Arthur Chun-Wing Lau

Development of a standard treatment protocol for severe acute respiratory syndrome

Summary A series of 31 patients with probable SARS, diagnosed from WHO criteria, were treated according to a treatment protocol consisting of antibacterials and a combination of ribavirin and methylprednisolone. Through experience with the first 11 patients, we were able to finalise standard dose regimens, including pulsed methylprednisolone. One patient recovered on antibacterial treatment alone, 17 showed rapid and sustained responses, and 13 achieved improvement with step-up or pulsed methylprednisolone. Four patients required short periods of non-invasive ventilation. No patient required intubation or mechanical ventilation. There was no mortality or treatment morbidity in this series.

Effectiveness of Noninvasive Positive Pressure Ventilation in the Treatment of Acute Respiratory Failure in Severe Acute Respiratory Syndrome

Objectives: To study the effectiveness of noninvasive positive pressure ventilation (NIPPV) in the treatment of acute respiratory failure (ARF) in severe acute respiratory syndrome (SARS), and the associated infection risk. Methods: All patients with the diagnosis of probable SARS admitted to a regional hospital in Hong Kong from March 9 to April 28, 2003, and who had SARS-related respiratory distress complications were recruited for NIPPV usage. The health status of all health-care workers working in the NIPPV wards was closely monitored, and consent was obtained to check serum for coronavirus serology. Patient outcomes and the risk of SARS transmission to health-care workers were assessed. Results: NIPPV was applied to 20 patients (11 male patients) with ARF secondary to SARS. Mean age was 51.4 years, and mean acute physiology and chronic health evaluation II score was 5.35. Coronavirus serology was positive in 95% (19 of 20 patients). NIPPV was started 9.6 days (mean) from symptom onset, and mean duration of NIPPV usage was 84.3 h. Endotracheal intubation was avoided in 14 patients (70%), in whom the length of ICU stay was shorter (3.1 days vs 21.3 days, p < 0.001) and the chest radiography score within 24 h of NIPPV was lower (15.1 vs 22.5, p = 0.005) compared to intubated patients. Intubation avoidance was predicted by a marked reduction in respiratory rate (9.2 breaths/min) and supplemental oxygen requirement (3.1 L/min) within 24 h of NIPPV. Complications were few and reversible. There were no infections among the 105 health-care workers caring for the patients receiving NIPPV. Conclusions: NIPPV was effective in the treatment of ARF in the patients with SARS studied, and its use was safe for health-care workers.

Over 8 years experience on severe acute poisoning requiring intensive care in Hong Kong, China

In order to obtain up-to-date information on the pattern of severe acute poisoning and the characteristics and outcomes of these patients, 265 consecutive patients admitted to an intensive care unit in Hong Kong for acute poisoning from January 2000 to May 2008 were studied retrospectively. Benzodiazepine (25.3%), alcohol (23%), tricyclic antidepressant (17.4%), and carbon monoxide (15.1%) were the four commonest poisons encountered. Impaired consciousness was common and intubation was required in 67.9% of admissions, with a median duration of mechanical ventilation of less than 1 day. The overall mortality was 3.0%. Among the 257 survivors, the median lengths of stay in the intensive care unit and acute hospital (excluding days spent in psychiatric ward and convalescent hospital) were less than 1 day and 3 days, respectively. Factors associated with a longer length of stay included age of 65 or older, presence of comorbidity, Acute Physiology and Chronic Health Evaluation II score of 25 or greater, and development of shock, rhabdomyolysis, and aspiration pneumonia, while alcohol intoxication was associated with a shorter stay. This is the largest study of its kind in the Chinese population and provided information on the pattern of severe acute poisoning requiring intensive care admission and the outcomes of the patients concerned.

Pseudallescheria boydii or Aspergillus fumigatus in a lady with an unresolving lung infiltrate, and a literature review

Abstract:  A 53‐year‐old lady with blood‐stained sputum and pleuritic pain had a lingular opacity on CXR which failed to resolve. A bronchial aspirate and transbronchial biopsy revealed features of bronchocentric granulomatosis with dichotomous branching hyphae suggestive of Aspergillus infection. However, subsequent fungal culture grew Pseudallescheria boydii. This case demonstrates the similarity of clinical and histological features caused by these two fungi. This appears to be the first reported case of pulmonary pseudallescheria with a bronchocentric granulomatous response.

Outcome of coronavirus-associated severe acute respiratory syndrome using a standard treatment protocol.

Objective:  There is so far no consensus on the optimal treatment strategy for the coronavirus‐associated severe acute respiratory syndrome (SARS). We aimed to analyse the outcomes of a standard treatment strategy comprising antibiotics, a combination of ribavirin, a 3‐week step‐down course of corticosteroids, and the possibility of pulsed methylprednisolone rescue in the event of deterioration.

Reference values of diffusing capacity of non-smoking Chinese in Hong Kong

Background and objective:  This study was conducted to define normal reference values and lower limits of normal (LLN) for single‐breath carbon monoxide diffusing capacity (DLco) and DLco per unit of alveolar volume (Kco) for Chinese adults in Hong Kong.

Corticosteroid treatment of severe acute respiratory syndrome in Hong Kong

Summary Background The patterns of corticosteroids usage in severe acute respiratory syndrome (SARS) and associated treatment outcomes in Hong Kong were studied. Method Patients≥18years old who either had not received corticosteroid or had taken corticosteroids within 14days from symptom onset were included. Patients receiving corticosteroids beyond 15days or other investigational treatment within 21days from symptom onset were excluded. Of 1313 eligible patients, 1287 with major corticosteroid dosage-type combinations were analysed. Results Crude death rate was lower among 1188 steroid-treated patients compared to 99 patients in Group No Steroid (17.0% vs. 28.3%). Among four corticosteroid groups studied, mortality was lowest in the low-dose oral prednisolone (Group P) and high-dose methylprednisolone (Group MP) groups. On multivariate analysis of the corticosteroid groups, independent factors related to death were: corticosteroid group, older age, co-morbidity, worse chest X-ray score, worse respiratory status at Days 8–10 and higher admission white cell count. Again Groups P and MP had significantly lower adjusted odds ratios for death and lower bacterial and fungal culture rates. Despite worse chest X-ray scores and higher cumulative corticosteroid dosages in Group MP compared to Group P, fewer patients required rescue pulsed corticosteroid. Patients on hydrocortisone (Group HC) had the highest positive culture rates. Conclusion We speculate that corticosteroid with higher in-vitro inflammatory potency administered at timing and dosages commensurate with disease severity may be conducive to better outcome from SARS as a consequence of more effective control of immunopathological lung damage.

CC16 levels correlate with cigarette smoke exposure in bronchial epithelial cells and with lung function decline in smokers

BackgroundClub cell protein-16 (CC16) expression has been associated with smoking-related lung function decline. The study hypothesis was that CC16 expression in both serum and bronchial epithelium is associated with lung function decline in smokers, and exposure to cigarette smoke will lead to reduction in CC16 expression in bronchial epithelial cells.MethodsIn a cohort of community-based male Chinese subjects recruited for lung function test in 2000, we reassessed their lung function ten years later and measured serum levels of CC16. CC16 expression was further assayed in bronchial epithelium from endobronchial biopsies taken from an independent cohort of subjects undergoing autofluorescence bronchoscopy, and tested for correlation between CC16 immunostaining intensity and lung function. In an in-vitro model, bronchial epithelial cells were exposed to cigarette smoke extract (CSE), and the expression levels of CC16 were measured in bronchial epithelial cells before and after exposure to CSE.ResultsThere was a significant association between FEV1 decline and serum CC16 levels in smokers. Expression of CC16 in bronchial epithelium showed significant correlation with FEV1/FVC. Bronchial epithelial cells showed significant decrease in CC16 expression after exposure to CSE, followed by a subsequent rise in CC16 expression upon removal of CSE.ConclusionsResults of these clinical and laboratory investigations suggested that low serum CC16 was associated with smoking-related decline in lung function, demonstrated the first time in a Chinese cohort. The data also lend support to the putative role of CC16 in protection against smoking-related bronchial epithelial damage.(Abstract word count: 243)US clinical trial registryNCT01185652, first posted 20 August, 2010.

Response to SARS as a prototype for bioterrorism: Lessons in a Regional Hospital in Hong Kong

Publisher Summary This chapter reviews the response to severe acute respiratory syndrome (SARS), which can serve as a prototype for combating acts of bioterrorism, in the setting of a Hong Kong acute-care hospital. After overcoming the onslaught of SARS, the Hong Kong community has become aware that emerging infections can occur at any time. This is reinforced by the recent avian influenza outbreaks, which act as a reminder of this looming threat. Hospitals have to evaluate their levels of preparedness against bioterrorism, which can simulate infectious disease outbreaks. The priority areas for improvement include community involvement, staff education, improved information technology, disease surveillance, and additional equipment and staff. Multidimensional and flexible-response plans require strong leadership and clear directions to be effective, and such plans must also consider human frailties during great stress, when every resource is stretched to its utmost limit. The chapter concludes by discussing the various infection-control measures implemented in Hong Kong.

Current status of therapy of SARS

The severe acute respiratory syndrome (SARS) caused by the SARSassociated coronavirus (SARS-CoV) has caused a worldwide outbreak in 2003. This chapter will start with a description of the pathogenesis of this disease, followed by a review of the various pharmacological treatments and supportive ventilatory strategies adopted during the outbreak. The principles used to design various combinations of therapeutic agents and treatment modalities will also be described based on the present knowledge.