Ching-Lung Liu

Clinical and Laboratory Features of Severe Acute Respiratory Syndrome Vis-A ` -Vis Onset of Fever*

Study objectives: Severe acute respiratory syndrome (SARS) is a rapidly progressive disease caused by a novel coronavirus (CoV) infection. However, the disease presentation is nonspecific. The aim of this study was to define clearly the presentation, clinical progression, and laboratory data in a group of patients who had SARS. Design: Retrospective observational study. Setting: A tertiary care medical center with 51 negative-pressure isolation rooms in Taipei, Taiwan. Patients: Fifty-three patients with SARS seen between April 27 and June 16, 2003. Results: Fever (ie, temperature > 38°C) was the most common symptom (98%) and the earliest. When admitted to the isolation unit of the hospital for observation, most patients reported nonspecific symptoms associated with their fever. Only two patients with preexisting illnesses had cough on the same day the fever began. Eventually, 39 patients (74%) developed cough, beginning at a mean (± SD) time of 4.5 ± 1.9 days after fever onset, and 35 patients (66%) had diarrhea beginning at a mean time of 6.0 ± 3.3 days after fever onset. Thirty-one patients (59%) had abnormal findings on chest radiographs on hospital admission, and all but 1 patient (98%) eventually developed lung infiltrates that were consistent with pneumonia. The majority of patients (63%) first developed unifocal infiltrates at a mean time of 4.5 ± 2.1 days after fever onset, while in 37% of patients the initial infiltrates were multifocal, appearing at a mean time of 5.8 ± 1.3 days after fever onset. Common laboratory findings included lymphopenia (on hospital admission, 70%; during hospitalization, 95%), thrombocytopenia (on hospital admission, 28%; during hospitalization, 40%), elevated lactate dehydrogenase (on hospital admission, 58%; during hospitalization, 88%), creatine kinase (on hospital admission, 18%; during hospitalization, 32%), and aspartate aminotransferase or alanine aminotransferase levels (on hospital admission, 27%; during hospitalization, 62%). Throat or nasopharyngeal swab for SARS-CoV by reverse transcriptase polymerase chain reaction (PCR) and real-time PCR was positive in 40 of the 47 patients (85%) in whom the test was performed. Conclusions: None of the presenting symptoms or laboratory findings are pathognomonic for SARS. Even though cough developed in a majority of patients, it did not occur until later in the disease course, suggesting that a cough preceding or concurrent with the onset of fever is less likely to indicate SARS. While PCR for SARS-CoV appears to be the best early diagnostic test currently available, it is clear that better methods are needed to differentiate between SARS and non-SARS illness on initial presentation.

Neutralizing Antibody Response and SARS Severity

Antibody response correlates with severity of infection.

Areca nut extract represses migration and differentiation while activating matrix metalloproteinase-9 of normal gingival epithelial cells.

BACKGROUND AND OBJECTIVE Areca (betel) chewing is associated with an increase in the incidence of periodontal diseases. Aberrations in matrix metalloproteinase (MMP) expression have been reported to be associated with periodontal disease. This study investigated the effects of areca nut extract on MMP activity and the phenotype of human gingival epithelial cells. MATERIAL AND METHODS Reverse transcription-polymerase chain reaction, western blotting and gelatin zymography were used to assay MMPs. Cell viability, mobility and detachment assays were performed to characterize the phenotypic impact. Confocal microscopy was employed to evaluate cell aggregation and the distribution of E-cadherin and F-actin. RESULTS Treatment of gingival epithelial cells with 10 microg/mL of areca nut extract reduced its cell viability. Treatment with 5 and 10 microg/mL of areca nut extract for 24 h activated MMP-9 but not MMP-2 in gingival epithelial cells. This activation could be nuclear factor-kappaB dependent and was abrogated by 10 microM curcumin. Areca nut extract also reduced the migration and detachment of gingival epithelial cells. The differentiated cell-cell contact of gingival epithelial cells was markedly impaired by areca nut extract. This was accompanied by a disruption of distribution of E-cadherin and F-actin. CONCLUSION The areca nut extract-mediated activation of MMP-9 in gingival epithelial cells could signify a potential periodontal pathogenesis in areca chewers. The areca nut extract-mediated inhibition of cell viability and migration, together with the changed aggregation in gingival epithelial cells, suggests that impairment of the re-epithelization underlies the process and this, in turn, might exacerbate gingival inflammation.

Viral load and outcome in SARS infection: The role of personal protective equipment in the emergency department

Abstract This study was conducted to evaluate the effectiveness of personal protective equipment (PPE) against severe acute respiratory syndrome (SARS). Sixteen patients in a SARS cluster, including 4 health care workers (HCWs) and 12 non-HCWs were studied. We compared the initial viral load by nasopharyngeal swabs, clinical progression, and outcome of this cluster. The HCWs had a lower viral load. The non-HCWs had a higher mean C-reactive protein, lower oxygen saturation, and a higher incidence of intubation and death. Secondary household transmission developed in three of the non-HCWs’ families. One month after discharge, non-HCWs had more signs of fibrosis on high resolution computed tomography (HRCT) scan and an impaired pulmonary function test. Although most of the PPE do not confer absolute protection against SARS, it seems that they may lower exposure to the virus, leading to a lower risk of secondary transmission, and be associated with relatively mild disease and a better early outcome.

Bronchodilatation Effects of a Small Volume Spacer Used with a Metered-Dose Inhaler

Background and objective. In an effort to improve the delivery of drugs to the lungs, various spacer devices have been developed to attach to metered-dose inhalers (MDIs). The aim of the study was to determine whether use of a small volume tube spacer with MDI is associated with better bronchodilatation. Methods. We assessed bronchodilatation by measuring forced expiratory volume in 1 second (FEV1) before and after inhalation of fenoterol 0.4 mg (2 puffs) delivered by using a MDI in four different ways: with or without a spacer alone or with a mouth rinse of 100 mL of water immediately after inhalation with or without a spacer. Results. A total of 303 patients who had a positive bronchodilator test were studied. There was no significant difference in the ΔFEV1 (mL or %) with or without a spacer (MDI + spacer vs. MDI, mean ± SD, 365.1 ± 146.5 mL vs. 356.3 ± 131.1 mL, p = 0.696; and 21.4 ± 9.4% vs. 21.4 ± 9.5%, p = 0.968, respectively). When patients rinsed their mouth after inhalation, bronchodilatation was significantly less in those using an MDI alone compared with MDI + spacer (302.6 ± 116.5 mL vs. 367.6 ± 128.3 mL, p = 0.002; and 18.0% ± 7.9% vs. 21.7% ± 9.5%, p = 0.013, respectively). Conclusions. When patients correctly use an MDI, addition of a spacer does not significantly improve bronchodilatation. However, if the mouth is rinsed after inhalation, a spacer does yield better bronchodilatation. Our results suggest that systemic effects from bronchodilator inhalation may not be negligible.

Effects of Age on 1-Second Forced Expiratory Volume Response to Bronchodilation

SUMMARY Background: The bronchodilation test is used to detect reversible airways obstruction, considered important for diagnosing asthma. However, little is known about the effects of age on the bronchodilation response. The aim of this study was to evaluate the effects of age on the bronchodilation response by determining changes in the 1-second forced expiratory volume (FEV1) in a Chinese population. Methods: All patients underwent pulmonary function testing to evaluate forced vital capacity, peak expiratory flow, and FEV1. We assessed bronchodilation by measuring the change in FEV1 (FEV1) before and after inhalation of 0.4 mg of fenoterol (two puffs) delivered by a metered-dose inhaler with a spacer. Results: Of the 1,616 patients tested in the clinic, the 333 (21%) who had a positive bronchodilator test, defined as FEV1 > 12% and 200 mL, were enrolled in the study. For this population, the FEV1 was +360.8 ± 138.6 mL (mean ± standard deviation) or +21.0% ± 9.1%. In a multiple linear regression model, the absolute FEV1 (expressed in milliliters) was independently and negatively predicted by age (p < 0.001), and baseline peak expiratory flow (p < 0.001), but positively predicted by height (p < 0.001). Conclusion: Age was an important determinant for response to bronchodilation as determined by the absolute change in FEV1. [International Journal of Gerontology 2009; 3(3): 149–155]

Thoracic Empyema Associated with Colorectal Cancer - A Case Report and Literature Review

A previously healthy 31-year-old female was transferred to our hospital after laparoscopic drainage of an abdominal abscess. She was found to have a left-sided empyema, which grew Bacteroides fragilis on culture. She was then diagnosed with rectal adenocarcinoma that had perforated, accounting for the abdominal abscess. An unusual pathologic finding in the resected specimen was septic thrombi in the lumen of a small vein. To our knowledge, only six other cases of empyema associated with colorectal cancer have been reported since the 1960s. Aside from the cob-pleural fistula in two of those cases, the route of pleural infection in the reported cases was not totally clear. The finding of septic thrombi in a small vein in our case is good evidence that B. fragilis, a normal flora in the colorectum, may enter the circulation causing bacteremia and empyema. Therefore, unusual infections with fecal flora may indicate the presence of a malignancy.