Immunosuppression in patients with severe acute pancreatitis

Background In severe acute pancreatitis (SAP), immunologic impairment in the early phase may be linked to subsequent infectious complications. In this study, immunologic alterations in patients with SAP were analyzed, and immunologic parameters related to infectious complications were clarified. Methods A total of 101 patients with SAP were analyzed retrospectively. Various immunologic parameters on admission were analyzed and compared between the infection group and noninfection group during SAP. Furthermore, chronologic change in the lymphocyte count was investigated, and its utility for predicting infection was compared with conventional scoring systems. Results Serum immunoglobulin G (IgG), serum IgM, lymphokine-activated killer cell activity, and natural killer cell activity were low, and the incidence of abnormally low values was 50.0%, 65.0%, 45.5%, and 42.4%, respectively. Serum complement factor 3 was significantly negatively correlated with the APACHE II score. The lymphocyte count was decreased below the normal range, and was significantly negatively correlated with the APACHE II score. CD4-, CD8-, and CD20-positive lymphocyte counts were below the normal range, and CD4- and CD8-positive lymphocyte counts were significantly lower in the infection group. The lymphocyte count on day 14 after admission was significantly lower in the infection group and was more useful for predicting infection than conventional scoring systems. Conclusions Immunosuppression occurs from the early phase in SAP, and quantitative impairment of lymphocytes, mainly T lymphocytes, may be closely related to infectious complications during SAP. CD4- and CD8-positive lymphocyte counts on admission and the lymphocyte count on day 14 after admission may be useful for predicting infection.     

Effects of severe acute respiratory syndrome (SARS) coronavirus infection on peripheral blood lymphocytes and their subsets.

INTRODUCTION: Severe acute respiratory syndrome (SARS) caused large outbreaks of atypical pneumonia in 2003, with the largest localized outbreak occurring in Beijing, China. Lymphopenia was prominent amongst the laboratory abnormalities reported in acute SARS. METHODS: The effect of SARS on peripheral blood lymphocytes and their subsets was examined in 271 SARS coronavirus-infected individuals. RESULTS: There was a significant decrease in the CD45+, CD3+, CD4+, CD8+, CD19+ and CD16+/56+ cell counts over the five weeks of the SARS illness although CD4+/CD8+ ratios did not change significantly. The lymphopenia was prolonged, reaching a nadir during days 7-9 in the second week of illness before returning towards normal after five weeks, with the lowest mean CD4+ cell count of 317 cellsx10(6)/L at day 7, and CD8+ cell count of 239 cellsx10(6)/L at day 8. Patients with more severe clinical illness, or patients who died, had significantly more profound CD4+ and CD8+ lymphopenia. DISCUSSION: Lymphopenia is a prominent part of SARS-CoV infection and lymphocyte counts may be useful in predicting the severity and clinical outcomes. Possible reasons for the SARS-associated lymphopenia may be direct infection of lymphocytes by SARS-CoV, lymphocyte sequestration in the lung or cytokine-mediated lymphocyte trafficking. There may also be immune-mediated lymphocyte destruction, bone marrow or thymus suppression, or apoptosis.     

Early activation of peripheral lymphocytes in human acute pancreatitis

BACKGROUND: The CD69 antigen is an indicator of early lymphocyte activation. GOALS: To evaluate the early activation of peripheral lymphocytes T, B, and NK in patients with acute pancreatitis in comparison with patients with acute abdomen of nonpancreatic origin. STUDY: Thirty patients with acute pancreatitis were studied; 20 of them had the mild form of the disease and 10 had the severe form. Thirty patients with nonpancreatic acute abdomen were used as controls. All patients were enrolled within 48 hours of the onset of pain. In all patients, leukocytes and total lymphocyte and lymphocyte subset counts (CD4+, CD8+, CD56+, CD19+, CD4+CD69+, CD8+CD69+, CD56+CD69+, CD19+CD69+) were determined upon hospital admission. RESULTS: The percentage of total lymphocytes was significantly lower in acute pancreatitis patients than in those with nonpancreatic acute abdomen (P = 0.014); patients with severe pancreatitis had a percentage of total lymphocytes significantly lower when compared with patients with mild pancreatitis (P < 0.001). The CD19+CD69+ count was significantly lower in patients with severe pancreatitis (24.6 +/- 14.6%) than in patients with mild pancreatitis (46.7 +/- 16.5%; = 0.006). The counts of the other lymphocyte subsets were not statistically different between patients with acute pancreatitis and those with nonpancreatic acute abdomen, as well as between patients with mild and severe acute pancreatitis. CONCLUSIONS: Patients with severe pancreatitis show impaired early activation of peripheral CD19+ cells.     

Lymphocyte count and mortality risk in older persons. The Leiden 85-Plus Study

OBJECTIVES: To investigate whether a low peripheral blood lymphocyte count is associated with increased mortality risk in older persons and to determine whether this association could be ascribed to ill health. DESIGN: A cohort study with a total follow-up period of 1,602 person years. SETTING: Leiden, the Netherlands. PARTICIPANTS: Four hundred thirty-six community-dwelling residents aged 85 and older. MEASUREMENTS: Health status and leukocyte total and differential counts were assessed at baseline. Lymphocyte subsets were measured with a fluorescence-activated cell sorter. Age- and sex-adjusted mortality risks were estimated using Cox proportional hazard regression analysis. RESULTS: There was no association between lymphocyte count and mortality in persons with ill health (mortality risk lowest vs highest quartile=1.16; 95% confidence interval (CI)=0.85-1.58, P=.35), but mortality was dependent on lymphocyte count if disease was excluded (mortality risk lowest vs highest quartile=2.14; 95% CI=1.08-4.23, P=.03). A similar increase in mortality risk was found when the cluster designation (CD)4+, CD8+, and CD16+ lymphocyte subsets were analyzed. Within individuals, low values of the lymphocyte subsets were related and there was no compensatory increase in CD16+ lymphocyte counts. A low lymphocyte count was not associated with specific causes of death. CONCLUSION: A low lymphocyte count was associated with an increased mortality risk in older persons without apparent disease. This association was not only found for the total lymphocyte count but also for the CD4+, CD8+, and CD16+ lymphocyte subset counts.     

严重急性呼吸综合征患者淋巴细胞亚群的动态变化及意义

目的　了解成人严重急性呼吸综合征 (SARS)患者淋巴细胞亚群的改变对疾病的发生、发展及预后的影响。方法　依据卫生部颁发的传染性非典型肺炎临床诊断标准及预后将 2 0 6例SARS患者分为 3组 :即非重症组 13 3例、重症存活组 50例、重症死亡组 2 3例 ,用流式细胞仪进行淋巴细胞亚群CD4+、CD8+、CD19+、CD16+淋巴细胞的动态检测。建立数据库并对检测结果进行统计学分析。结果　SARS患者CD4+、CD8+、CD19+淋巴细胞计数均值分别是非重症组 >重症存活组 >重症死亡组 ,组间比较均P <0 .0 5。CD16+均值非重症组与重症存活组比较P >0 .0 5,两组与死亡组比较均P <0 .0 1。通过对CD4+、CD8+、CD19+、CD16+淋巴细胞计数动态观察 ,发现非重症组与重症存活组随病程CD4+、CD8+先下降后上升 ,CD19+随病程逐渐上升 ,CD 16+在发病早期有短暂的升高 ,然后波动在正常范围内。重症死亡组CD4+、CD8+、CD19+、CD16+在发病初期即处于较低水平 ,发病 15d后CD4+、CD8+、CD19+仍持续低水平 ,而CD16+随病程呈持续性降低。结论　成人SARS患者有明显的细胞免疫损伤 ,其淋巴细胞亚群的改变与临床分型及预后相关 ,对预后判断有一定的指导意义。SARS患者CD4+、CD8+淋巴细胞计数在发病初期是降低的 ,非重症组、重症存活组发病 9～15d是最     

Parallel decline of CD8＋CD38＋ lymphocytes and viremia in treated hepatitis B patients

AIM:To assess the peripheral T lymphocyte subsets in chronic hepatitis B virus(HBV) infection,and their dynamics in response to adefovir dipivoxil monotherapy.METHODS:Proportions and absolute counts of peripheral natural killer cells,B cells,CD8+,CD4+,CD8+ CD38+,CD8+CD28+ and CD4+CD28+ T cells were determined using three-color flow cytometry in chronic hepatitis B patients(n = 35),HBV carriers(n = 25) and healthy controls(n = 35).Adefovir dipivoxil was initiated in 17 chronic hepatitis B patients who were r...     

Immunomodulatory effects of secondary hyperparathyroidism on circulating CD4+ and CD8+ T-lymphocytes in chronic renal failure patients

The immunomodulatory effects of parathyroid hormone (PTH) in patients with end stage renal disease (ESRD) is controversial. This study was carried out to investigate the effect of PTH levels on the circulating CD4+, CD8+ T cell counts (%) in patients with chronic renal failure (CRF) on regular hemodialysis ((HD). The study included 22 patients with serum levels of PTH < 300 pg/ml (group 1), 18 patients with PTH > 300 pg/ml (group II) and 10 age and sex matched normal controls (group III). Chemiluminescence and flowcytometry assays were performed for determination of serum PTH levels and T cell subset counts respectively. The mean (%) of total lymphocyte, CD4+, CD8+ and CD4\CD8 ratio of group I were (81.68+/- 9.38), (52.00+/-6.24), (27.13+/- 6.31) and (1.99+/-0.42) respectively, as compared to (73.83+/-13.30), (46.05+/-8.59), (23.05+/-4.63) and (2.03+/-0.41) respectively in group II. Values of group I and II were significantly (P<0.001) lower than controls (88.50 +/- 6.02), (63.30 +/- 6.44), (36.80 +/- 6.44) and (1.76+/-0.36) respectively. In group II, the reduction was significantly (P<0.001) prominent in patients with high PTH levels, with significant inverse correlations (P<0.001) between PTH and % of total lymphocyte (r= -0.93), CD4+ (r= -0.74) and CD8+ % (r=-0.69). In conclusion, increased level of PTH in CRF patients on hemodialysis is associated with lymphopenia and reduction in CD4+ & CD8+ subsets of T cells. Monitoring circulating PTH levels in such patients can restore their immune competence.     

Clinical course, prognostic factors, and outcome prediction for HIV patients in the ICU. The PIP (Pulmonary complications, ICU support, and prognostic factors in hospitalized patients with HIV) study

STUDY OBJECTIVE: To describe the clinical course and prognostic factors in patients with HIV admitted to the ICU. DESIGN: Prospective, observational. SETTING: A university-affiliated medical center. METHODS:: We included 169 consecutive ICU admissions, from April 1995 through March 1999, of 141 adults with HIV. Data collected included APACHE (acute physiology and chronic health evaluation) II score, CD4(+) lymphocyte count, serum albumin level, in-hospital mortality, and the development of organ failure, systemic inflammatory response syndrome (SIRS), and ARDS. RESULTS: The ICU admission rate of hospitalized patients with HIV infection was 12%. The most common reason for ICU admission was respiratory failure, occurring in 65 patient admissions. Mechanical ventilation was required in 91 admissions (54%), ARDS developed in 37 admissions (22%), Pneumocystis carinii pneumonia was diagnosed in 24 admissions (14%), and SIRS developed in 126 admissions (75%). One or more organ failures developed in 131 admissions (78%). The actual and predicted mortality rates were 29.6% and 45.2%, respectively, with a standardized mortality ratio of 0.65. The most frequent immediate cause of death was bacterial infection. The CD4(+) lymphocyte count (median, 27.5 cells/microL vs 59 cells/microL; p = 0.0310) and serum albumin level (median 2.2 g/dL vs 2.6 g/dL; p = 0.0355) of nonsurvivors were lower and the APACHE II score (median, 30 vs 21; p < 0.0001) was higher, compared to those of survivors. A higher APACHE II score (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.05 to 1.16) and a transfer from another hospital ward (OR, 3.03; 95% CI, 1.20 to 7.68) were independently associated with increased mortality. The median number of organ failures that developed in survivors was one, compared to four in nonsurvivors (p < 0.0001). CONCLUSIONS: The outcome of HIV-infected patients admitted to the ICU has improved over the years. The CD4 count does not correlate with in-hospital mortality. Higher APACHE II scores and a transfer from another hospital ward are associated with a poor outcome.     

93例传染性非典型肺炎患者外周血T淋巴细胞亚群变化及临床意义

目的　了解传染性非典型肺炎 (世界卫生组织又称严重急性呼吸综合征 ,SARS)患者外周血T淋巴细胞亚群的变化。方法　采用流式细胞仪对 93例临床确诊的SARS患者、5 0例获得性免疫缺陷综合征 (AIDS)患者及 6 4例健康体检者外周血T淋巴细胞亚群进行检测。 93例患者中 ,男4 0例、女 5 3例 ;年龄 17～ 88岁 ,平均 4 4岁 ;重型 35例、普通型 5 8例。结果　健康体检者外周血CD+ 3 、CD+ 4 、CD+ 8分别为 (15 2 7± 4 70 )、(787± 2 5 7)、(6 33± 2 80 )个 / μl;93例急性期SARS患者分别为(72 2± 5 33)、(438± 35 3)、(30 7± 2 17)个 / μl,均有不同程度的下降 (P值均 <0 .0 1) ,重症病例下降尤其明显 ,5例死亡患者外周血CD+ 4 均低于 2 0 0个 / μl;SARS患者恢复期CD+ 3 、CD+ 4 、CD+ 8多数恢复正常。而AIDS患者以CD+ 4 降低为主 ,为 (2 96± 2 98)个 / μl;且CD+ 8升高 ,为 (818± 5 6 6 )个 / μl。 结论SARS患者有明显的细胞免疫损伤。     

Factors associated with hospital mortality in community-acquired legionellosis in France

The aims of this study were to describe the clinical, biological and radiological features of community-acquired (CA) Legionnaires' disease (LD) and identify the predictors of mortality in hospitalised patients. Demographic data, risk factors, clinical and biological features, medical management, complications, and outcome from 540 hospitalised patients with confirmed CA LD were prospectively recorded. 8.1% of patients (44 out of 540) died. The predictors of survival after Kaplan-Meier analysis were male sex (p = 0.01), age <60 yrs (p = 0.02), general symptoms (p = 0.006), intensive care unit (ICU) stay (p<0.001), and class II-III Pneumonia Severity Index score (p = 0.004). Six predictors of death were identified by multivariate analysis: age (per 10-yr increment) (relative hazard (RH) 1.50, 95% CI 1.21-1.87), female sex (RH 2.00, 95% CI 1.08-3.69), ICU admission (RH 3.31, 95% CI 1.67-6.56), renal failure (RH 2.73, 95% CI 1.42-5.27), corticosteroid therapy (RH 2.54, 95% CI 1.04-6.20) and C-reactive protein (CRP) >500 mg · L(-1) (RH 2.14, 95% CI 1.02-4.48). Appropriate antibiotic therapy was prescribed for 70.8% (292 out of 412) of patients after admission and for 99.8% (537 out of 538) of patients after diagnosis confirmation. In conclusion, female sex, age, ICU stay, renal failure, corticosteroid treatment and increased level of CRP are significant risk factors for mortality in CA LD.     

Reconstruction of the immune system after unrelated or partially matched T-cell-depleted bone marrow transplantation in children: immunophenotypic analysis and factors affecting the speed of recovery

We prospectively studied immune reconstitution in 102 children who underwent T-lymphocyte depleted bone marrow transplants using either closely matched unrelated donors or partially matched familial donors by assaying total lymphocyte counts (TLC), T-cell subsets, B cells, and natural killer cells. TLC, CD3+, and CD4+ T-cell counts remained depressed until 2 to 3 years posttransplant, whereas CD8+ T-cell counts normalized by 18 months, resulting in an inverted CD4:CD8 ratio until 12 months posttransplant. Although the percentage of NK cells was elevated early posttransplant, their absolute numbers remained normal. CD20+ B cells were depressed until 12 to 18 months posttransplant. Factors affecting immunophenotypic recovery were analyzed by nonparametric statistics. Younger patients tended to have higher TLC posttransplant. Higher marrow cell doses were not associated with hastened immunophenotypic recovery. Graft-versus-host disease (GVHD) and/or its treatment significantly delayed the immune reconstitution of CD3+, CD4+, and CD20+ cells. The presence of cytomegalovirus was associated with increased CD8+ counts and a decrease in the percentages of CD4+ and CD20+ cells.     

急性胰腺炎患者血清sCD40早期检测的临床意义

背景:CD40是免疫应答中的共刺激分子,通过与其配体CD40L结合,参与介导免疫调节信号。研究显示在多种疾病状态下,外周血和体液可溶性CD40(sCD40)水平异常增高。目的:检测急性胰腺炎(AP)患者的入院早期血清sCD40水平并探讨其临床意义。方法:随机选取72例住院AP患者(MAP 44例,SAP 28例),以ELISA法检测入院24h内血清sCD40水平,21例健康体检者作为对照。以ROC曲线评价早期血清sCD40对AP以及AP相关急性肺损伤(ALI)的诊断效能。结果:AP组入院24 h内血清sCD40水平显著高于对照组(P0.01),其中SAP组又高于MAP组,并与入院24 h内血清CRP水平呈显著正相关(r=0.413,P=0.000)。血清sCD40诊断AP的ROC曲线下面积(AUC)为0.806,最佳诊断界值为≥29.45 pg/mL;预测AP相关ALI的AUC为0.808,诊断效能明显高于APACHEⅡ评分(AUC=0.733)、Ranson评分(AUC=0.648)和血清CRP(AUC=0.625),最佳诊断界值为≥47.96 pg/mL。结论:早期检测血清sCD40有助于早期识别AP、判断病情严重程度以及预测AP相关ALI的发生。     

Association of ICAM3 genetic variant with severe acute respiratory syndrome

Genetic polymorphisms have been demonstrated to be associated with vulnerability to human infection. ICAM3, an intercellular adhesion molecule important for T cell activation, and FCER2 (CD23), an immune response gene, both located on chromosome 19p13.3, were investigated for host genetic susceptibility and association with clinical outcome. A case-control study based on 817 patients with confirmed severe acute respiratory syndrome (SARS), 307 health care worker control subjects, 290 outpatient control subjects, and 309 household control subjects unaffected by SARS from Hong Kong was conducted to test for genetic association. No significant association to susceptibility to SARS infection caused by the novel coronavirus (SARS-CoV) was found for the FCER2 and the ICAM3 single nucleotide polymorphisms. However, patients with SARS homozygous for ICAM3 Gly143 showed significant association with higher lactate dehydrogenase levels (P=.0067; odds ratio [OR], 4.31 [95% confidence interval {CI}, 1.37-13.56]) and lower total white blood cell counts (P=.022; OR, 0.30 [95% CI, 0.10-0.89]) on admission. These findings support the role of ICAM3 in the immunopathogenesis of SARS.     

胱抑素C改良的GRACE风险评分对急性冠状动脉综合征患者心血管事件的预测价值

目的 探讨入院时胱抑素C水平是否增强GRACE风险评分对急性冠状动脉综合征（ACS）患者12个月心血管事件的预测价值.方法 回顾性分析我院2011年6月至2012年6月400例ACS患者入院时的胱抑素C水平和GRACE风险评分.通过绘制受试者工作特征曲线（ROC）,分析胱抑素C对心血管事件的预测价值和最佳界值,并根据Logistic回归分析中的OR值,确定胱抑素C在评分中的分值,建立胱抑素C改良的GRACE风险评分.通过计算ROC曲线下面积（AUC）比较胱抑素C改良的GRACE风险评分和常规的GRACE风险评分对心血管事件的预测价值.结果 ACS患者12个月内的心血管事件发生率为33.5％.胱抑素C水平对12个月内的心血管事件有良好的预测价值（AUC：0.706,95％ CI：0.631～0.780,P=0.000）,而且在Logistic回归分析中经GRACE风险评分校正后仍保留其预测价值.GRACE风险评分预测12个月心血管事件的AUC为0.623（95％ CI：0.545～0.701）,增加胱抑素C参数后,增强了GRACE风险评分对12个月心血管事件的预测价值（AUC0.721,95％ CI：0.650 ～0.792）,差异有统计学意义（Z=2,P=0.03）.结论 入院时胱抑素C水平可以增强GRACE风险评分对ACS患者12个月心血管事件的预测价值.     

Community-acquired pneumonia in patients with liver cirrhosis: clinical features, outcomes, and usefulness of severity scores

We performed an observational analysis of a prospective cohort of nonimmunocompromised hospitalized adults with community-acquired pneumonia (CAP) to determine the epidemiology, clinical features, and outcomes of patients with liver cirrhosis. We also analyzed the prognostic value of several severity scores. Of 3420 CAP episodes, 90 occurred in patients with liver cirrhosis. The median value of the Model for End-Stage Liver Disease (MELD) was 14 (range, 6-36). On the Child-Pugh (CP) score, 56% of patients were defined as grade B and 22% as grade C. Patients with liver cirrhosis were younger (61.8 vs. 66.8 yr; p = 0.001) than patients without cirrhosis, more frequently presented impaired consciousness at admission (33% vs. 14%; p < 0.001) and septic shock (13% vs. 6%; p = 0.011), and were more commonly classified in high-risk Pneumonia Severity Index (PSI) classes (classes IV-V) (74% vs. 58%; p = 0.002). Streptococcus pneumoniae (47% vs. 33%; p = 0.009) and Pseudomonas aeruginosa (4.4% vs. 0.9%; p = 0.001) were more frequently documented in patients with cirrhosis. Bacteremia was also more common in these patients (22% vs. 13%; p = 0.023). Areas under the curve (AUCs) from disease-specific scores (MELD, CP, PSI, and CURB-65 [confusion, urea, respiratory rate, blood pressure, and age ≥65 yr]) were comparable in predicting severe disease (30-d mortality and intensive care unit [ICU] admission). A new score based on MELD, multilobar pneumonia, and septic shock at admission (MELD-CAP) had an AUC of 0.945 (95% confidence interval [CI], 0.872-0.983) for predicting severe disease and was significantly different from other scores. Early (5.6% vs. 2.1%; p = 0.048) and overall (14.4% vs. 7.4%; p < 0.024) mortality rates were higher in cirrhotic patients than in patients without cirrhosis. Factors associated with mortality were impaired consciousness, multilobar pneumonia, ascites, acute renal failure, bacteremia, ICU admission, and MELD score. Among the severity scores, MELD-CAP was the only score associated with severe disease (odds ratio [OR], 1.33; 95% CI, 1.09-1.52) and mortality (OR, 1.21; 95% CI, 1.03-1.42). In conclusion, CAP in patients with liver cirrhosis presents a distinctive clinical picture and is associated with higher mortality than is found in patients without cirrhosis. The severity of hepatic dysfunction plays an important role in the development of adverse events. Cirrhosis-specific scores may be useful for predicting and stratifying cirrhotic patients with CAP who have a high risk of severe disease.     

Triggering receptor (TREM-1) expressed on myeloid cells predicts bacteremia better than clinical variables in community-acquired pneumonia

Background and objective: Some clinical variables are associated with bacteremia in patients with community‐acquired pneumonia (CAP). The aim of this study was to analyse the accuracy of the soluble form of triggering receptor expressed on myeloid cells‐1 (sTREM‐1) to predict positive blood cultures in comparison with established clinical prognostic variables. Methods: In addition to collecting clinical and laboratory information, a commercially available immunoassay kit was used to measure the serum sTREM‐1 levels on the first day of admit ion in patients with CAP. Receiver operating characteristic (ROC) curves were used to compare the ability of sTREM‐1 and commonly used clinical variables to identify bacteremia. Results: Blood cultures yielded a pathogen in 13 (10.4%) out of 124 patient samples. The microorganisms isolated were Streptococcus pneumoniae (11 patients) and Klebsiella pneumoniae (2 patients). The presence of pleuritic chest pain, tachycardia and extreme white cell count (WCC) were associated with bacteremia. However, ROC curve analysis showed an accuracy of sTREM‐1 (area under the receiver operating characteristic curve (AUC) 0.84, 95% CI: 0.72–0.95), which was higher than pleuritic chest pain (AUC 0.71, 95% CI: 0.57–0.84), tachycardia (AUC 0.73, 95% CI: 0.58–0.88) and extreme WCC (AUC 0.70, 95% CI: 0.55–0.85) for predicting positive blood cultures. Low admission sTREM‐1 serum values had a high negative predictive value for excluding bacteremia (sTREM‐1 <120 pg/mL = 98.8%). Conclusions: This preliminary study suggests that the determination of sTREM‐1 serum levels on admission may be more accurate than clinical variables for identifying bacteremic patients.     

糖皮质激素治疗重症急性呼吸综合征初探

目的　探讨糖皮质激素对重症急性呼吸综合征 (SARS)病情的影响。方法　定期观察我院自 2 0 0 3年 3月 2 6日至 5月初收治的SARS病人 30例 ,病程均为 3周以上。统计激素治疗的时间和剂量 ,观察治疗前后CD+ 4 、CD+ 8、CD+ 3 T淋巴细胞计数 ,以及电解质、血象、血清白蛋白变化。结果　激素治疗前 2 7例患者CD+ 4 、CD+ 8、CD+ 3 T淋巴细胞计数分别为 (个 / μl ) 4 0 1± 2 0 3、340± 187、75 6± 383。30例中 2 9例使用甲泼尼龙治疗 ,2 4例剂量为 80～ 16 0mg/d ,最大剂量为 10 0 0mg/d(入我院前 )。应用激素后血白细胞升高 (P <0 .0 1) ;血K+ 、Na+ 、Cl-无明显变化 (P >0 .0 5 ) ;血糖升高 (P =0 .0 1) ;血清白蛋白明显下降 (P <0 .0 1) ;较大剂量的激素可明显抑制CD+ 4 、CD+ 8、CD+ 3 T淋巴细胞的水平 ;3例重症病例在大剂量激素应用下出现二重感染。结论　SARS病人在病程早期免疫功能已受到抑制 ,大剂量应用糖皮质激素可明显加重这一抑制 ,并使机体处于高代谢状态 (血糖升高、血清白蛋白下降 ) ,进一步导致病情加重 ,病人在后期易出现严重继发感染 ,因此应严格掌握激素适应证 ,不宜大剂量使用。     

Is prognostic nutritional index a predictive marker for estimating all-cause in-hospital mortality in COVID-19 patients with cardiovascular risk factors?

BackgroundThis study examined the possible association between the prognostic nutritional index (PNI) and in-hospital mortality rates in cases with a high cardiovascular risk burden and hospitalized with the diagnosis of coronavirus disease 2019 (COVID-19).Material and MethodsThis retrospective and cross-sectional study included 294 COVID-19 patients hospitalized in a tertiary referral pandemic center. The study cohort was grouped into tertiles based on the initial PNI values as T1, T2, and T3. The PNI was calculated for each case and the prognostic value of this index was compared to CURB-65 and 4C mortality risk scores in predicting in-hospital mortality.ResultsPatients stratified into the T1 tertile had a lower lymphocyte count, serum albumin level, and PNI values. In a multivariate analysis, the PNI (OR: 0.688,%95CI: 0.586–0.808, p < 0.001) was an independent predictor for all-cause in-hospital death. After adjusting for confounding independent parameters, patients included in the T1 tertile were found to have 11.2 times higher rates of in-hospital mortality compared to the T3 group, which was presumed as the reference group. In addition, we found that the area under curve (AUC) value of PNI was significantly elevated than that of serum albumin level and total lymphocyte counts alone. [(AUC):0.79 vs AUC:0.75 vs AUC:0.69; respectively).ConclusionThis study demonstrated that the PNI is independently related with in-hospital mortality in patient with COVID-19 and cardiovascular risk factors. The power of the PNI was also validated using well-accepted risk scores of COVID-19 such as CURB-65 and 4C mortality risk scores.     

Value of initial chest radiographs for predicting clinical outcomes in patients with severe acute respiratory syndrome

PURPOSE: To determine whether the initial chest radiograph is helpful in predicting the clinical outcome of patients with severe acute respiratory syndrome (SARS). METHODS: Of 343 patients who met the World Health Organization's case definition of probable SARS and who had been admitted to a regional hospital in Hong Kong, 201 patients had laboratory evidence of SARS coronavirus infection. The initial frontal chest radiographs of these 201 patients were assessed in a blinded fashion by 3 radiologists; individual findings were accepted if at least 2 of the radiologists concurred. Independent predictors of an adverse outcome, defined as the need for assisted ventilation, death, or both, were identified by multivariate analysis. RESULTS: Bilateral disease and involvement of more than two zones on the initial chest radiograph were associated with a higher risk of liver impairment and poor clinical outcome. Forty-two patients (21%) developed an adverse outcome. Multivariate analysis showed that lung involvement of more than two zones (odds ratio [OR] = 7.0; 95% confidence interval [CI]: 2.7 to 17.9), older age (OR for each decade of life = 1.5; 95% CI: 1.1 to 2.0), and shortness of breath on admission (OR = 2.8; 95% CI: 1.1 to 7.4) were independent predictors of an adverse outcome. CONCLUSION: Frontal chest radiographs on presentation may have prognostic value in patients with SARS.