Advances in clinical diagnosis and treatment of severe acute respiratory syndrome

It has been proved that severe acute respiratory syndrome(SARS) is caused by SARS-associated coronavirus, a novel coronavirus. SARS originated in Guangdong Province, the People‘s Republic of China at the end of 2002. At present,it has spread to more than 33 countries or regions all over the world and affected 8 360 people and killed 764 by May 31,2003. Identification of the SARS causative agent and development of a diagnostic test are important. Detecting disease in its early stage, understanding its pathways of transmission and implementing specific prevention measures for the disease are dependent upon swift progress. Due to the efforts of the WHO-led network of laboratodes testing for SARS, tests for the novel coronavirus have been developed with unprecedented speed. The genome sequence reveals that this coronavirus is only moderately related to other known coronaviruses. WHO established the definitions of suspected and confirmed and probable cases. But the laboratory tests and definitions are limited. Until now, the primary measures include disolation, ribavirin and corticosteroid therapy, mechanical ventilation, etc. Other therapies such as convalescent plasma are being explored. It is necessary to find more effective therapy. There still are many problems to be solved in the course of conquering SARS.     

Validation of a clinical prediction rule for severe acute lower intestinal bleeding

OBJECTIVES: Acute lower intestinal bleeding is a heterogeneous disorder and identification of high-risk patients is challenging. We previously retrospectively identified predictors of severity in patients with acute lower intestinal bleeding. The aim of this study was to prospectively validate a clinical prediction rule for severe acute lower intestinal bleeding. METHODS: This was a prospective, observational cohort study of consecutive patients admitted to an academic, tertiary care or a community-based teaching hospital for management of acute lower intestinal bleeding. Data were collected on seven previously identified predictors of severe bleeding: heart rate > or = 100/min, systolic blood pressure < or = 115 mmHg, syncope, nontender abdominal exam, rectal bleeding in the first 4 h of evaluation, aspirin use, and >2 comorbid conditions. Severe bleeding was defined as transfusion of > or =2 units of red blood cells, and/or a decrease in hematocrit of > or =20% in the first 24 h, and/or recurrent rectal bleeding after 24 h of stability (accompanied by a further decrease in hematocrit of > or =20%, and/or additional blood transfusions, and/or readmission for acute lower intestinal bleeding within 1 wk of discharge). Patients were stratified into 3 risk groups according to the previously developed prediction rule: low (no risk factors), moderate (1-3 risk factors), and high (>3 risk factors). RESULTS: A total of 275 patients with acute lower intestinal bleeding were identified. The risk of severe bleeding in each risk category was similar in the validation and derivation cohorts (p values >0.05): low risk 6%versus 9%, moderate risk 43%versus 43%, and high risk 79%versus 84%. The area under the receiver operating characteristic curve was 0.754 for the validation cohort and 0.761 for the derivation cohort. The magnitude of the risk score was significantly correlated with major clinical outcomes including surgery, death, blood transfusions, and length of stay. CONCLUSION: We have developed and prospectively validated a clinical prediction rule for acute severe lower intestinal bleeding. This prediction rule could improve the triage of patients to appropriate levels of care and interventions, and guide a more standardized approach to acute lower intestinal bleeding.     

传染性非典型肺炎的血清学诊断研究

目的 评估传染性非典型肺炎(世界卫生组织又称严重急性呼吸综合征，SARS)血清病毒特异性抗体检测在SARS诊断中的实用价值，了解免疫荧光抗体法(IFA)和酶联免疫吸附法(ELISA)对SARS病毒特异性抗体检测结果的一致性程度。方法 用IFA和ELISA检测267例不同病程SARS患和132例对照组血清SARS病毒特异性抗体，以敏感度、特异度、阳性预测值(17PV)、阴性预测值(NPV)和准确度评价其诊断价值，并以Kappa值评价两种检测方法结果的一致性。结果 以IFA检测的血清特异性IgM类和IgG类抗体阳性率在病程第11天明显增高，病程≥11天，IgM类抗体诊断SARS的敏感度为65．6％，特异度100．0％，PPV 100．0％，NPV 71．0％，准确度81．3％；IgG类抗体则分别为敏感度91．1％，特异度97．0％，PPV 97．3％，NPV 90．1％，准确度93．8％。以ELISA方法所测结果与IFA结果相仿。对IFA和ELISA法检测的一致性检验示Kappa值分别为0．640和0．779。结论 血清病毒特异性抗体在SARS发病10天以上阳性率高，抗体检测有助于确立发病10天以上SARS的血清学诊断。IFA和ELISA检测SARS病毒抗体的一致性较好。     

Validation of a clinical prediction rule for the differential diagnosis of acute meningitis

Objective: To attempt to validate a previously reported clinical prediction rule derived to assist in distinguishing between acute bacterial meningitis and acute viral meningitis. Design: Retrospective chart review of patients treated at five hospitals between 1981 and 1990. The criterion standard for bacterial meningitis was a positive cerebrospinal fluid (CSF) or blood culture or a positive test for bacterial antigen in the CSF. For viral meningitis, the criterion standard was a positive viral culture from CSF, stool, or blood or a discharge diagnosis of viral meningitis with no other etiology evident. Setting: Two Department of Veterans Affairs (VA) hospitals, two county hospitals, and one private hospital, each affiliated with one of two medical schools. Patients: All persons aged more than 17 years who were hospitalized over a ten-year period at one of five academically affiliated hospitals for the management of acute meningitis. Measurements and main results: Sixty-two cases of bacterial meningitis and 98 cases of viral meningitis were confirmed. With all patients included, the discriminatory power of the model as measured by the area under the receiver operating characteristic curve (AUC) was 0.977 (95% CI, 0.957–0.997), compared with the AUC of 0.97 in the derivation set of the original publication. The AUCs (95% CIs) for data subsets were: Dallas cases 0.994 (0.986–1.0), Milwaukee cases 0.912 (0.834–0.990); ages 18–39 years 0.952 (0.892–1.0), ages 40–59 years 0.99 (0.951–1.0), and age >60 years 0955 (0.898–1.0). Conclusions. The authors conclude that the clinical prediction rule proved robust when applied to a geographically distinct population comprised exclusively of adults. There was sustained performance of the model when applied to cases from each city and from three age strata. Prospective validation of this prediction rule will be necessary to confirm its utility in clinical practice. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, DC, April 29, 1992. Supported by an Institutional Research Grant under the Regents Appropriations program at UT/Southwestern Medical School.     

A bedside clinical prediction rule for detecting moderate or severe aortic stenosis

OBJECTIVE: To evaluate a bedside clinical prediction rule for detecting moderate or severe aortic stenosis. DESIGN: Cross-sectional study with independent comparison to a diagnostic reference standard, doppler echocardiography. SETTING: Urban university hospital. PARTICIPANTS: Consecutive hospital inpatients (n=124) who had been referred for echocardiography. MEASUREMENTS AND MAIN RESULTS: Participants were examined by a third-year general internal medicine resident and a staff general internist. We hypothesized in advance that absence of a murmur over the right clavicle would rule out aortic stenosis, while the presence of three or four associated findings (slow carotid artery upstroke, reduced carotid artery volume, maximal murmur intensity at the second right intercostal space, and reduced intensity of the second heart sound) would rule in aortic stenosis. Study physicians were unaware of echocardiographic findings. The outcome was echocardiographic moderate or severe aortic stenosis, defined as a valve area of 1.2 cm² or less, or a peak instantaneous gradient of 25 mm Hg or greater. Absence of a murmur over the right clavicle ruled out aortic stenosis (likelihood ratio [LR] 0.10; 95% confidence interval [CI] 0.01, 0.44). The presence of three or four associated findings ruled in aortic stenosis (LR 40; 95% CI 6.6, 240). If a murmur was present over the right clavicle, but no more than two associated findings were present, then the examination was indeterminate (LR 1.8; 95% CI 0.93, 2.9). CONCLUSION: A clinical prediction rule, using simple bedside maneuvers, accurately ruled in and ruled out aortic stenosis.     

重症急性呼吸综合征的临床特点与分期

目的 通过分析重症急性呼吸综合征(SARS)患者的临床特点,制订SARS的临床分期。方法 回顾性分析1170例SARS患者症状体征、实验室检查、影像学结果在病程不同时期的特点。结果 发热为SARS患者的首发症状,自然热程14d左右。呼吸道症状和感染中毒症状在病程第2周出现或维持一个高峰,3周后恢复正常。低氧血症是其特点之一,动脉血氧分压、脉搏血氧饱和度在病程前2周明显下降,2周后逐渐恢复。100％患者X线胸片异常,病程第1天即可出现,前2周明显加重,2周后开始恢复。淋巴细胞亚群计数在发病初期全面下降,2～3周后恢复正常。结论 典型SARS病程约4周,1～7d为早期,8～14d为极期,15～28d为恢复期。     

急性呼吸窘迫综合征诊断的困惑与反思

急性呼吸窘迫综合征（ARDS）是一组复杂的临床综合征,自1967年首次提出其概念和诊断标准以来,一直存在争议。模糊的概念与缺乏特征性的诊断标准,不仅造成误诊或诊断延误,同时也使众多ARDS患者未得到恰当治疗。近年报道,ARDS的病死率为25．0％～68．7％,其原因不仅与治疗对策有关,亦与概念和诊断标准的不确切有明显关系。故反思并分析当前ARDS概念和诊断标准存在的问题与偏差,提出明确的概念和具有特征性的诊断标准,具有重要临床意义。[第一段]     

Pentaglobin in steroid-resistant severe acute respiratory syndrome.

SETTING: The treatment of severe acute respiratory syndrome (SARS) is at best controversial, although there is considerable anecdotal experience to show the benefits of corticosteroid therapy for selected patients. Some patients deteriorate relentlessly despite treatment with antibiotic, corticosteroid and mechanical ventilation. OBJECTIVE: To attempt to determine the clinical efficacy of pentaglobin, an IgM-enriched immunoglobulin preparation, on 12 severe SARS patients who continued to deteriorate despite corticosteroid and ribavirin therapy. DESIGN: Retrospective analysis of daily quantitative and radiographic data on the cohort in a regional teaching hospital. RESULTS AND CONCLUSION: There was significant improvement in radiographic scores, when compared with day 1, on days 5, 6 and 7 (P < 0.05) after commencement of pentaglobin treatment. Similarly, there was significant improvement in oxygen requirement, when compared with day 1, on days 6 and 7 (P < 0.05) after commencement of pentaglobin treatment. There were no reported adverse events attributable to pentaglobin administration. Ten patients made an uneventful recovery after treatment. One elderly man died from cardiorespiratory arrest despite clinical and radiological improvement, and another patient is making good progress. Pentaglobin is safe and probably effective in the treatment of steroid-resistant SARS. A double-blind placebo-controlled study should therefore be considered.     

重症急性呼吸综合征影像学变化和临床分期的研究

目的分析重症急性呼吸综合征(SARS)患者临床特点、实验室检测结果和胸部影像学变化,提出临床分期.方法对2003年3～5月间有完整胸部影像学动态变化和实验室检测数据的45例SARS患者进行分析.结果 (1)影像学变化普通型23例肺部出现一侧片状阴影为病程的2～5(2.9±1.0) d;发展到双侧2～11(6.9±2.5) d;出现双肺广泛磨玻璃样变、实变6～19(11.0±2.0) d;开始吸收为10～21(15.0±4.1) d;胸部影像学改变完全吸收为18～46(25.9±7.2) d.重型患者22例发展到双肺广泛磨玻璃样变、实变(9.0±3.2) d,与普通型相比,差异无显著性(P>0.05);开始吸收为(19.0±4.6) d, P=0.009, 胸部影像学改变完全吸收为(36.0±8.1) d, P=0.001, 其中7例死亡患者胸部影像学表现均在7 d内进展到双肺广泛实变.(2)实验室检测早期SARS患者T细胞亚群和淋巴细胞明显降低,38例存活组患者在10～15 d恢复;但7例死亡患者T细胞亚群和淋巴细胞未见恢复.结论 SARS患者可分5期潜伏期2～10 d,前驱期1～3 d,进展期4～7 d,极期8～15 d,恢复期16～24 d.从发病到胸部影像学改变初步吸收时间为10～15 d.1周之内进展到双肺广泛实变且2周左右T细胞亚群和淋巴细胞不能恢复的患者,可能预后极差.     

A clinical prediction rule for the diagnosis of ureteral calculi in emergency departments

Objective: To determine: 1) whether a simple clinical prediction rule could identify emergency department patients with ureteral calculi; 2) whether the kidney, ureter, and bladder (KUB) radiograph provides diagnostic information beyond that obtained from the history and physical examination; and 3) whether ureteral calculi can be diagnosed accurately in the emergency department without emergency excretory urography, commonly known as intravenous pyelography (IVP). Patients: Two hundred three patients who underwent emergency KUB and IVP studies for nontraumatic abdominal or flank pain (derivation group) were retrospectively identified from radiology department records; 72 patients were prospectively evaluated in the emergency department for suspected ureteral stones (validation group).     

Treatment and vaccines for severe acute respiratory syndrome

The causative agent of severe acute respiratory syndrome (SARS), which affected over 8000 individuals worldwide and was responsible for over 700 deaths in the 2002-2003 outbreak, is a coronavirus that was unknown before the outbreak. Although many different treatments were used during the outbreak, none were implemented in a controlled fashion. Thus, the optimal treatment for SARS is unknown. Since the outbreak, much work has been done testing new agents against SARS using in-vitro methods and animal models. In addition, global research efforts have focused on the development of vaccines against SARS. Efforts should be made to evaluate the most promising treatments and vaccines in controlled clinical trials, should another SARS outbreak occur.     

关于严重急性呼吸综合征的反思

20 0 3年 6月 2 4日 ,北京终于以 2 50 0余人患病 ,1 91人死亡的代价迎来了“双解除”。我们在庆幸有效控制严重急性呼吸综合征 (SARS)流行的同时 ,也应及时总结经验与教训 ,为有朝一日SARS卷土重来或其他重大公共卫生事件的发生做好准备。一、防治的成功与科研的缺憾2 0 0 3年 4月 2 0日以来 ,政府采取了果断的措施 ,充分发挥了“群众运动”的优势 ,仅用 2个月的时间就使SARS在全国范围内得到有效控制 ,避免了更大的损失 ,不能不说这是一个巨大的成就 ,是一奇迹 ,也是其他国家无法效仿的。但是 ,有关部门如果从开始阶段就能对SARS的…     

The aetiology, origins, and diagnosis of severe acute respiratory syndrome

Severe acute respiratory syndrome (SARS) is a new infectious disease that first emerged in Guangdong province, China, in November, 2002. A novel coronavirus was later identified in patients with SARS. The detection of the virus in these patients, its absence in healthy controls or other patients with atypical pneumonia, and the reproduction of a similar disease in a relevant animal model fulfilled Koch's postulates for implicating this coronavirus as the causal agent of SARS. The full genome sequence was determined within weeks of the virus's identification. The rapid progress in the aetiology, the development of laboratory diagnostic tests, and the defining of routes of viral transmission were facilitated through a unique WHO-coordinated virtual network of laboratories, which shared information on a real-time basis through daily teleconferences. Subsequent studies have indicated that the SARS coronavirus is of animal origin, that its precursor is still present in animal populations within the region, and that live-animal markets in southern China may have provided the animal-human interphase that allowed this precursor virus to adapt to human-human transmission. These findings underscore the potential for the re-emergence of SARS and the need for laboratory tests for early diagnosis. However, the low viral load in the respiratory tract makes early diagnosis of SARS a diagnostic challenge, although improvements in the sensitivity of molecular diagnostic methods continue to be made.     

严重急性呼吸道综合征研究动态

世界卫生组织 (WHO)和美国疾病预防与控制中心 (CDC)正致力于研究在许多国家流行的严重呼吸道综合征。流行病学与实验室研究仍在继续。一种新的冠状病毒已被确定为本病的致病因子。CDC暂行的可疑病例标准着重临床表现和与患者的接触史和疫区旅行史。医务人员、患者家属及社区的感染控制应遵循消毒隔离措施