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》執行主編，訪談傳染病專家Dr. Eric Rubin 和Dr. Lindsey Baden，兩位也《NEJM》副主編和執行編輯。最近一周醫界一直在探討關於治療和支持治療Covid-19感染患者，也爭議藥物驗證方法和老藥新用選擇，大家似乎在談同一件事情，又好像各持己見和觀點。聆聽專家評論【語音】:WHO拉響全球公共衛生緊急警報快兩個月了；從美國確診第一例Covid-19患者到今天飆升至2萬多人確診，時間不到一個月時間。《新英格蘭醫學雜誌》形象地比喻，大家都聽了警報聲音震天響，但誰都沒當會兒，直到三周前開始抓瞎了。談什麼亡羊補牢呀！案例報告一
案例報告簡述如下(英文)，希望有關醫學專家和臨床醫生仔細研讀，從中汲取一些教訓。
藉此機會表述一觀點：微信裡一篇文章說「國內醫生向美國頂級專家、政界分享抗疫經驗」。提到張文宏、曹彬和彭志勇三位。
坦率講，他們三位所說的不是經驗，而是經歷！甚至是倉促上陣迎戰疫情的慘烈經歷。
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.*
案例報告二
新冠病毒疫情全球化引發了業界討論：現有公共衛生策略能否阻擋住病毒入侵？
新冠病毒已遍布全球！各國政府以前所未有的規模實施自我隔離和旅行禁令。中國封閉武漢長達兩個月之久；義大利也實施了全國限行。緊接著美國讓加州整個矽谷和紐約停擺，超過7千多萬美國人必須遵守緊急法案「自我隔離」至少15天。
此外，全球各國紛紛暫停國際旅行和禁止非本國國民入境。然而這樣做的目的，並非是降低死亡人數，僅僅緩慢疫情爆發的曲線(curve)。
從傳統流行病學和傳染病學角度看，隔離和旅行禁令是對傳染病的第一反應。這些傳統工具和策略看來應對高度傳染性疾病，似乎作用有限，如果用力過大或過度強硬，會適得其反，不但阻止不了疫情的蔓延，反而徹底拖垮了全球經濟發展。
尋找治療方案——應對Covid-19病毒感染
當自我隔離後，你認為是為了保護其他人，或者你本身就是潛在傳播源？案例分享：兒童Covid-19感染病例