Mar. 19th, 2020 (摘要)：
Featuring articles on diskectomy or conservative care for sciatica, no sedation or light sedation in ventilated ICU patients, long-acting therapy to maintain HIV-1 suppression,A screening program to eliminate hepatitis C in Egypt; a review article on hereditary angioedema; A case report of a man with shortness of breath, cough, and hypoxemia; and Perspective articles on universal disease screening and treatment, on when medical care ignores social forces, on opioid prescribing in the midst of crisis, and on the dishonesty of informed consent rituals.
Dr. Stephen Morrissey《NEJM》执行主编，访谈传染病专家Dr. Eric Rubin 和Dr. Lindsey Baden，两位也《NEJM》副主编和执行编辑。最近一周医界一直在探讨关于治疗和支持治疗Covid-19感染患者，也争议药物验证方法和老药新用选择，大家似乎在谈同一件事情，又好像各持己见和观点。聆听专家评论【语音】: 新冠病毒可能疗法和最新研究 来自全球医生组织 00:00 15:37 WHO拉响全球公共卫生紧急警报快两个月了；从美国确诊第一例Covid-19患者到今天飙升至2万多人确诊，时间不到一个月时间。《新英格兰医学杂志》形象地比喻，大家都听了警报声音震天响，但谁都没当会儿，直到三周前开始抓瞎了。谈什么亡羊补牢呀！
案例报告一
案例报告简述如下(英文)，希望有关医学专家和临床医生仔细研读，从中汲取一些教训。
借此机会表述一观点：微信里一篇文章说“国内医生向美国顶级专家、政界分享抗疫经验”。提到张文宏、曹彬和彭志勇三位。
坦率讲，他们三位所说的不是经验，而是经历！甚至是仓促上阵迎战疫情的惨烈经历。
Courtney Enix, M.D., Kevin Seitz, M.D., DavidRoach, M.D., Robin Stiller, M.D.
University of Washington Department of Medicine, Harborview Medical Center
Case presentation:
A man in his 6th decade of life with no significant past medical historypresented with acute onset fever and difficulty breathing.
The patient had been in his usual state ofgood health until late 2019, when he experienced a polytraumatic injury,requiring prolonged hospitalization and ultimate discharge to a skilled nursingfacility (SNF) for ongoing rehabilitation. He had been residing at the SNFsince, and in the week leading up to admission started to develop coughproductive of sputum. On day of admission, he developed fevers and tachypneaand was brought in for evaluation.
Physical exam:
On arrival, he was found to be febrile to 40.7°, tachycardic to the 140s, andtachypneic to the low 40s requiring 15L by nonrebreather to maintain an SpO2greater than 90%. The patient was in distress and unable to speak in fullsentences. He was using his accessory ventilatory muscles; breath sounds werecoarse bilaterally. His cardiac rhythm was regular and he was warm and wellperfused.
Pertinent laboratory values:
A venous blood gas revealed a pH of 7.46 and pCO2 of 45 mmHg. Lab work wasremarkable for hypernatremia to 151 mEq/L, hypokalemia to 3.1 mEq/L, creatinineof 1 mg/dL (baseline 0.5mg/dL) and BUN of 39mg/dL. He had a leukocytosis to16K/μL with neutrophilic predominance to 82% and mild leukopenia 0.9K/μL. Hisliver function tests and lactate were normal. Influenza and RSV were negative.
Pertinent imaging:
Chest radiograph demonstrated bilateral patchy opacities but notably improvedfrom prior films in our system from months before this admission. A CTPulmonary Embolism Protocol was obtained, as well, and showed bronchial wallthickening, nodular consolidations and centrilobular nodules favored torepresent endobronchial spread of infection (image attached).
Treatment and Outcomes
Blood and urine cultures were obtained and the patient was started on empiricantibiotics with cefepime, linezolid (due to vancomycin allergy) andazithromycin. He was admitted to the medical intensive care unit (MICU) forongoing management of his respiratory failure. While in the MICU, the patientcontinued to have hypoxemia and tachypnea despite oxygen delivery by high flownasal cannula. A conversation was held with the patient’s wife and durablepower of attorney, who felt that further invasive interventions would not be inline with the patient’s goals of care and he was transitioned to comfort basedmeasures. He was transferred to the acute care medicine service and died twodays later. Post-mortem COVID-19 testing was performed and later confirmed tobe positive.
Lessons learned:
This case highlights the increased risk to individuals who reside in communalsettings, particularly those with other medical comorbidities. Vulnerablepopulations deserve close consideration of COVID-19 testing.
*This case has been reviewed by a NEJMeditor.*
案例报告二
新冠病毒疫情全球化引发了业界讨论：现有公共卫生策略能否阻挡住病毒入侵？
新冠病毒已遍布全球！各国政府以前所未有的规模实施自我隔离和旅行禁令。中国封闭武汉长达两个月之久；意大利也实施了全国限行。紧接着美国让加州整个硅谷和纽约停摆，超过7千多万美国人必须遵守紧急法案“自我隔离”至少15天。
此外，全球各国纷纷暂停国际旅行和禁止非本国国民入境。然而这样做的目的，并非是降低死亡人数，仅仅缓慢疫情爆发的曲线(curve)。
从传统流行病学和传染病学角度看，隔离和旅行禁令是对传染病的第一反应。这些传统工具和策略看来应对高度传染性疾病，似乎作用有限，如果用力过大或过度强硬，会适得其反，不但阻止不了疫情的蔓延，反而彻底拖垮了全球经济发展。
寻找治疗方案——应对Covid-19病毒感染
当自我隔离后，你认为是为了保护其他人，或者你本身就是潜在传播源？
在医院里，当你救治患者时是否意识到也在无意中传染了更多其他患者？据WHO数据统计，在武汉确诊患者中41%是在医院环境中传染播散的。
案例分享：儿童Covid-19感染病例
尽管本报告中探讨的儿童Covid-19感染患者为轻度症状，即65％的儿童患有肺炎，并且认为儿童是低危人群。难道这是一个错误或失误的判断？在评述这个案例时，甚至有人公开质疑中国的临床数据和信息。
