手足口病诊疗指南(2018年版)

手足口病(Hand foot and mouth disease, HFMD)是由肠道病毒(Enterovirus, EV)感染引起的一种儿童常见传染病,5岁以下儿童多发.手足口病是全球性疾病,我国各地全年均有发生,发病率为37.01/10万～205.06/10万,近年报告病死率在6.46/10万～51.00/10万之间.为进一步规范和加强手足口病的临床管理,降低重症手足口病病死率,有效推进手足口病诊疗工作,根据手足口病诊疗新进展制定本指南.《手足口病诊疗指南(2010版)》和《肠道病毒71型(EV71)感染重症病例临床救治专家共识》同时废止.     

中华医学会重症医学分会成立大会征文通知

为促进我国重症医学发展，全面提高重症患者诊疗救治水平，经中华医学会常务理事会议审议批准，决定成立中华医学会重症医学分会。经过1年的筹备，将于2005年4月在北京召开中华医学会重症医学分会成立大会。大会以危重症领域内基本问题及前沿性问题为重点内容，并对重症监护病房规范性建设和危重病人抢救指南进行讨论。会议将邀请国内外著名专家就本学科领域的最新进展作重要学术报告。     

本期导读

前段时间, 全国多地出现奥密克戎(Omicron)变异株所致的重症新型冠状病毒感染(COVID?19)。重症救治是我国医疗机构面临的最大挑战, 如何程序化、规范化地管理这些患者, 最大限度地降低病死率, 是每位不同专业背景的一线医务人员都要面临的问题。因此, 中华医学会呼吸病学分会危重症学组与中国医师协会呼吸病学分会危重症医学专家组共同发起并组织呼吸与危重症专家, 基于目前的循证医学证据及临床实践, 撰写了《奥密克戎变异株所致重症新型冠状病毒感染临床救治专家推荐意见》, 以期规范重症患者的临床救治。该推荐意见先行以预发表的形式于1月5日在线出版。     

救治湖南省新型甲型H1N1流感重症患儿的临床思考

新型甲型H1N1流感是以呼吸系统损害为主的新发急性感染性疾病,全球的发病人数及其危重症患者的病死率不断增加,因此,认真总结我国危重症患者救治经验十分重要.中南大学湘雅医院于2009年10月成功救治了2例具有不同基础疾病的重症患儿,其救治经验可为我国"甲型H1N1流感诊疗方案"的修订提供素材,同时对临床医生可能具有一定的指导意义.     

ICU运用损伤控制外科理论救治严重多发伤的临床研究

目的 探讨在重症监护病房(ICU)中运用损伤控制外科理论救治严重多发伤的临床效果.方法 回顾总结130例严重多发损伤患者,按救治原则分为实验组(损伤控制组)和对照组(常规组).比较两组得到确定性治疗的时间、手术时间以及病死率、救治成功率的差异.结果 严重多发伤患者在ICU经过损伤控制外科理论救治后,患者得到确定性治疗的时间和手术持续时间较对照组缩短(P＜0.05);救治后患者的病死率降低,救治成功率提高(P＜0.05).结论 由ICU主导应用损伤控制外科理论救治严重多发伤能明显缩短确定性治疗时间、手术时间,显著降低病死率,提高教治成功率;ICU主导多科协作模式对严重多发伤救治具有重要的临床指导意义.     

中国消除疟疾流行后如何加强临床医生疟疾的诊治能力

作为无疟疾认证的国家,输入性疟疾的防治现已成为我国保持消除疟疾状态的重要任务,而提高临床医生对疟疾的诊治能力,降低疟疾的病死率是其中重要一环.本文从延迟诊断、检验能力、延迟给药、抗疟疾药物使用不规范及重症疟疾综合抢救能力不足这5个导致重症疟疾病死率难以降低的原因逐一阐述,以期提高疟疾诊治水平和重症疟疾救治成功率.     

支气管堵塞并重症类鼻疽肺炎1例

<正>类鼻疽(melioidosis)缺乏特异性，以肺部感染最常见，常合并败血症，通常病情危重，不及时救治病死率较高。而伴有支气管肉芽增生堵塞的病人罕有报道，本文报道我院救治的1例支气管新生物堵塞并重症类鼻疽肺炎致败血症的诊治过程，以期提高临床医生对该病的认识及诊疗。1 临床资料病人男，71岁，退休干部，因“尿急尿频尿痛发热3 d”于 2020-08-27入住我院泌尿外科。病人于入院前3 d开始出现尿急、尿频、尿痛，无尿失禁，     

奥密克戎变异株所致重症新型冠状病毒感染临床救治专家推荐意见

近期全国多地出现奥密克戎(Omicron)变异株所致的重症新型冠状病毒感染(COVID-19)。重症救治是目前我国医疗机构面临的最大挑战, 如何程序化、规范化地管理这些患者, 最大限度地降低病死率, 是每位不同专业背景的一线医务人员都要面临的问题。因此, 中华医学会呼吸病学分会危重症学组与中国医师协会呼吸病学分会危重症医学专家组共同发起并组织呼吸与危重症专家, 基于目前的循证医学证据及临床实践, 撰写本推荐意见, 以期规范重症患者的临床救治。     

目标性救治措施救治重症手足口病的临床效果分析

目的：探讨目标性救治措施救治重症手足口病（ HFMD）患儿的临床效果。方法对2012年在该院住院的138例重症手足口病患儿（研究组）采用目标性救治。同时将该院2010年未进行目标性救治（均按国家诊疗规范救治）的152例患儿作为对照组进行回顾性对比分析。结果研究组的病情加重率低于对照组（P＜0.01）,但两组的抢救成功率和病死率比较差异无统计学意义（P均＞0.05）;研究组的症状消失时间和住院时间均短于对照组（ P＜0.05或＜0.01）;研究组的高血糖和神经系统后遗症发生率均低于对照组（ P均＜0.01）。结论目标性救治措施为重症HFMD的救治提供了系统性、可操作性的救治方案,可显著缩短临床症状消失时间和住院时间,降低高血糖和神经系统后遗症的发生率,改善预后。     

迎接新的挑战努力提高急性肾损伤的诊治水平

急性肾衰竭（ARF）是临床常见重症急性肾脏疾病。近30年来,ARF的发病率不断上升。有资料显示,随着人群的老龄化、住院患者合并症发生率升高、新的诊疗技术的应用,ARF的发病率每年递增11％。尽管ICU的救治技术和肾脏替代治疗（RRT）取得了显著进步,但ICU患者ARF的病死率仍高达50％～70％;幸存者中有13％的患者在未来的3年内进展为慢性肾衰竭。因此,提高ARF的诊治水平是临床工作中亟待解决的重要问题。[第一段]     

Clinical Update of Severe Fever with Thrombocytopenia Syndrome

Severe fever with thrombocytopenia syndrome (SFTS) is an acute febrile illness characterized by fever, leukopenia, thrombocytopenia, and gastrointestinal symptoms such as diarrhea, nausea, and vomiting resulting from infection with the SFTS virus (SFTSV). The SFTSV is transmitted to humans by tick bites, primarily from Haemaphysalis longicornis, Amblyomma testudinarium, Ixodes nipponensis, and Rhipicephalus microplus. Human-to-human transmission has also been reported. Since the first report of an SFTS patient in China, the number of patients has also been increasing. The mortality rate of patients with SFTS remains high because the disease can quickly lead to death through multiple organ failure. In particular, an average fatality rate of approximately 20% has been reported for SFTS patients, and no treatment strategy has been established. Therefore, effective antiviral agents and vaccines are required. Here, we aim to review the epidemiology, clinical manifestations, laboratory diagnosis, and various specific treatments (i.e., antiviral agents, steroids, intravenous immunoglobulin, and plasma exchange) that have been tested to help to cope with the disease.     

Loperamide Inhibits Replication of Severe Fever with Thrombocytopenia Syndrome Virus

Background: Severe fever with thrombocytopenia syndrome (SFTS) is an emerging tick-borne infectious disease caused by the SFTS virus (SFTSV). SFTS is mainly prevalent in East Asia. It has a mortality rate of up to 30%, and there is no approved treatment against the disease. In this study, we evaluated the effect of loperamide, an antidiarrheal and antihyperalgesic agent, on the propagation of SFTSV in a cell culture system. Methods: SFTSV-infected human cell lines were exposed to loperamide, and viral titers were evaluated. To clarify the mode of action of loperamide, several chemical compounds having shared targets with loperamide were used. Calcium imaging was also performed to understand whether loperamide treatment affected calcium influx. Results: Loperamide inhibited SFTSV propagation in several cell lines. It inhibited SFTSV in the post-entry step and restricted calcium influx into the cell. Furthermore, nifedipine, a calcium channel inhibitor, also blocked post-entry step of SFTSV infection. Conclusions: Loperamide inhibits SFTSV propagation mainly by restraining calcium influx into the cytoplasm. This indicates that loperamide, a Food and Drug Administration (FDA)-approved drug, has the potential for being used as a treatment option against SFTS.     

Viral and Immunologic Factors Associated with Fatal Outcome of Patients with Severe Fever with Thrombocytopenia Syndrome in Korea

Significant progress has been made on the molecular biology of the severe fever with thrombopenia virus (SFTSV); however, many parts of the pathophysiological mechanisms of mortality in SFTS remain unclear. In this study, we investigated virologic and immunologic factors for fatal outcomes of patients with SFTS. We prospectively enrolled SFTS patients admitted from July 2015 to October 2020. Plasma samples were subjected to SFTSV RNA RT-PCR, multiplex microbead immunoassay for 17 cytokines, and IFA assay. A total of 44 SFTS patients were enrolled, including 37 (84.1%) survivors and 7 (15.9%) non-survivors. Non-survivors had a 2.5 times higher plasma SFTSV load than survivors at admission (p < 0.001), and the viral load in non-survivors increased progressively during hospitalization. In addition, non-survivors did not develop adequate anti-SFTSV IgG, whereas survivors exhibited anti-SFTSV IgG during hospitalization. IFN-α, IL-10, IP-10, IFN-γ, IL-6, IL-8, MCP-1, MIP-1α, and G-CSF were significantly elevated in non-survivors compared to survivors and did not revert to normal ranges during hospitalization (p < 0.05). Severe signs of inflammation such as a high plasma concentration of IFN-α, IL-10, IP-10, IFN-γ, IL-6, IL-8, MCP-1, MIP-1α, and G-CSF, poor viral control, and inadequate antibody response during the disease course were associated with mortality in SFTS patients.     

Vaccine Development for Severe Fever with Thrombocytopenia Syndrome

Severe fever with thrombocytopenia syndrome (SFTS), which is caused by SFTS virus (SFTSV), is a tick-borne emerging zoonosis with a high case-fatality rate. At present, there is no approved SFTS vaccine, although the development of a vaccine would be one of the best strategies for preventing SFTS. This article focused on studies aimed at establishing small animal models of SFTS that are indispensable for evaluating vaccine candidates, developing these vaccine candidates, and establishing more practical animal models for evaluation. Innate immune-deficient mouse models, a hamster model, an immunocompetent ferret model and a cat model have been developed for SFTS. Several vaccine candidates for SFTS have been developed, and their efficacy has been confirmed using these animal models. The candidates consist of live-attenuated virus-based, viral vector-based, or DNA-based vaccines. SFTS vaccines are expected to be used for humans and companion dogs and cats. Hence for practical use, the vaccine candidates should be evaluated for efficacy using not only nonhuman primates but also dogs and cats. There is no practical nonhuman primate model of SFTS; however, the cat model is available to evaluate the efficacy of these candidate SFTS vaccines on domesticated animals.     

Clinical progress and risk factors for death in severe Fever with thrombocytopenia syndrome patients

Background.?Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease caused by the SFTS virus (SFTSV) with an average fatality rate of 12%. The clinical factors for death in SFTS patients remain unclear. Methods.?Clinical features and laboratory parameters were dynamically collected for 11 fatal and 48 non-fatal SFTS cases. Univariate logistic regression was used to evaluate the risk factors associated with death. Results.?Dynamic tracking of laboratory parameters revealed that during the initial fever stage, the viral load was comparable for the patients who survived as well as the ones that died. Then in the second stage when multi-organ dysfunction occurred, from 7-13 days after disease onset, the viral load decreased in survivors but it remained high in the patients that died. The key risk factors that contributed to patient death were elevated serum aspartate aminotransferase, lactate dehydrogenase, creatine kinase, and creatine kinase fraction, as well as the appearance of CNS (central nervous system) symptoms, hemorrhagic manifestation, disseminated intravascular coagulation, and multi-organ failure. All clinical markers reverted to normal in the convalescent stage for SFTS patients who survived. Conclusions.?We identified a period of 7-13 days after the onset of illness as the critical stage in SFTS progression. A sustained serum viral load may indicate that disease conditions will worsen and lead to death.     

发热伴血小板减少综合征多脏器损伤的临床研究

目的探讨发热伴血小板减少综合征(severe fever with thrombocytopenia syndrome,SFTS)多脏器损伤的特点及发生规律。方法收集68例SFTS的临床和实验室资料,对肝脏、心脏、血液系统、肾脏、脑等脏器损伤的症状和体征、生化指标进行动态分析。结果肝损伤发生率为97.06%(66/68)。早期、极期和恢复期ALT四分位数分别为76.6(44.1,126.0)、131.1(73.0,219.5)、120.6(74.3,199.0)U/L,AST四分位数分别为164.6(92.3,283.6)、249.5(107.5,426.0)、101.3(49.0,188.0)U/L。心肌酶变化以LDH和α-羟丁酸脱氢酶(α-HBDH)升高为主,早期、极期和恢复期LDH四分位数分别为677.5(389.0,1 412.5)、922.0(618.0,1 804.5)、470.0(306.0,733.0)U/L,α-HBDH四分位数分别为398.5(196.3,662.3)、584.0(372.5,895.0)、317.0(226.0,478.0)U/L,肌酸激酶同工酶基本正常。WBC降低、PLT减少发生率分别为67.65%和100%。早期、极期和恢复期WBC四分位数分别为2.56(1.00,6.40)、3.14(1.93,7.16)、4.22(3.11,6.34)×10~9/L,PLT四分位数分别为40.7(23.3,53.3)、40.0(25.2,51.3)、123.0(58.0,218.8)×10~9/L。27例尿潜血阳性,45例尿蛋白阳性,但肾功能指标肌酐和尿素氮无明显异常。11例意识状态改变,5例病理反射阳性。4例(5.88%)死亡,均死于多脏器功能衰竭。结论肝脏、心脏、肾脏、血液等器官系统损伤是SFTS的重要临床特征,在该病早期即出现损伤并持续加重,极期损伤最重,多数患者可逐渐恢复正常,少数患者可死于多脏器功能衰竭。     

发热伴血小板减少综合征流行病学研究进展

发热伴血小板减少综合征（Severe fever with thrombocytopenia syndrome,SFTS）是近几年来新发现的一种以发热伴血小板减少为主要临床表现的传染性疾病,新布尼亚病毒是引起该病的病原体.蜱叮咬是主要的传播途径,可通过人-人接触传播.该病发病急,病情进展快,部分患者可因多脏器功能衰竭而死亡,病死率约10％.本文对该病病原学、病例分布特点及其传染源、传播途径和易感人群三个流行环节方面的最新研究进展作一综述.     

Acute pancreatitis in patients with severe fever with thrombocytopenia syndrome virus infection

BackgroundSevere fever with thrombocytopenia syndrome (SFTS), a novel tick-borne disease caused by SFTS virus (SFTSV), has been reported in China, Japan, South Korea, and Vietnam since 2009. SFTSV infection can cause multiple organ damage, including acute pancreatitis (AP). We summarize the clinical features, treatment and outcome of AP associated with SFTSV.MethodsWe retrospectively review the clinical manifestations, laboratory tests, treatment, and outcome of AP associated with SFTSV infection from January 2009 to December 2018 in Liaoning Province, China.ResultsA total of 418 SFTS patients were reviewed. Fifteen (3.6%) of 418 met the criteria for AP associated with SFTSV infection. The first reported symptom for all SFTS-AP patients was fever. All the SFTS-AP patients presented with thrombocytopenia, and 13 (86.7%) of them presented with leukopenia on admission. Thirteen (86.7%) of 15 SFTS-AP patients were severe SFTS patients, and 9 (60.0%) patients were diagnosed with multiple organ dysfunction syndrome. One SFTS-AP patient died of multiple organ failure. Six (40%) of 15 SFTS-AP patients were not confirmed with SFTSV infection when AP was diagnosed, and the median delay between SFTSV infection and AP diagnosis was 5 days (range, 2–7 days).ConclusionsAP is not a frequent complication of SFTS, and is more frequently seen in severe SFTS patients. Most patients with SFTS-AP have mild or moderate disease, and can recover with conservative management; however, severe SFTS-AP can be fatal. In SFTS endemic areas, clinicians should be alert to the possibility of SFTS when AP patients with tick exposure, thrombocytopenia, and leukopenia have a fever before abdominal pain.     

2014年浙江省发热伴血小板减少综合征流行特征分析

目的分析浙江省2014年发热伴血小板减少综合征(SFTS)流行病学特征。方法收集2014年浙江省SFTS病例资料,建立数据库并分析。结果2014年浙江省SFTS确诊病例57例,死亡10例,病死率为17.54%。病例呈现出5月和8月两个高峰期;平均年龄为(58.75±16.30)岁,不同年龄组人群病死率不同(χ²=10.148,P=0.008,P=0.05);农民占89.29%。病例发病前2周内53.85%的病例有户外活动史,多从事种地、割草、采茶等活动,29.09%有明确蜱暴露史,54.90%家里饲养动物,51.06%有老鼠暴露史。大部分病例有发热、疲劳、畏寒、肌痛等非特异性症状,且均伴有血小板和白细胞进行性下降;存活和死亡病例间牙龈出血症状不同(χ²=4.114,P=0.043,P=0.05)。存活组从发病到确诊时间间隔平均5.5 d,死亡组7.5 d,病例从确诊到死亡平均3.5 d,其中有2人是死亡后才被确诊。结论浙江省发热伴血小板减少综合征发病具有一定的地域性和季节性,中老年农民高发,户外活动做好个人防护及早诊断、早治疗对该病的预防控制有重要意义。