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Condensing 30 experts experience and wisdom, "Shanghai Plan" introduced, expertinterpretation of the five bright spots

SIFIC Infection Evidence-Based Information 4 days ago
The Story comes article from the news author Gu Yong

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The much-watched "Shanghai 2019 Coronary Virus Disease Comprehensive Treatment Expert Consensus" was officially announced on the 2nd, focusing on 18 writing experts, 12 consulting experts common wisdom of the consensus, also known as the "Shanghai Program", which condenses more than a month of Shanghai treatment of skilled experience and results.
Shanghai expert team while groping while discovering, while summing up while adjusting, after the publication of several papers to introduce expert consensus, based on the sample secretary analysis timely summary, the formation of a plan. What are the highlights of the "Shanghai Program" and what clinical experience can help patients recover at an early date? This reporter interviewed the national new coronavirus pneumonia medical treatment expert group member, Fudan University affiliated Zhongshan Hospital infection department director Professor Hu Bijie.

Highlights One
No longer called new coronary pneumonia, but "new coronavirus disease"
There are many bright spots in the "Shanghai Programme", and the name of the disease itself is one of them. Hu Bijie told reporters that "new coronavirus pneumonia" in the program changed its name to "new coronavirus disease", such a change is also in line with WHO. On 11 February, WHO officially named the disease caused by the new coronavirus "COVID-19", where CO stands for coronary, VI is for virus, and D is for disease.

The reason why we have renamed us is that the human disease caused by this virus is not limited to pneumonia, but that some patients with mild illness do not have pneumonia. Experts said, "Although so far can not be measured without pneumonia performance of the proportion of viral infections, but from the Shanghai treatment experience, this is definitely not an individual patient, based on more rigorous considerations, the disease changed to the new coronavirus disease." "And such a naming more emphasis on the spread of the virus, rather than the spread of pneumonia, which also highlights the virus infection has a strong transmission capacity, prevention and control pressure is still relatively large.

"Shanghai program", the general overview of pathogens and epidemiology and the national version is basically the same, droplets, contact can be spread, aerosols also have the risk of transmission, but the infectiousness of feces is not specifically mentioned, it can be seen that patients will be positive for fecal nucleic acid. In particular, children and infants are mentioned in the programme, but the overall condition is mild, the vast majority of them are mild.

Highlights TWO
Which people are prone to serious illness? Shanghai removes "old slow spending" to increase extreme obesity

The clinical characteristics of the patients mentioned in the "Shanghai Plan" are generally consistent with the national version and are nuanced. Hu Bijie said that the current Shanghai data, the average incubation period of the virus is 6.4 days, in which patients are prone to serious illness description, Shanghai slightly different, removed the national version of the "old slow support", increased the "extremely obese population", "despite the old age, chronic diseases and other patients prone to serious illness, but we clinically found that, The old slow patientis is doing well. "

Other clinical performance, the Shanghai version of clinical CT diagnosis than the national version of more detailed, in view of the developed medical resources, Shanghai experts at the same time for many other provinces and cities patients reading tablets, chest CT diagnosis content is relatively detailed and objective. Experts believe that CT is crucial to the diagnosis of disease, to determine the progression of the disease, the improvement of the disease, and even to meet the discharge criteria.

In addition, in the laboratory inspection project, Shanghai added CD4 lymphocyte testing on the basis of the national version. Hu Bijie explained that the national version listed lymphocytes but did not further refine, Shanghai in the study summary found that CD4 lymphocytes are low patients are prone to severe diagnosis, based on this, this check list.

Highlights Three
The structure of the treatment framework is different, and the antiviral therapy is listed in a single chapter
From the "Shanghai Program" can be seen, the new coronavirus patient setypes are consistent with the national version, divided into four types, namely, light, ordinary, heavy, critical type, the field of clinical monitoring shanghai is more integrated, including heart super, ECMO artificial lung, etc. are involved.

However, the therapeutic framework structure in the field of medicine, "Shanghai program" is many different, mainly divided into antiviral treatment, light and general patient treatment, criticaland patients with organ function support treatment, as well as treatment of special problems and treatment of four aspects.
"We have listed the antiviral drug in particular, compared to the national version, the 'Shanghai Program' antiviral drugs are not many, but clinically proven to be very effective. The national version lists chloroquine phosphate, which we believe is still very effective in treatment and has few side effects, followed by Abigail. Two interferons are listed at the same time.

Hu Bijie also said, "The program emphasizes that it is not recommended that a variety of antiviral drugs are used at the same time, the national version of the recovery period plasma input, 'Shanghai program' is also listed." "

Highlights four
The handling of special problems in the treatment of treatment embodies the characteristics of Shanghai
For different types of patients, the "Shanghai Program" is detailed. Light and general patients in the national version of the detailed development, "Shanghai Program" mentioned in the "Good immune function, including diet, electrolyte balance, proper oxygen absorption, sleep management, mood management, etc. are important."

For heavy and critical patients, the national version of the previous sixth version of the consultation plan after the introduction of a special addition to the article. Mr Hu said the "Shanghai plan" would combine the two to be more operational. In addition to emphasis on circulatory support, lung protection, hibernating therapy, especially the protection of intestinal function.

As for the previously mentioned "inflammatory storm" problem, clinical lying is rare and confined to a few cases.

In particular, the experts highlighted the section "Special problems in treatment and treatment".

"Shanghai program" reflects the characteristics of Shanghai, he gave four examples, first of all, corticosteroids as far as possible do not use, such as to use to reduce the dose and short-range use. Second, immune regulation is important (listthion thymosin, immunoglobulin applications). Shanghai has more new applications of thymus, but not many C-type globulin s Furthermore, common infections do not use antibiotics, combined bacterial fungal infection patients need to strengthen pathogen examination and even nucleic acid testing, in order to find the source of the disease with the most accurate. Finally, highly alert to multi-drug resistance, pan-drug resistance and other phenomena, the current municipal public health center in the treatment of 9 cases of heavy, critical patients, or to avoid patients with multiple drug resistance and hospital infection.

Highlights Five
No light weight for three weeks, discharge required 6 conditions

In the "Shanghai program" clear and stringent discharge standards, patients must meet 6 conditions: normal body temperature is greater than 3 days, respiratory symptoms improved significantly, pulmonary imaging examination showed a significant improvement in acute oxudion lesions, two consecutive respiratory sample nucleic acid test negative (sampling time at least 1 day interval), respiratory sample nucleic acid test negative after negative respiratory sample nucleic acid test negative Fecal nucleic acid tests were also negative; Hu Bijie explained, "fecal nucleic acid to negative, the total course of more than 2 weeks of the setting, is worried that the time is too short, the virus has not been cleaned."

He also mentioned that the "Shanghai Plan" can not be separated from the help of Traditional Chinese medicine. In high-fever patients, critical lychee patients, constipation, diarrhea and other symptoms improve, Chinese medicine has played an extraordinary role. In addition, the improvement of the immune function of Chinese medicine to patients can not be ignored.
"The 'Shanghai Plan' is written on Shanghai patients, " said Professor Zhang Wenhong, head of the expert group. As of March 3, 294 confirmed cases in Shanghai have been discharged from hospital. Over the past three weeks, no light patients have been turned heavy, and no heavy patients have turned to critical, thus showing that the accumulation of experience is very effective. Hu Bijie finally said that many countries in the international community are now showing case outbreaks, condensing the Shanghai experience of the 'Shanghai Program' is willing to "stand up" to provide their own experience and results, to help other countries win the war against the epidemic.

(Originally published as "Top News" on March 3, 2020)

凝结30位专家救治经验及智慧，“上海方案”出台，专家解读五大亮点
SIFIC感染循证资讯 4 days ago
 
The following article comes from 上观新闻 Author 顾泳

上观新闻时政 · 热点 · 话题 | 解放日报出品，高端资讯品牌
 
备受关注的《上海市2019冠状病毒病综合救治专家共识》2日正式公布，集中18位执笔专家、12位咨询专家共同智慧的共识，又被誉为 “上海方案”，其中凝结一个多月上海救治的娴熟经验及成果。

上海专家团队一边摸索一边发现、一边总结一边调整，在发表数篇论文后出台专家共识，基于样本书记分析及时总结，形成方案。“上海方案”有哪些亮点?怎样的临床经验能帮助患者早日痊愈？记者就此采访国家新型冠状病毒肺炎医疗救治专家组成员、复旦大学附属中山医院感染科主任胡必杰教授。

亮点一

不再称呼新冠肺炎，而是“新冠病毒病”

“上海方案”中有不少亮点，疾病名字本身就是其中之一。胡必杰告诉记者，“新冠病毒肺炎”在方案中更名为“新冠病毒病”，这样的改变也是与世卫组织接轨的表现。2月11日世卫组织将新冠病毒引发的疾病正式命名为“COVID-19”，其中CO代表冠状物，VI代表病毒，D代表疾病。

我们更名的原因在于，这一病毒引起的人体疾病不仅仅局限于肺炎，而部分轻症病人的表现中，并没有肺炎。“专家说，“尽管目前为止还测算不出没有肺炎表现的病毒感染者占比多少，但从上海治疗经验来看，这绝对不是个别病人，基于更加严谨的考量，疾病更名为新冠病毒病。”而这样的命名更强调病毒传播，而非肺炎传播，这也凸显了病毒感染具有很强传播能力，防控压力还是比较大的。

“上海方案”中，病原学与流行病学的总体概述与国家版基本一致，飞沫、接触均可传播，气溶胶也存在传播风险，不过粪便的传染性没有具体提及，目前可见患者粪便核酸会呈阳性。方案中尤其提及，儿童和婴幼儿会发病，但病情总体较轻，绝大多数都是轻症。

亮点二

哪些人群易重症？上海去除“老慢支”增加极度肥胖

“上海方案”中提及的患者临床特征，总体与国家版一致，有细微调整。胡必杰说，目前上海数据来看，病毒潜伏期平均为6.4天，在哪些患者容易发生重症的描述中，上海略微不同，去除了国家版的“老慢支”，增加了“极度肥胖人群”，“尽管高龄、慢性病等患者易转为重症，但我们临床发现，老慢支患者的情况还好。”

其他临床表现上，上海版临床CT诊断比国家版更为详细，有鉴于发达的医疗资源，上海专家同时为不少其他省市患者读片，胸部CT的诊断内容相对详实、客观。专家认为，CT对疾病诊断、判断疾病进展、疾病好转、乃至是否符合出院标准都至关重要。

此外，实验室检查项目中，上海在国家版基础上增加了CD4淋巴细胞检查。胡必杰对此解释，国家版列出淋巴细胞但未进行进一步细化，上海在研究总结中发现，CD4淋巴细胞低的患者很容易重症化，基于此，此次将这一检查单列出来。

亮点三

治疗框架结构不同，抗病毒治疗单列成章

从“上海方案”可见，新冠病毒病患者分型与国家版一致，分为四种，即轻型、普通型、重型、危重型；临床监测领域上海则更具体化，包括心超、ECMO人工肺等都有涉及。

不过用药领域的治疗框架结构，“上海方案”多有不同，主要分为抗病毒治疗、轻型和普通型患者治疗、重症与危重症患者脏器功能支持治疗、以及救治中的特殊问题及处理四个方面。

“我们将抗病毒药物这一块特别列了出来，相较国家版，‘上海方案’的抗病毒药物数量并不多，但临床证明还是很有效。国家版列出磷酸氯喹，而我们在治疗中认为，羟氯喹还是很有效的，且副作用小，推荐放在首位；其次是阿比朵尔。同时列出两款干扰素。”胡必杰也说道，“方案强调，不建议多种抗病毒药物同时应用，国家版提及的恢复期血浆输入，‘上海方案’也列了进去。”

亮点四

救治中的特殊问题处理体现上海特色

针对不同类型患者，“上海方案”进行详列。轻型和普通型患者在国家版中没有详细展开，“上海方案”中提及，保持免疫功能良好状态，包括饮食、电解质平衡、适当吸氧、睡眠管理、情绪管理等都很重要。

针对重型和危重型患者，国家版之前在第六版诊疗方案出台之后，专门增补一文。胡必杰表示，此次“上海方案”将两者融合在一起，可更具操作性。除却强调循环支持、肺部保护、冬眠疗法外，尤其强调肠道功能的保护。至于此前提及的“炎症风暴”问题，临床并不多见，还是局限于少数病例中。

专家特别强调了“救治中的特殊问题及处理”这一章节。“上海方案”体现上海特色，他举例四点，首先，皮质激素尽量不用，如要用需减少剂量和短程使用。其次，免疫调节很重要（列出胸腺肽、免疫球蛋白应用）。上海应用胸腺法新较多，但丙种球蛋白应用不多。再者，普通感染不用抗生素，合并细菌真菌感染的患者需加强病原学检查甚至核酸检测等，以最精准找到疾病源头。最后，高度警惕多重耐药、泛耐药等现象，目前市公卫中心在收治9例重型、危重型患者，还是要避免患者出现多重耐药以及院内感染。

亮点五

三周未出现轻型转重，出院需严格符合6个条件

“上海方案”中明晰严苛的出院标准，患者必须符合6个条件：体温恢复正常大于3天；呼吸道症状明显好转；肺部影像学检查显示急性渗出性病变明显改善；连续两次呼吸道标本核酸检测阴性（采样时间至少间隔1天）；呼吸道标本核酸检测阴性后，粪便病原核酸检测也阴性；总病程超过2周。胡必杰对此解释，“粪便核酸转阴，总病程超过2周的设定，是担心时间太短，病毒还没有清除干净”。

他同时提及，“上海方案”离不开中医的帮助。在高热患者、危重型患者胀气、便秘、腹泻等症状改善中，中医起到了非同凡响的作用。此外，中医对患者免疫功能的改善也不可忽视。

“‘上海方案’写在上海病人身上”，专家组组长张文宏教授的总结掷地有声。截至3月3日，上海已有294例确诊病例痊愈出院。三周以来，没有轻型患者转为重型，也没有重型患者转为危重型，由此可见经验积累是很有效的。胡必杰最后表示，如今国际上多个国家也呈现病例暴发现象，凝结上海经验的‘上海方案’愿意“挺身而出”，提供自己的经验和成果，帮助他国共同打赢这场抗疫战。

（原载于2020年3月3日“上观新闻”）