This article is from the WeChat public account: Academic Headline (ID: SciTouTiao), author: Academic Jun, the original title is "The first and second cases of new crown patients in the country have been dissected, what is the significance?" Where are the difficulties? 》
At 3:50 a.m. on February 16, with the permission of national laws and policies and with the consent of the patient's family, the autopsy of the remains of the first patient who died of the new crown virus in the country was completed in Wuhan Jinyintan Hospital.
At 18:45 on the same day, the autopsy of the second case of new crown pneumonia death in the country was also successfully completed in Jinyintan Hospital.
The autopsy of the remains was carried out by the team of forensic pathologists who had participated in the anatomy of SARS cases, Professor Liu Liang, president of the Hubei Forensic Identification Association, and other relevant experts. At present, the anatomical pathology of these two bodies has been sent for examination, and it is expected that the pathology report will be available within 10 days.
Professor Liu Liang, a forensic doctor at Tongji Medical College of Huazhong University of Science and Technology, participated in the autopsy of the remains
What is the significance of the decontamination of the remains?
Existing medical diagnoses generally confirm the existence of the new crown virus from the patient's throat swab and the lung lavage sample of the severe patient, although this method can be more accurate to screen the confirmed patient, but if there is no pathological anatomy, the pathology does not collect a complete and systematic information, can not explain the etiology and pathological mechanism of the new crown virus disease as a whole, can not recognize how the disease occurs as a whole, and can not know where these viruses are distributed in the lungs. And whether it is also distributed in other parts and organs of the body.
Clinically, some patients do not show symptoms of the respiratory system, but instead show symptoms of the cardiovascular, neurological, and digestive systems. All this needs to be clarified through pathological anatomy, and only through the study of pathological sections of various organs and the way in which viruses damage human cells and tissues and organs can we prescribe the right medicine and carry out precise treatment.
Another important reason for the emphasis on pathological anatomy is that pathology is a bridge between basic medicine and clinical medicine. With the existence of pathological anatomy and pathology, we can transition from basic medicine to clinical medicine, and then treat diseases and save people. Many clinically unclear questions can be found in the pathologist's anatomical results.
Similarly, pathological dissection gives a clearer picture of where the virus has gathered in what parts and organs, what damage it has caused, how severe it is, and whether the damage is caused by the virus's own virulence or by an overreaction by the body's immune system.
Patients with severe covid-19 pneumonia often produce white lungs in the later stages, and the respiratory function of the lungs is seriously impaired, resulting in respiratory failure. Only through pathological anatomy can we know whether this is caused by the new crown virus alone or by the combined action of human immune cells such as macrophages, neutrophils, monocytes or B cells.
The pathology of new crown pneumonia obtained by dissection is of great help to explore the pathological changes and disease mechanisms of the new crown pneumonia patients, and can fundamentally find the pathogenicity and lethality of new crown pneumonia, providing a basis for future clinical treatment of critically ill patients.
In addition, from the perspective of transmission, forensic testing is also related to the problem of the route of infection, such as judging whether fecal-oral infection has occurred, and whether more viruses can be found in the esophagus or trachea.
Liu Liang said in an interview with the Health Times reporter that the dissection work on February 16 was mainly based on materials, "the virus should be inactivated, so the tissues taken from the materials should be soaked more." Next, the slice will be placed under the microscope to see the structure of its cells and how the tissue structure has changed. At the same time, in view of the similarities and differences between the new crown virus infection and SARS, Professor Liu Liang said that the preliminary naked eye observation can not yet draw a comparison between the two, and needs follow-up microscopy and pathological and virological research.
The autopsy of the remains is difficult
Since the outbreak of the new crown virus pneumonia in Wuhan in December last year, it has aroused continuous concern from all walks of life. With the rising number of infected people, major academic journals around the world have also published relevant clinical case studies, but there have never been any studies related to autopsy.
According to Professor Liu Liang, who participated in the autopsy, when facing the media, "Although we all know that we died of illness, the death factors are not clear how to do it." I have been calling for the autopsy of the dead body from COVID-19 since January 22, but it is too difficult to push. ”
Why is the autopsy so difficult?
First of all, Chinese the traditional view that it is safe to go into the ground, it is not easy to persuade the patient's family to accept that the relatives have not been rescued and still undergo an autopsy;
Secondly, it is worried about the spread of virus infection, because it is worried that there are still a large number of viruses in the deceased patients, and if the dissection process is improperly protected, there will be a risk of secondary infection, which is particularly dangerous for the dissector himself;
Finally, the autopsy of the body must be carried out in accordance with relevant laws and regulations, and it is necessary to contact multiple departments for review and approval, and the process is extremely cumbersome. A combination of factors makes it difficult to perform anatomy of the remains.
The first breakthrough step occurred in the team of Professor Zheng Junhua, the leader of the first batch of Shanghai Aid-E medical team, the secretary of the provisional party general branch, and the vice president of Shanghai First People's Hospital.
Professor Zheng Junhua said in an interview with the Health Times reporter that from the first batch of Shanghai medical teams led by him rushed to Jinyintan Hospital to take over the treatment of patients, the condition of these two patients has always been in a critical state, and after more than 20 days of non-stop treatment by medical staff, they still have not been pulled back and unfortunately passed away.
However, after this period of meticulous treatment, the urgency and dedication of medical staff to rescue patients' moods are in the eyes of the patient's family. "After the unfortunate death of the patient, we are very sad about the death of the patient, but after experiencing this grief, we are more eager to have more guidance for later treatment through dissection." After the death of the first patient, after two hours of unremitting communication, the family endured the grief to understand the significance of the autopsy and finally signed the consent form. In the interview with the Health Times reporter, Zheng Junhua did not forget to pay tribute to the patient's family for many times.
Zheng Junhua (second from left) and the first batch of patients who recovered and were discharged from the hospital
The autopsy was carried out so quickly, thanks to the efficient support and approval of the Health Commission. Professor Liu Liang introduced that the National Health Commission held an emergency meeting on the morning of the 15th in accordance with the principle of the special affairs office, and quickly gave oral notice to key hospitals while urgently issuing documents.
There is a set of domestic standards for the dissection of the remains of infectious diseases and the prevention of the spread of the virus. At present, there are very few dissection rooms in China that meet the anatomical standards of infectious diseases, and there is one in Beijing Ditan Hospital, which was used for SARS research and is not available elsewhere. Since it was impossible to transport the remains from Wuhan to Beijing, Jinyintan Hospital first vacated a clean operating room with negative pressure to ensure that the autopsy could not spread the virus at the same time. Finally, with the cooperation of Professor Liu Liang and other relevant experts, the autopsy of the remains of the deceased patients with new crown pneumonia was successfully completed.
The far-reaching effects of SARS autopsy
According to a paper by the ICTV Coronavirus Research Group on the preprint platform BioRxiv, "based on the systemic occurrence, taxonomy, and conventions of the virus, its team identified the virus as a sister virus of coronaviruses associated with severe acute respiratory syndrome (SARS-CoVs)," and in layman's terms, the new coronavirus belongs to the same species as the SARS virus as we know it.
So what important information did the SARS virus anatomy uncover at that time?
Professor Ding Yanqing, former director of the Department of Pathology of Southern Medical University and director of the Department of Pathology of Southern Hospital, once completed the world's first SARS autopsy. Since then, 3 autopsies have been performed, which have made outstanding contributions to the clarification of the pathogenesis, treatment, protective measures and the establishment of emergency measures for national public health emergencies.
According to the results of his papers in the New England Journal of Medicine (NEJM) and J Pathol, Ding Yanqing's team found that in addition to the SARS virus positivity in the lungs, the sweat glands, kidneys, gastrointestinal tract and so on also had SARS virus positive. This result clarifies that in addition to respiratory transmission, SARS virus may also be transmitted through feces, sweat and urine, providing substantial evidence of the transmission route of the virus.
SARA virus present in the stomach (2A), intestines (3A), sweat glands (8A), and kidneys (7A)
And Ding Yanqing's team for the first time proposed that lung and immune organs are the main target organs attacked by SARS virus, and for the first time proposed that the overexpression of "pro-inflammatory factor" is closely related to acute lung injury of SARS and the damage of multiple organs throughout the body, effectively guiding clinical practice.
John M Nicholls, a Fellow of the Royal College of Pathology of Australia and Professor of Clinical Medicine in the Department of Pathology at the University of Hong Kong, performed an autopsy on six patients who died of SARS in February 2003 and March 2003, and studied cadaveric tissue samples and an open lung biopsy of one of the patients.
According to its paper published in the journal LANCET, the team, through histological and virological studies, based on autopsy results, showed that all six patients had serological evidence of recent SARS-CoV infection, and diffuse alveolar damage was common but not common. The morphological changes identified are bronchial epithelial exfoliation, ciliary loss and squamous metaplasia.
Among them, one case had secondary bacterial pneumonia, and giant cell infiltration was observed in four patients, a significant increase in macrophages in the alveoli and lung stromal, two patients had hematophagocytosis, and alveolar lung cells also showed hypertrophy with granular amphiphilic cytoplasm. Patients undergoing a complete autopsy suffer from atrophy of the white pulp of the spleen. Electron microscopy shows that viral particles in the cytoplasm of epithelial cells correspond to coronaviruses.
Therefore, based on the results of autopsy, SARS is inferred to be associated with epithelial cell proliferation and macrophage proliferation in the lungs. The presence of phagocytes supports the argument that cytokine dysregulation may be an important factor in the clinical severity of clinical symptoms in patients with SARS. This result provides some academic support for the hormone therapy plan for SARA patients that year.
The road to war is promising
Medical understanding of a disease requires a process that includes clinical, basic, scientific, and pathological anatomy. Only when all departments and all parties work together can the understanding of the disease continue to deepen and provide a basis for the complete attack of the disease.
So far, medical knowledge of COVID-19 is at a relatively low level. In the period when the epidemic is in full swing and the diagnosis and treatment plan is not yet perfect, it is believed that if some of the deceased can be systematically dissected, it will certainly help to understand the pathophysiological progress and pathogenesis of the new coronavirus pneumonia from the pathological aspect, and will also help prevent and treat.
Let us look forward to the smooth progress of the relevant anatomical research work and the guidance of clinical work as soon as possible, and also look forward to the relevant epidemic being contained as soon as possible. Come on China!
Resources:
http://www.jksb.com.cn/html/2020/jjxxgzbd_0217/159702.html
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)13413-7/fulltext #
https://www.ncbi.nlm.nih.gov/pubmed/15141376
This article is from the WeChat public account: Academic Headlines (ID: SciTouTiao), author: Academic Jun