Hypoxia and inflammation are risk factors for acute myocardial injury in patients with coronavirus disease 2019 / 北京大学学报(医学版)

OBJECTIVE@#To investigate the risk factors for acute myocardial injury in coronavirus disease 2019 (COVID-19) patients.@*METHODS@#This is a retrospective analysis of a COVID-19 cohort, in which 149 confirmed COVID-19 patients enrolled were divided into the group of myocardial injury (19 cases) and the group of non-myocardial injury (130 cases). Myocardial injury was defined according to Fourth universal definition of myocardial infarction released by European Society of Cardiology (ESC) in 2018, that cardiac troponin (cTn) was above 99th percentile of the reference level. Clinical information and results of laboratory tests of the eligible patients were collected. Factors associated with myocardial injury in COVID-19 patients were evaluated.@*RESULTS@#Compared with the group of non-injury, the patients in the group of injury were older and had a larger proportion of severe or critical cases (P < 0.05), higher respiratory rate and lower percutaneous oxygen saturation (SpO2) without oxygen therapy on admission (P < 0.05). All inflammatory indexes except for tumor necrosis factor α (TNF-α) showed significant elevation in the patients of the group of injury (P < 0.05). Analyzed by Spearman correlation test, we showed that the levels of circulatory cTnI were in positive correlation with the levels of high-sensitivity C-reactive protein (hs-CRP), ferritin, receptor of interleukin-2 (IL-2R), interleukin-6 (IL-6) and interleukin-8 (IL-8) (ρ > 0, P < 0.05). Lower SpO2 without oxygen therapy on admission (OR: 0.860, 95%CI: 0.779-0.949, P=0.003) and higher plasma IL-6 levels (OR: 1.068, 95%CI: 1.019-1.120, P=0.006) were independent risk factors for acute myocardial injury in the patients with COVID-19 by multivariate Logistic regression analyses.@*CONCLUSION@#Hypoxic state and inflammation may play a key role in the pathogenesis of acute myocardial injury in COVID-19 patients.

Analysis of the correlation between lymphocyte subsets and severity of corona virus disease 19 / 北京大学学报(医学版)

OBJECTIVE@#To understand the differences in lymphocyte subsets in patients with different clinical classifications of corona virus disease 19 (COVID-19).@*METHODS@#Eighty-one patients with COVID-19 who were admitted to the isolation ward under the responsibility of three medical aid teams in the Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, from February 8, 2020 to March 28, 2020, were selected to collect clinical data. According to the relevant diagnostic criteria, the disease status of the patients was classified into moderate cases (n=35), severe cases (n=39) and critical cases (n=7) when lymphocyte subset testing was performed. Their blood routine tests, lymphocyte subsets and other indicators were tested to compare whether there were differences in each indicator between the patients of different clinical classification groups.@*RESULTS@#The differences in the absolute count of total lymphocytes, T-lymphocytes, CD4+T-lymphocytes, CD8+T-lymphocytes and natural killer (NK) cells among the three groups of patients were all statistically significant (P < 0.05), and the critical cases were significantly lower than the moderate and severe cases in the above indicators, and the indicators showed a decreasing trend with the severity of the disease. In 22 patients, the six indicators of the absolute count of T-lymphocytes, B-lymphocytes, CD4+T-lymphocytes, CD8+T-lymphocytes and NK cells, CD4+/CD8+ ratio were all within the normal reference range in the first test, and 59 patients had abnormalities of the above indicators, with the absolute count of NK cells and CD8+ T lymphocytes decreasing most frequently (61%, 56%). The patients with the absolute count of NK cells and CD8+ T lymphocytes below the normal reference range were one group, and the remaining abnormal patients were the other group. There were more critical cases in the former group (moderate : severe : critical cases were 4 : 8 : 7 vs. 19 : 21 : 0, respectively, P=0.001), and all the deaths were in this group (6 cases vs. 0 case, P=0.001). The absolute B lymphocyte count was below the normal reference range in 15 patients, and the remaining 64 cases were within the normal range. The ratio of moderate, severe and critical cases in the reduced group was 4 : 7 : 4, and the ratio of critical cases was more in normal group which was 30 : 31 : 3, and the difference between the two groups was statistically significant (P=0.043).@*CONCLUSION@#The more critical the clinical subtype of patients with COVID-19, the lower the absolute count of each subset of lymphocytes.

Detection and evaluation of SARS-CoV-2 nucleic acid contamination in corona virus disease 19 ward surroundings and the surface of medical staff's protective equipment / 北京大学学报(医学版)

OBJECTIVE@#To determine the environmental contamination degree of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in corona virus disease 2019 (COVID-19) wards, to offer gui-dance for the infection control and to improve safety practices for medical staff, by sampling and detecting SARS-CoV-2 nucleic acid from the air of hospital wards, the high-frequency contact surfaces in the contaminated area and the surfaces of medical staff's protective equipment in a COVID-19 designated hospital in Wuhan, China.@*METHODS@#From March 11 to March 19, 2020, we collected air samples from the clean area, the buffer room and the contaminated area respectively in the COVID-19 wards using a portable bioaerosol concentrator WA-15. And sterile premoistened swabs were used to sample the high-frequency contacted surfaces in the contaminated area and the surfaces of medical staff's protective equipment including outermost gloves, tracheotomy operator's positive pressure respiratory protective hood and isolation clothing. The SARS-CoV-2 nucleic acid of the samples were detected by real-time fluorescence quantitative PCR. During the isolation medical observation period, those medical staff who worked in the COVID-19 wards were detected for SARS-CoV-2 nucleic acid with oropharyngeal swabs, IgM and IgG antibody in the sera, and chest CT scans to confirm the infection status of COVID-19.@*RESULTS@#No SARS-CoV-2 nucleic acid was detected in the tested samples, including the 90 air samples from the COVID-19 wards including clean area, buffer room and contaminated area, the 38 high-frequency contact surfaces samples of the contaminated area and 16 surface samples of medical staff's protective equipment including outermost gloves and isolation clothing. Moreover, detection of SARS-CoV-2 nucleic acid by oropharyngeal swabs and IgM, IgG antibodies in the sera of all the health-care workers who participated in the treatment for COVID-19 were all negative. Besides, no chest CT scan images of medical staff exhibited COVID-19 lung presentations.@*CONCLUSION@#Good ventilation conditions, strict disinfection of environmental facilities in hospital wards, guidance for correct habits in patients, and strict hand hygiene during medical staff are important to reduce the formation of viral aerosols, cut down the aerosol load, and avoid cross-infection in isolation wards. In the face of infectious diseases that were not fully mastered but ma-naged as class A, it is safe for medical personnel to be equipped at a high level.

Severe acute respiratory syndrome coronavirus 2 infection in renal transplant recipients: A case report / 北京大学学报(医学版)

The novel coronavirus is a newly discovered pathogen in late December 2019, and its source is currently unknown, which can lead to asymptomatic infection, new coronavirus pneumonia or serious complications, such as acute respiratory failure. Corona virus disease 2019 (COVID-19) is a new type of respiratory disease that is currently spreading all over the world and caused by this coronavirus. Its common symptoms are highly similar to those of other viruses, such as fever, cough and dyspnea. There is currently no vaccine or treatment for COVID-19. Everyone is susceptible to infection with this disease, and owing to the long-term use of immunosuppressants, the immunity of kidney transplant recipients is suppressed, and it is more likely to be infected with the disease. At present, its impact on kidney transplant recipients is unclear. This article reports the clinical features and therapeutic course of novel coronavirus infection in a patient after renal transplantation. A 37-year-old female patient who received a kidney transplant 6 months before was diagnosed with novel coronavirus pneumonia. The patient's symptoms (such as fever, chills, dry cough, muscle aches), laboratory tests (such as decreased white blood cell count, elevated liver enzymes and D-dimer, positive viral nucleic acid test), and chest CT (multiple left lower lung plaque ground glass shadow) were similar to those of non-transplanted novel coronavirus pneumonia patients. In terms of treatment, because the immunity of kidney transplant recipients has been suppressed for a long time, it is a very common strategy to suspend the use of immunosuppressive agents. Therefore, the patient immediately discontinued the immunosuppressive agent after admission, so that she could restore immunity against infection in a short time. At the same time, the use of glucocorticoids was also very important. Its immunosuppressive and anti-inflammatory effects played a large role in the treatment process.In addition, prophylactic antibiotics was needed, and nephrotoxic drugs should be used with caution. Finally, following discounting the use of immunosuppressant and a low-dose glucocorticoid-based treatment regimen, COVID-19 in this renal transplant recipient was successfully cured. The cure of this case was of great significance, and this adjuvant nonspecific antiviral therapy could provide a template for the treatment of other such patients.

Risks factors for death among COVID-19 patients combined with hypertension, coronary heart disease or diabetes / 北京大学学报(医学版)

OBJECTIVE@#The pathogenesis of myocardial injury upon corona virus disease 2019 (COVID-19) infection remain unknown,evidence of impact on outcome is insufficient, therefore, we aim to investigate the risk factors for death among COVID-19 patients combined with hypertension, coronary heart disease or diabetes in this study.@*METHODS@#This was a single-centered, retrospective, observational study. Patients of Sino-French Eco-City section of Tongji Hospital, Wuhan, China attended by Peking University Supporting Medical Team and admitted from Jan. 29, 2020 to Mar. 20, 2020 were included. The positive nucleic acid of COVID-19 virus and combination with hypertension, coronary heart disease or diabetes were in the standard. We collected the clinical data and laboratory examination results of the eligible patients to evaluate the related factors of death.@*RESULTS@#In the study, 94 COVID-19 patients enrolled were divided into the group of death (13 cases) and the group of survivors (81 cases), the average age was 66.7 years. Compared with the survival group, the death group had faster basal heart rate(103.2 beats/min vs. 88.4 beats /min, P=0.004), shortness of breath(29.0 beats /min vs. 20.0 beats /min, P<0.001), higher neutrophil count(9.2×109/L vs. 3.8×109/L, P<0.001), lower lymphocyte count(0.5×109/L vs. 1.1×109/L, P<0.001), creatine kinase MB(CK-MB, 3.2 μg/L vs. 0.8 μg/L, P<0.001), high sensitivity cardiac troponin Ⅰ(hs-cTnⅠ, 217.2 ng/L vs. 4.9 ng/L, P<0.001), N-terminal pro brain natriuretic peptide(NT-proBNP; 945.0 μg/L vs. 154.0 μg/L, P<0.001), inflammatory factor ferritin(770.2 μg/L vs. 622.8 μg/L , P=0.050), interleukin-2 recepter(IL-2R, 1 586.0 U/mL vs. 694.0 U/mL, P<0.001), interleukin-6(IL-6, 82.3 ng/L vs. 13.0 ng/L, P<0.001), interleukin-10(IL-10, 9.8 ng/L vs. 5.0 ng/L, P<0.001)were higher than those in the survival group. Univariate logistic regression analysis showed that the risk factors for death were old age, low non oxygen saturation, low lymphocyte count, myocardial injury, abnormal increase of IL 2R, IL-6, and IL-10. Multivariate regression showed that old age (OR=1.11, 95%CI=1.03-1.19, P=0.026), low non oxygen saturation(OR=0.85, 95%CI=0.72-0.99, P=0.041), and abnormal increase of IL-10(＞9.1 ng/L, OR=101.93, 95%CI=4.74-2190.71, P=0.003)were independent risk factors for COVID-19 patients combined with hypertension, coronary heart disease or diabetes.@*CONCLUSION@#In COVID-19 patients combined with hypertension, coronary heart disease or diabetes, the risk factors for death were old age, low non oxygen saturation, low lymphocyte count, myocardial injury, and abnormal increase of IL-2R, IL-6, and IL-10. Old age, low non oxygen saturation and abnormal increase of IL-10 were independent risk factors.

Individualized vancomycin dosing for a patient diagnosed as severe acute pancreatitis with concurrent extracorporeal membrane oxygenation and continuous veno-venous hemofiltration therapy: a case report / 北京大学学报(医学版)

Pharmacokinetic parameters can be significantly altered for acute kidney injury (AKI), extracorporeal membrane oxygenation (ECMO) and continuous veno-venous hemofiltration therapy (CVVH). Here we reported a case of individualized vancomycin dosing for a patient diagnosed as severe acute pancreatitis treated with concurrent ECMO and CVVH. A 65 kg 32-year-old woman was admitted to hospital presented with severe acute pancreatitis (SAP), respiratory failure, metabotropic acidosis and hyperkalemia. She was admitted to intensive care unit (ICU) on hospital day 1 and was initiated on CVVH. She progressed to multiple organ dysfunction syndrome (MODS) and acute respiratory distress syndrome (ARDS) on ICU day 2, and veno-venous ECMO was instituted. Several catheters were inserted into the body to support ECMO, CVVH and pulse indicator continuous cardiac output (PiCCO), so vancomycin was prescribed empirically on ICU day 3 for prevention of catheter-related infection. Given the residual renal function and continuous hemofiltration intensity on day 3, vancomycin bolus of 1 000 mg was prescribed, followed by a maintenance dose of 500 mg every 8 hours. On ICU day 4, a vancomycin trough serum concentration of 14.1 mg/L was obtained before the fourth dose, which was within the target range of 10-20 mg/L. By ICU day 7, vancomycin dosage was elevated to 1.0 g every 12 hours because of aggravated infection and improved kidney function. On ICU day 14, a vancomycin trough serum concentration of 17 mg/L was obtained. Her white blood cell (WBC) and neutrophil percentage (Neut%) dropped to the normal level by ICU day 19. This vancomycin regimen was successful in providing a target attainment of trough serum concentration ranging from 10-20 mg/L quickly and in controlling infection-related symptoms and signs properly. With the help of this case report we want to call attention to the clinically significant alteration in vancomycin pharmacokinetics among critically ill patients. Individualized vancomycin dosing regimens and therapeutic drug monitoring are necessary for critically ill patients receiving CVVH and ECMO to ensure that the target serum vancomycin levels are reached to adequately treat the infection and avoid nephrotoxicity.

The WHO near miss criteria are appropriate for admission of critically ill pregnant women to intensive care units in China / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Evaluation of the severity of the pregnant women with suitable admission to the Intensive Care Unit (ICU) is very important for obstetricians. By now there are no criteria for critically ill obstetric patients admitted to the ICU. In this article, we investigated the admission criteria of critically ill patients admitted to the ICU in order to provide a referral basis of reasonable use of the ICU.</p><p><b>METHODS</b>A retrospective analysis of critically ill pregnant women admitted to the ICU in Perking University Third Hospital in China in the last 6 years (from January 2006 to December 2011) was performed, using acute physiology and chronic health evaluation II (APACHE-II), Marshall and WHO near miss criteria to assess the severity of illness of patients.</p><p><b>RESULTS</b>There were 101 critically ill pregnant patients admitted to the ICU. Among them, 25.7% women were complicated with internal or surgical diseases, and 23.8% women were patients of postpartum hemorrhage and 23.8% women were patients of pregnancy-induced hypertension. Sixty-nine cases (68.3%) were administrated with adjunct respiration with a respirator. Sixteen cases (15.8%) required 1-2 types of vasoactive drugs. Fifty-five cases (54.5%) required a hemodynamic monitoring. Seventy-three cases (72.3%) had multiple organ dysfunctions (MODS). The average duration in ICU was (7.5 ± 3.0) days. A total of 12.9%, 23.8% and 74.3% of women were diagnosed as critically ill according to the APACHE-II, Marshall and WHO near miss criteria, respectively. The rate was significantly different according to the three criteria (P < 0.01).</p><p><b>CONCLUSIONS</b>The WHO near miss criteria can correctly reflect the severity of illness of pregnant women, and the WHO near miss criteria are appropriate for admission of critically ill pregnant women to ICU in China.</p>