【医药健康(SARS) 严重急性呼吸道症候群

1、severe acute respiratory syndrome (sars) 嚴重急性呼吸道症候群臺大醫院內科部sarsqsars是世界衛生組織(who)在2003年3月15日新公布的名稱，在這之前稱為非典型肺炎。qsars流行事件開始於2003年2月26日越南河內的一位美國商人發病就醫，後來送香港治療後死亡。之後在香港、越南陸續出現非典型肺炎合併有呼吸道感染症狀的案例。q其特點為發生瀰漫性肺炎及呼吸衰竭，較過去所知病毒、細菌引起的非典型肺炎嚴重，因此取名為嚴重急性呼吸道症候群(severe acute respiratory syndrome, sars) 與時間賽跑sars的全球疫情q

2、3月12日，世界衛生組織針對sars提出全球警訊q3月14日，美國疾病管制局啟動緊急醫療中心，並派出專家至亞洲國家協助世界衛生組織進行疫情調查。q3月14日，台大醫院通報國內第一、二例sars極可能病例。第一例是境外移入的指標病例，第二例是家族內傳播的第一例本土病例。q3月5日，加拿大多倫多第一例sars病例死亡。q自2003年2月1日起兩個月內，已經超過1800人被診斷sars ，分佈在17個國家。who 5/8/2003country/ cumulative # of# of date last area # of cases death recovered probable case r

3、eportedchina 4698 224 1529 8/may/2003hong kong 1661 208 1008 8/may/2003taiwan 131 13 26 8/may/2003 singapore 204 27 153 5/may/2003total 7053 506 2959 case definitions for surveillance of sars who 5/1/2003q objective to describe the epidemiology of sars and to monitor the magnitude and the spread of

4、this disease, in order to provide advice on prevention and controlq introduction the surveillance case definitions based on available clinical and epidemiological data are now being supplemented by a number of laboratory tests and will continue to be reviewed as tests currently used in research sett

5、ings become more widely available as diagnostic tests.q introduction (cont.) preliminary clinical description of severe acute respiratory syndrome summarizes what is currently known about the clinical features of sars. countries may need to adapt case definitions depending on their own disease situa

6、tion. retrospective surveillance is not expected.case definitions for surveillance of sars suspect case who 5/1/20031. a person presenting after 11/1/2002 with history of: -high fever (38c) and - cough or breathing difficulty and one or more of the following exposures during the 10 days prior to ons

7、et of symptoms: -close contact with a person who is a suspect or probable case of sars; -history of travel, to an area with recent local transmission of sars-residing in an area with recent local transmission of sars case definitions for surveillance of sars suspect case who 5/1/20032.a person with

8、an unexplained acute respiratory illness resulting in death after 11/1/2002, but on whom no autopsy has been performed and one or more of the following exposures during to 10 days prior to onset of symptoms: -close contact, with a person who is a suspect or probable case of sars; - history of travel

9、 to an area with recent local transmission of sars-residing in an area with recent local transmission of sarscase definitions for surveillance of sars probable case who 5/1/20031.a suspect case with radiographic evidence of infiltrates consistent with pneumonia or respiratory distress syndrome (rds)

10、 on chest x-ray. 2.a suspect case of sars that is positive for sars coronavirus by one or more assays. 3.a suspect case with autopsy findings consistent with the pathology of rds without an identifiable cause.case definitions for surveillance of sars who 5/1/2003q exclusion criteria a case should be

11、 excluded if an alternative diagnosis can fully explain their illness. q reclassification of cases case definitions for surveillance of sars reclassification of cases who 5/1/2003q as sars is currently a diagnosis of exclusion, the status of a reported case may change over time. q a patient should a

12、lways be managed as clinically appropriate, regardless of their case status. q a case initially classified as suspect or probable, for whom an alternative diagnosis can fully explain the illness, should be discarded after carefully considering the possibility of co-infection. case definitions for su

13、rveillance of sars reclassification of cases who 5/1/2003q a suspect case who, after investigation, fulfils the probable case definition should be reclassified as probable. q a suspect case with a normal cxr should be treated, as deemed appropriate, and monitored for 7 days. those cases in whom reco

14、very is inadequate should be re-evaluated by cxr. q those suspect cases in whom recovery is adequate but whose illness cannot be fully explained by an alternative diagnosis should remain as suspect. case definitions for surveillance of sars reclassification of cases who 5/1/2003q a suspect case who

15、dies, on whom no autopsy is conducted, should remain classified as suspect. q if this case is identified as being part of a chain transmission of sars, the case should be reclassified as probable. q if an autopsy is conducted and no pathological evidence of rds is found, the case should be discarded

16、.case definitions for surveillance of sars who 5/1/2003q the surveillance period begins on 11/1/2002 to capture cases of atypical pneumonia in china now recognized as sars. international transmission of sars was first reported in march 2003 for cases with onset in february 2003. q close contact: hav

17、ing cared for, lived with, or had direct contact with respiratory secretions or body fluids of a suspect or probable case of sars.q reporting procedures - all probable sars cases should be managed in the same way for the purposes of infection control and outbreak containment q at this time, who is m

18、aintaining surveillance for clinically apparent cases only ie probable and suspect cases of sars. q testing of clinically well contacts of probable or suspect sars cases and community based serological surveys are being conducted as part of epidemiological studies which may ultimately change our und

19、erstanding of sars transmission. however, persons who test sars cov positive in these studies will not be notified as sars cases to who at this time.case definitions for surveillance of sars who 5/1/2003q where laboratory tests are not available or not done, probable sars cases as currently defined

20、above should continue to be reported in the agreed format.q suspect cases with positive laboratory results will be reclassified as probable cases for notification purposes only if the testing laboratories use appropriate quality control procedures. case definitions for surveillance of sars who 5/1/2

21、003q no distinction will be made between probable cases with or without a positive laboratory result and suspect cases with a positive result for the purposes of global surveillance. q who will negotiate sentinel surveillance of sars with selected partners to collect detailed epidemiological, labora

22、tory and clinical data.q cases that meet the surveillance case definition for sars should not be discarded on the basis of negative laboratory tests at this time.case definitions for surveillance of sars who 5/1/2003rationale for retaining the current surveillance case definitions for sars who 5/1/2

23、003 q the reason for retaining the clinical and epidemiological basis for the case definitions is that at present there is no validated, widely and consistently available test for infection with the sars coronavirus. q antibody tests may not become positive for three or more weeks after the onset of

24、 symptoms. we do not yet know if all patients will mount an antibody response. 首先，我们先抛弃任何病理性及并发症因素，我们从物理学角度来看高血压，根据流体力学的原理及压缩动力学原理，我把心脏和血管及毛细血管比喻成密封的压力循环系统，就是说人体是一台机器，心脏和血管就是润滑系统。中医认为高血压形成原理是：血管内皮组织代谢不稳定、交感和副交感神经系统混乱造成血压的升高。 1、从最常见的肥胖者高血压说起，太胖脂肪过多，对血管造成一定的挤压，当管道被挤压以后，动力源需要加大动力才可能使原来的循环达到流通，动力源动力加大，管

25、道压力也会随之加大，就形成了高压。 2、内部血液及其他疾病引起的血栓造成的，血液的新陈代谢，排出不够彻底，在管道内部形成污垢，对管道造成一定的堵塞，会使压力升高。 3、老年性管道硬化及疾病性硬化，管道打折硬化的话，会造成高压。 4、疾病性毛细血管堵塞和外伤性毛细血管堵塞，也是其中的因素之一。 5、机体病变性引起的，一部分高血糖患者，是因为消化系统太过亢奋，在肠胃方面有病变，在肠胃机体方面就会形成一定的血液循环堵塞，也会造成高压，这里只举一个例子。 6、心脏方面的先天及后天的缺失。 7、脑血管疾病引起的。 8、血液干涸造成的高压。 以上因素受季节变化影响，容易发病！ 血压调控机制血压调控机制多种

26、因素都可以引起血压升高。心脏泵血能力加强（如心脏收缩力增加等），使每秒钟泵出血液增加。另一种因素是大动脉失去了正常弹性，变得僵硬，当心脏泵出血液时，不能有效扩张，因此，每次心搏泵出的血流通过比正常狭小的空间，导致压力升高。这就是高血压多发生在动脉粥样硬化导致动脉壁增厚和变得僵硬的老年人的原因。由于神经和血液中激素的刺激，全身小动脉可暂时性收缩同样也引起血压的增高。可能导致血压升高的第三个因素是循环中液体容量增加。这常见于肾脏疾病时，肾脏不能充分从体内排出钠盐和水分，体内血容量增加，导致血压增高。 相反，如果心脏泵血能力受限、血管扩张或过多的体液丢失，都可导致血压下降。这些因素主要是通过肾脏功能

27、和自主神经系统（神经系统中自动地调节身体许多功能的部分）的变化来调控。 编辑本段编辑本段临床表现临床表现1、头疼：部位多在后脑，并伴有恶心、呕吐等症状。若经常感到头痛，而且很剧烈，同时又恶心作呕，就可能是向恶性高血压转化的信号。 2、眩晕：女性患者出现较多，可能会在突然蹲下或起立时有所感觉。 3、耳鸣：双耳耳鸣，持续时间较长。 4、心悸气短：高血压会导致心肌肥厚、心脏扩大、心肌梗死、心功能不全。这些都是导致心悸气短的症状。 5、失眠：多为入睡困难、早醒、睡眠不踏实、易做噩梦、易惊醒。这与大脑皮质功能紊乱及自主神经功能失调有关。 6、肢体麻木：常见手指、脚趾麻木或皮肤如蚁行感，手指不灵活。身体其

28、他部位也可能出现麻木，还可能感觉异常，甚至半身不遂。 物(特别是阿司匹林和非甾体类消炎药，参见消化性溃疡的治疗部分)，克罗恩病或病毒感染所引起。幽门螺杆菌可能在此不发挥重要作用。 症状多为非特异性的，可包括恶心，呕吐和上腹部不适。内镜下显示在增厚的皱襞隆起边缘有点状糜烂，中央有白斑或凹陷。组织学变化多样。尚无某种方法具有广泛疗效或可治愈。 治疗多为对症治疗，药物包括制酸剂，h2拮抗剂和质子泵。 2慢性胃炎的癌变慢性胃炎的癌变 对于胃溃疡发生癌变，人们比较容易理解，但对于有些类型的慢性胃炎也会发生癌变，许多人会感到不可思议然而，慢性萎缩性胃炎发生癌变却是事实编辑本段现代中医史（df4肺炎88gd

29、g青霉素d25f肝炎df6）轴心时代中、西医学的峰巅之作。雅斯贝而斯曾说：“如果历史有一个轴心，那么我们就必须将这轴心作为一系列对全部人类都有意义的事件，发生于公元前800至200年间的这种精神历程似乎构成了这样一个轴心。 本文档下载后可以修改编辑，欢迎下载收藏。rationale for retaining the current surveillance case definitions for sars who 5/1/2003q molecular assays must be performed using appropriate reagents and controls unde

30、r strictly controlled conditions, and may not be positive in the early stages of illness using currently available reagents. q we are not yet able to define the optimal specimen to be tested at any given stage of the illness. q this information is accruing as more tests are being performed on patien

31、ts with known exposures and/or accompanied by good clinical and epidemiological information. we hope that in the near future an accessible and validated diagnostic assay(s) will become available which can be employed with confidence at a defined, early stage of the illness.qsars的潛伏期通常為2至7天，但也可能長達10天

32、。q疾病通常先以發燒為前趨症狀（38），通常為高溫，有時會發冷及寒顫；q有時尚伴隨著其他症狀包括頭痛、倦怠及肌肉痛。q有些病人發病時會產生輕微的呼吸道症狀。q雖然有部份病人在發燒時會發生腹瀉，但通常並不會有皮疹及神經或腸胃道症狀。 sars 臨床症狀sars 臨床症狀q3至7天後進入下呼吸道期（lower respiratory phase），開始沒有痰的乾咳，或因呼吸困難而導致血氧過低。q有10-20%的病人，呼吸道疾患嚴重到必須插管及使用呼吸器。q合乎目前世界衛生組織sars極可能（probable）及疑似病例定義者之致死率約為3%。 sars胸部x光攝影q在發燒前驅症狀，甚至整個病程，胸

33、部x光攝影可能正常。q不過在大部份的病患，呼吸道時期（respiratory phase）的特性為從早期的局部（focal）浸潤，進展到較廣泛性、斑狀（patchy）、間質性浸潤，q有些sars晚期病人的胸部x光攝影可見部份區域實質化（consolidation）。 傳播方式q飛沫傳染：近距離、反覆接觸。q空氣傳染q口糞傳播：有些動物的糞便可培養出冠狀病毒許多台大的病人初期有腹瀉qvector-borne：fomites，因為冠狀病毒可在環境中生存數小時之久。a hospital outbreak of severe acute respiratory syndrome in hong kon

34、glee et al., april 7, 2003qfrom march 11 to 25, 2003, a total of 156 patients were hospitalized with sars at the prince of wales hospital q138 cases were identified as having either secondary or tertiary cases and were admitted to the isolation wards ofclinical featuresq symptoms: fever

35、 (100%); chills, rigors, or both (73.2%); myalgia (60.9%) cough (57.3%), headache (55.8%), dizziness (42.8%); sputum production (29.0), sore throat (23.2%), coryza (22.5%), nausea & vomiting (19.6%), diarrhea (19.6%) q physical findings on admission: fever 38.4c (3540.3c), inspiratory crackles a

36、t the base of the lunglaboratory findingsq lymphopenia (69.6%)q thrombocytopenia (44.8%)q elevated lactase dehydrogenase (71.0%)q creatine kinase levels (32.1%) cxr at the onset of fever, 78.3% had abnormal cxr, all showed air-space consolidation, indistinguishable from those associated with other c

37、auses of bronchopneumonia, peripheral- zone involvement predominant unilateral focal involvement (54.6%), unilateral multifocal or bilateral involvement (45.4%)q thoracic ct: peripheral air-space consolidation, similar to those found in bronchiolitis obliterans organizing pneumonia prospective study

38、 of the clinical progression of sars in a community outbreakq the fever and pneumonia initially responded to treatment. q however, patients developed recurrent fever (85.3%) on day 8.9 3.1 (range 4 to 18), watery diarrhoea (73.3%) on day 7.5 2.3 (range 3 to 15), radiological deterioration (80%) on d

39、ay 7.4 2.2 (range 3 to 13) and respiratory deterioration (45.3%) on day 8.6 3 days (range 5 to 19). peiris et al., and members of the hku / uch sars study group. lancet 2003prospective study of the clinical progression of sars in a community outbreakq in 45.3% of patients, marked improvement of init

40、ial pulmonary lesions was closely associated with appearance of new radiological lesions at other sites. q 20% progressed to acute respiratory distress syndrome (ards) during the third week. q age and chronic hbv infection are independent significant risk factors for progression to ards on multivari

41、ate analysis. subsequent analysis of clinical specimen of 20 patients with initial npa rt-pcr positive and antibody seroconversion to sars associated coronavirusday after 10 13161921onsetnpa (positivity rate) 95%90%90%75%47.4%stool (positivity rate) 100% 100%95%80%66.7%urine (positivity rate) 50%45%

42、35%30%21.1%clinical progression and viral load of sars associated coronavirus pneumoniaq quantitative rt-pcr of nasopharyngeal aspirates in 14 patients (4 had ards and 10 without ards) consistently demonstrated a peak viral load at day 10 and a decrease to admission level at day 15. q faecal excreti

43、on of coronavirus was present and continued through the period of follow-up. q seroconversion and rt-pcr of nasopharyngeal aspirates and stool are useful for confirmation of sars.interpretation:q the consistent clinical progression, shifting radiological infiltrates and an inverted v viral load prof

44、ile suggested that deterioration during the second week is not related to uncontrolled viral replication but may rather be related to immunopathological damage. incubation period 潛伏期q incubation period: intervals between exposure to the index patient or ward and the onset of feverq sarstsang et al.,

45、 nejm, mar 31, 2003: 2-11 days lee et al. nejm, apr 7, 2003: 216 days (median, 6 days)q common atypical pneumoniamycoplasma pneumoniae: 6-32天（14天）clamydia pneumoniae: 10-30天leginella pneumoniae: 不會人傳給人incubation period who 5/7/2003q who has also reviewed estimates of the incubation period of sars, u

46、sing individual case data. q on the basis of this review, who continues to conclude that the current best estimate of the maximum incubation period is 10 days.q the incubation period can vary from one case to another according to the route by which the person was exposed, the dose of virus received,

47、 and other factors, including immune status. q the incubation period, which is the time from exposure to a causative agent to onset of disease, is particularly important as it forms the basis for many recommended control measures, including contact tracing and the duration of home isolation for cont

48、acts of probable sars cases. q knowledge about the incubation period can also help physicians make diagnostic decisions about whether the presenting symptoms and clinical history of a patient point to sars or to some other disease.prompt isolation who 5/7/2003q who continues to recommend the earlies

49、t possible isolation of all suspect and probable cases of sars. a short time between onset of symptoms and isolation reduces opportunities for transmission to others. q it also reduces the number of contacts requiring active follow-up, and thus helps relieve some of the burden on health services. in

50、 addition, prompt hospitalization gives patients the best chance of receiving possibly life-saving care should their condition take a critical course.a comparison of the courses of common-source and propagated epidemicshigh infectivity of sars agentq 112 secondary cases: 69 health care workers and 1

51、6 medical students, who were work in the index ward; 54 patients who were either in the same ward or had visited their relatives thereq 26 tertiary cases: family members of the infected hcws q transmission by droplets and possibly by fomites were suspected. high infectivity of sars agentqthe use of

52、a jet nebulizer to administer aerosolized albuterol in the index patient had probably aggravated the spread of the disease by droplet infections.qairborne precautions and contact precautions were instituted therefore, as recommended by the cdc.course and outcomeq 23.2% were admitted to icuq 13.8% re

53、quired mechanical ventilationq 5 of 138 patients died, all of whom had coexisting conditions. lee et al., april 7, 2003independent predictors of an adverse outcomeq advanced age (or per decade of life, 1.80; 95% ci, 1.16 to 2.81; p=0.009)q high peak lactate dehydrogenase level (or per 1

54、00 u per liter, 2.09; 95%ci, 1.28 to 3.42; p=0.003) q high absolute neutrophil count on presentation (or, 1.60; 95%ci, 1.03 to 2.50; p=0.04). lee et al., april 7, 2003sars case fatality ratio 5/7/2003 q case fatality ratio who has today revised its initial estimates of the case fatality

55、 ratio of sars. the revision is based on an analysis of the latest data from canada, china, hong kong sar, singapore, and viet nam.q on the basis of more detailed and complete data, and more reliable methods, who now estimates that the case fatality ratio of sars ranges from 0% to 50% depending on t

56、he age group affected, with an overall estimate of case fatality of 14% to 15%.q the likelihood of dying from sars in a given area has been shown to depend on the profile of the cases, including the age group most affected and the presence of underlying disease. q based on data received by who to da

57、te, the case fatality ratio is estimated to be 1% 50% 65 yearstsang et al., nejm 3/31/2003tsang et al., nejm 3/31/2003poutanen et al. nejm 3/31/2003poutanen et al. nejm 3/31/2003sars致病菌q2003年3月24日美國疾病管制局及香港專家，宣布分離出一種冠狀病毒(coronavirus)。q目前正針對已知的冠狀病毒polymerase基因的核酸序列比對，發現與已知的人類病毒不同。q數個病人的急性期及恢復期血清顯示有血清

58、陽轉(seroconversion) 。支持冠狀病毒是sars致病菌的證據q 組織培養q 電子顯微鏡q microarray 技術q 間接免疫螢光染色q 聚合脢鏈反應(polymerase chain reaction)sars “super-spreaders”q “super-spreader” is a term that has been used to describe certain individuals with atypical pneumonia, now recognized as cases of sars, who have been implicated in sp

59、reading the disease to numerous other individuals.sars “super-spreaders”q in sars outbreaks, a “super-spreader” is a source case who has, for as yet unknown reasons, infected a large number of persons. q it remains unknown whether such “super-spreaders” are persons secreting an exceptionally high am

60、ount of infectious material or whether some other factor, perhaps in the environment, is working to amplify transmission at some key phase of virus shedding.q the phenomenon of a “super-spreader”, which is not a recognized medical condition, dates back to the early days of the outbreak. at that time, wh