatic type (P<0.05). The incidences of distention in consciousness and response to initial medical treat-ment were higher than those with extrahepatic type (P<0.05). The total mortality rate was 9.8% (16/164). Of all patients, 123 received open surgery. There was no significant difference in morbidity and mortality in patients with intrahepatic type and mixed type (χ~2=0.172,0.789; 1.769, 1.948, P>0.05). In emergency operation, the incidence of biliary high pressure and postoperative vital sign improvement rates were significant higher in patients with extrahepatic type than the other 2 types (P<0.05). The morbidity and mortality of patients who received emergency operation were higher than non-emergency operation (P<0.05). Conclusions The clinical manifestation of ACST is different between intrahepatic obstructive type and the other 2 types. There is no signi-ficant difference in morbidity and mortality among the 3 types of obstruction. The morbidity and mortality are high in patients who received emergency operation. Proper management of surgical timing is helpful in decreasing the morbidity and motality of ACST.

Timing of endoscopic treatment for acute cholangitis of severe type accompanying multiple organ dysfunction syndrome / 中国微创外科杂志

Objective To investigate the timing of endoscopic treatment for acute cholangitis of severe type(ACST) accompanying multiple organ dysfunction syndrome(MODS).Methods On the basis of routine medical measures,such as oxygen inhalation and antishock treatment,9 patients with ACST accompanying MODS were given endoscopic retrograde cholangiopancreatography(ERCP) with endoscopic sphincterotomy(EST),or endoscopic nasobiliary drainage(ENBD) after needle electrode fenestration and stone removal with basket,or endoscopic retrograde biliary drainage(ERBD) with internal stent.Results The endoscopic treatment was successfully accomplished within 35 min in all the 9 patients.Seven patients at stage 1~2 of MODS rehabilitated at 1~2 weeks after treatment,while 2 patients at stage 3 of MODS died in 2 weeks.Conclusions Endoscopic treatment should be applied to patients with ACST at stage 1~2 of MODS as early as possible.For patients with ACST at stage 3~4 of MODS,however,emphasis should be laid on the prevention of organ failure and the reversion of organ functions.

Discussion of the Operative Timing and Cause of Death in the Patients with Acute Cholangitis of Severe Type / 中国医师杂志

Objective To explore the operative timing and cause of death in the patients with acute cholangitis of severe type(ACST). Methods The clinical data on the treatment and the prognosis of 116 patients with ACST were analyzed retrospectively. Results 10 cases died during perioperative period.The patients who received operation within 6 hours after toxic shock all survived.Of 8 cases who received operation after 24 hours,7cases died from toxic shock and multiple organ deficiency of function (MODF) within 4 days of post-operation. Conclusion Operation should be performed before toxic shock or mental symptom occurred in the patients with ACST. The earlier the operation was performed, and the better the prognosis was. The main causes of death were delayed operative time,severe complications and senility.

Comparison between operation through laparotomy and the endoscope for senile and high risk patients with severe acute cholangitis (report of 84 cases) / 解放军医学杂志

objective To evaluate endoscopic surgery for high risk patients over 70 years old with severe acute cholangitis. Methods From October 1991 to October 2003, 84 high risk patients over 70 years old suffering from severe acute cholangitis were included and divided into laparotomy surgery (ST) and endoscopic surgery (ET) group. Results 80 patients were cured. The care rate was 81.2% in ST group and 91.6% in ET group. The mortality rate was lower in ET compared with ST (9.1% vs 18.8%). The rate of complication was reduced from 37.5% in ST group to 13.9% in ET group. The average duration of drainage was reduced from 49.4 days in ST group to 18.6 days in ET group. The total treatment days were shortened from 46.2 days to 22.8 days comparing ST with ET. Conclusions Endoscopic surgery should be the first choice for the senile and high risk patients with severe acute cholangitis. Endoscopic surgery was convenient, with mininal injury, safe and effective, and period of treatment was shortened, especially for elderly or critically ill patients, as well as those with MODS or previous billiary operations.