[Induction of injury to endothelium of pulmonary artery due to entero superantigen by up regulation of lymphocyte chemokine receptor 5].

OBJECTIVE: To observe the injurious effect of T cell activated by Staphylococcus enterotoxin B (SEB) on human pulmonary artery endothelial cell (HPAEC) and explore its possible mechanism. METHODS: HPAEC was cocultured with SEB-activated T cells supernatant, and the secretion of chemotactic factors from HPAEC was examined. The Transwell inserts was used in chemoattraction assays. After HPAECs were cocultured with T cells and 10 ng/ml SEB for 3 days, HPAEC damage was monitored by microscopy and the terminal deoxynucleotidyl transferase mediated dUTP nick end labeling (TUNEL) assay. RESULTS: Three kinds of tested chemokines showed a time dependent increase in all supernatant of HPAEC incubated with different concentrations of T cells. After 72 hours, the monocyte chemoattractant protein 1 (MCP 1, ng/ml) in 1×10(-2) , 1×10(-1), 1×10(0) T cell supernatant groups was 1.240±0.103, 4.200±0.305, 6.500±0.500, respectively, macrophage inflammatory protein 1α (MIP 1α, ng/ml) was 0.210±0.015, 0.287±0.012, 0.531±0.037, respectively , and Rantes (ng/ml) was 1.420±0.074, 7.634±0.630, 15.700±1.300, respectively. Rantes presented a two phase secretion mode: in early 6 hours it increased swiftly, but relatively slow at 12, 24, 48, 72 hours. T cell adherent to polycarbonate membrane increased after SEB stimulation in superantigen group compared with control group without SEB stimulation (86.38±14.50 vs. 16.50±2.50, P<0.01). When 10 ng/ml SEB-activated T cell was cocultured with HPAEC, more of originally suspended cultured T cells adhered to HPAEC monolayer [(15.50±1.08)% vs. (1.60±0.22)%, PP<0.01], whereas the cell adhesion ratio decreased markedly in 1 µg/ml Met Rantes group [(4.39±0.66)%, PP<0.01). FACs test of HPAEC adherent T cell showed lymphocyte chemokine receptor 5 (CCR5)/CD4 and CCR5/CD8 increased over 2.5 folds and 2.8 folds compared with 100 ng/ml SEB-activated T cell. Cell death rate of HPAEC was increased when cocultured with SEB-activated T cell in superantigen group compared with HPAEC normal incubation group [(32.50±4.50)% vs. (3.50±0.50)%, P<0.01]. CONCLUSION: Increased chemoattraction and adherence of SEB-activated T cells to HPAEC could damage HPAEC; this effect was possibly due to up regulation of CCR5 on T cell.

[Evaluation of compliance with bundle treatment in the management of severe infection].

OBJECTIVE: To evaluate compliance with bundle treatment in the management of severe infection in a tertiary hospital, aiming at analyzing clinical data in order to popularize guidelines for management of severe sepsis and septic shock. METHODS: A 14-month (from November 1, 2006 to December 31, 2007) prospective observational study of a group of 43 patients admitted to the respiratory intensive care unit in First Affiliated Hospital (tertiary hospital) of Guangzhou Medical College meeting the criteria for severe pneumonia and septic shock was carried out. Implementation of 6-hour and 24-hour bundle treatment for severe infection was divided into three phases consisting of education, trial, and application. A cohort of 43 patients with matched disease history admitted during January 1, 2004 to October 31, 2006 were enrolled as control group. RESULTS: (1) In 6-hour bundle treatment for severe infection, 20.9% (9/43) had serum lactate measured, blood culture was obtained prior to antibiotic administration in 7.0% (3/43) of patients, 100% (43/43) had empirical antibiotics administration within 1 hour, an infusion of an initial minimum of 20 ml/kg of crystalloid or colloid equivalent (1.1 ml/kg of 20% albumin or 4.8 ml/kg of 6% hydroxyethyl starch) was given in 44.2% (19/43), with infused fluid (converted into 6% hydroxyethyl starch) reaching (503.95+/-176.19) ml within 6 hours, in 94.7% (18/19) of patients had received vasopressors , and inotropic dobutamine and/or transfusion of packed red blood cells were administered in 7.0% (3/43). (2) In 24-hour bundle treatment for severe infection group, 31.6% (6/19) had received low-dose steroids, 34.9% (15/43) had their blood glucose controlled<8.3 mmol/L, mechanical ventilation with inspiratory plateau pressures maintained<30 cm H(2)O (1 cm H(2)O=0.098 kPa, 6 ml/kg tidal volume) was instituted in 97.6% (40/41) of patients. (3) The percentage of compliance with 6-hour and 24-hour bundle treatment for severe infection were 0 and 21.4% respectively, total compliance was also 0. (4) As compared with control group, a 23.30% absolute mortality reduction was found in bundle group (18.6% vs. 41.9%, P=0.019). CONCLUSION: Bundle treatment for severe infection is complied with partially in our hospital, suggesting that it is still quite arduous to popularize guidelines for management of severe sepsis and septic shock in our country.

[Severe respiratory failure after injection of botulinum toxin: case report and review of the literature].

OBJECTIVE: To describe the manifestations and management of respiratory failure caused by cosmetic injections of botulinum toxin type A (BTA). METHODS: A case of severe respiratory failure after cosmetic injections of BTA was reported and the literature was reviewed. RESULTS: A 24 year old female, seeking leg cosmetic therapy, received multiple point dorsal intramuscular injection of BTA (200 Units) in the legs. Two days later, 100 unit BTA was injected in the same sites. After the first injection, the patient felt no discomfort. But after the second injection, the patient developed diplopia and malaise but without breathlessness. Gradually, ptosis, dysphagia, and tetraparesis developed, and the patient felt difficult in raising her head, followed by systemic muscle paralysis and severe respiratory failure. After admission, the patient received mechanical ventilation, supportive therapies, active muscle functional exercise and she recovered slowly. The double proximal and distal upper limb strength were class III and V(-), and the double proximal and distal lower limb muscle strength were class IV and V(-). Cough reflex and deglutition reflex recovered gradually. The patient was successfully weaned off mechanical ventilation, and was able to walk on discharge. CONCLUSION: Even conventional doses of BTA injection could increase the risk of developing systemic muscle weakness and respiratory failure. Clinical application of botulinum toxin treatment should be strictly controlled.

[A survey of present situation of general intensive care unit in second grade hospitals and construction of intensive care network in Guangdong province].

OBJECTIVE: To investigate the present situation of general intensive care unit (ICU) in second grade hospitals, and to establish intensive care network for the Department of Public Health of Guangdong province in Guangdong province. METHODS: Data from ICU of 26 hospitals in Guangdong were collected through questionnaire concerning different aspects of critical care medicine. RESULTS: (1) ICU size was (10.12+/-3.82) beds per unit, ratios of doctors to beds and nurses to beds were 0.73+/-0.25 and 1.80+/-0.57 respectively, and proportions of closed model or semi-closed model of ICU management were 69.2% and 26.9% respectively. (2) Area occupied by per bed was (17.57+/-7.58) m2, ratio of basins with infrared control facet to beds was 0.47+/-0.33, proportions of ICU equipped with room equipped with positive or negative air pressure, laminar flow, or with room for preparing nutrition support were 15.4%, 30.8%, and 23.1% respectively. (3) All the ICU were capable of institution and management of artificial airway, mechanical ventilation, placement of deep vein line, cardioversion and defibrillation, parenteral nutrition, and sedation. Ninety-six point two percent of the ICU could accomplish trachea intubation independently. Fifty-three point eight percent of the ICU could perform hemodynamic monitoring. Continuous blood purification could be done in 73.1 % of the ICU. (4) Ninety-six point two percent of the ICU were equipped with continuous bedside multifunctional electrocardiogram monitor and ratio of the monitors to beds was 0.89+/-0.29. Ratios of resuscitation air bags to beds and ventilators to beds were 0.71+/-0.34 and 0.71+/-0.24 respectively. Portable ventilator was equipped in 34.6 % of the ICU. Forty percent of the ICU could not perform non-invasive ventilation, 65.4 % of the ICU were equipped with fiberoptic bronchoscope, blood gas analysis could be done during 24 hours round in 92.3 % of the ICU. (5) Twenty-six ICU investigated were found to be distributed over the district of Zhujiang delta, and east, north and west regions of Guangdong, forming the base of intensive care network in Guangdong province. CONCLUSION: Most of the general ICU in second grade hospitals in Guangdong province have fulfilled the main requirement for ICU in accordance with the guidelines for construction of ICU in Guangdong province and of guidelines for construction and management of ICU in China. The average level of the ICU is close to level II. It is possible for the intensive care network to integrate, the present resources effectively and then enhance the level of treatment of critical illness in the said district.

[Retrospective discriminant analysis of the clinical diagnostic criteria for serious contagious severe acute respiratory syndrome].

OBJECTIVE: To analyze the clinical diagnostic criteria for serious severe acute respiratory syndrome (SARS) in Guangdong retrospectively discriminant with SARS database, and to screen out the sensitive warning factors in predicting the outcome. METHODS: Four hundred and two SARS patients were selected based on the diagnostic criteria for SARS from Ministry of Health, China. Of them, 358 SARS patients were selected as their clinical manifestations conformed to the diagnostic criteria of serious SARS. The study subjects were divided into two groups. One group consisted of the patients with serious SARS (358 patients), and they either underwent invasive or non-invasive mechanical ventilation or died of the disease. The remaining 44 SARS patients constituted the non-serious SARS group. Taking the lowest value of oxygen index (OI) as the main index, the OI was categorized into 3 classes, namely< or =200 mm Hg (1 mm Hg=0.133 kPa) as 1,200-300 mm Hg as 2, and >300 mm Hg as 3. According to this index, the seriousness and the prognosis were analyzed. RESULTS: OI less than 300 mm Hg were identified as the unequivocal serious SARS patients, and the mistake judgement rate was 6.800%. Furthermore mortality and complications were compared with Logistic regression, and questionable SARS patients were excluded. The results showed that the patients identified with OI less than 300 mm Hg had worse outcome than the original ones diagnosed with criteria of Ministry of Health. CONCLUSION: OI less than 300 mm Hg in patients with ALI meet the diagnostic criteria of serious SARS better, and it can be taken as a prognostic criterion in clinic.

[Study of continuous blood purification in severe pneumonia patients with multiple organ failure].

OBJECTIVE: To review retrospectively the effect of continuous blood purification (CBP) on septic shock with acute renal failure and respiratory failure as a result of severe pneumonia, and to analyze its relationship with prognosis. METHODS: Twenty-five patients diagnosed as severe pneumonia with varying degrees of multiple organ failure (MOF), septic shock and anuria, were allocated into three groups based on outcome of the patients A (7 patients), died of progressive worsening of septic shock, (9 patients, yet died of severe pneumonia afterwards). Laboratory data and critical scored of the patients 1 day before and 24, 48, and 72 hours after the initiation of CBP were compared among the three groups. RESULTS: (1) The survival rate in group A was 28%, while the combined fatality in groups B and C was 72%. (2) CBP was forced to be stopped in group B patients within less than 48 hours from the start of treatment. Single-factor analysis suggested: group B exhibited higher level of blood sugar compared with group A [(13.17+/-5.84) mmol/L vs. (8.07+/-2.28) mmol/L, P<0.05], and higher fibrinogen levels compared with group C[(5.75+/-3.08) g/L vs. (3.10+/-1.06) g/L, P<0.05] before the treatment. Forty-eight hours after the initiation of CBP, patients in group B exhibited higher fibrinogen and dopamine levels compared with those of groups A and C [(8.24+/-3.57) g/L vs. (5.13+/-0.94) g/L, (3.01+/-1.22) g/L, P<0.05 and (12.00+/-6.93) microgxkg(-1)xmin(-1) vs. (1.00+/-2.45) microgxkg(-1)xmin(-1), (2.89+/-4.37) microgxkg(-1)xmin(-1), P<0.05, respectively]. (3) Acute physiology and chronic health evaluation III (APACHE III) score of group A before treatment was significantly lower than those in groups B and C (89.43+/-11.28 vs. 108.00+/-15.10 and 104.67+/-13.77, both P<0.05). After 72 hours of CBP treatment, patients in groups A and C showed significantly different changed in APACHE II scores compared with group B (-10.43+/-4.89, -9.11+/-3.76 vs. -2.33+/-4.39, P<0.05) and APACHE III scores (-2.14+/-2.19, -1.00+/-1.87 vs. 0.56+/-1.88, P<0.05). CONCLUSION: (1) CBP is curative for some patients in septic shock with acute renal failure and respiratory failure as a result of severe pneumonia, with and overall survival rate of 28%. (2) APACHE III score is a sensitive index before and after CBP treatment, and scores of 90-100 may be taken as an indication for CBP. (3) High blood sugar and fibrinogen levels may be potential risk factors, in particular, a high fibrinogen level implies a poor prognosis.

[The adverse reactions of parenteral norvancomycin in 1031 patients].

OBJECTIVE: To investigate the safety of norvancomycin, and provide basis for its rational use in clinical practice. METHODS: We documented all adverse events occurred in inpatients who receive intravenous infusion of norvancomycin, then we evaluated the relationship between adverse events and norvancomycin and calculated the rates of adverse reaction. RESULTS: 1031 patients were enrolled in this study from March 2002 to June 2003 and 965 of them could be evaluated. 80 adverse reactions occurred in 965 patients who received norvancomycin, giving a total adverse reaction rate of 8.29%. The systemic adverse reactions included renal impairment (4.04%), hepatic impairment (2.38%) and allergic reaction (1.76%). 15 patients discontinued the treatment because of the adverse reaction. The rates were higher in patients who use other antimicrobial agents concomitantly or whose age >/= 60 years. The rates of renal impairment were higher in those with age >/= 60 years, and the rates of hepatic impairment were higher in whose received this agent longer than 14 days. These factors were independent risk factors (P < 0.05). CONCLUSIONS: The overall adverse reaction rate of norvancomycin was low. A few patients experienced drug-related reaction, most of these adverse reactions were mild and tolerable. The adverse reactions tended to occur in older patients, those who use other antibiotic concomitantly or those who receive this agent longer than 14 days.

[Severe acute respiratory syndrome in 78 patients: a retrospective study].

OBJECTIVE: To analyze the clinical features of severe acute respiratory syndrome (SARS) and the diagnosis and treatment of the disease. METHODS: Seventy-eight patients with SARS referred to the Guangzhou Institute of Respiratory Diseases (GIRD), China from December 22, 2002 to March 2003 were studied retrospectively. The data reviewed included those of clinical manifestations, laboratory investigation and roentgenology. RESULTS: The patients consisted of 42 men and 36 women, aged 20 - 75 years (mean 37.5 +/- 11.6 years), including 44 infected health-care professionals. Clinical symptoms of these patients were fever (100%), coughing (88%), and dyspnea (80%). Routine blood test revealed WBCs <4.0 x 10(9)/L in 12 patients (15%), (4.0 -10.0) x 10(9)/L in 49 (63%), and over 10.0 x 10(9)/L in 17 (22%) [average (7.6 +/- 5.0) x 10(9)/L]. The level of neutrophilic granulocyte was 0.75 +/- 0.13 and that of lymphocyte was 0.18 +/- 0.11. Chest X-ray and CT scanning revealed changes related to pneumonia. The transmission of the disease was likely via close contact with contagious droplets. The prevalences of acute lung injury (ALI,37 patients) and acute respiratory distress syndrome (ARDS, 21 of the 37 patients) were considerably high among the patients. Seven patients who developed ARDS complicated with MODS died. CONCLUSIONS: A history of close contact, fever, X-ray signs of pneumonia and normal or lowered WBC counts are favorable for the diagnosis of SARS. Recognition of ALI as the important index for critical SARS and comprehensive supportive management are of paramount importance in decreasing the mortality of patients with SARS.

[Roentgenography and CT appearance in patients with severe acute respiratory syndrome].

OBJECTIVE: To evaluate the appearance and dynamic change of chest roentgenography and CT in patients with severe acute respiratory syndrome (SARS). METHODS: Serial roentgenography and CT of 61 confirmed SARS patients were analyzed. RESULTS: The onset symptom was fever in all patients. In the early phase of SARS, the main abnormal appearance was single or bilateral localized patchy clouding opacity on roentgenography, which progressed rapidly. The area of opacity peaked at about 2 weeks, involving the majority area of the lung in 57% of the patients. The area involved was correlated with the severity of clinical symptoms. The opacity disappeared gradually in 5 weeks in 84% of the patients. Lungs complicated infection were found in 6 patients with a prolonged duration of the illness. Among the 61 patients, 4 died. CT scan was performed in 16 SARS patients in the recovery phase, of whom 13 showed lung fibrosis. CONCLUSIONS: Lung infiltration in early phase develops rapidly and involves most area of the lung in advanced phase in most SARS patients. Lungs fibrosis was found in some patients in the recovery phase.

[Death risk factors of severe acute respiratory syndrome with acute respiratory distress syndrome].

OBJECTIVE: To discuss the possible death risk factors of severe acute respiratory syndrome (SARS) with acute respiratory distress syndrome (ARDS). METHODS: Twenty-five patients suffered from SARS with ARDS in the intensive care unit were retrospectively analyzed from December 2002 to April 2003. Statistical analysis was made using SPSS 10.0 and forward stepwise (wald) logistic regression analysis were used to determine the interrelationships between multiple variables and death. P<0.05 was considered statistically significant. RESULTS: The following factors were associated with a significantly higher mortality rate in the SARS with ARDS patients, including age increase (OR=1.203, CI=1.036 to 1.396, P=0.016), long-time hypoxia(OR=1.067, CI=1.014 to 1.122, P=0.013), thrombocytopenia(OR=111.932, CI=6.096 to 2 055.252, P=0.001), hypernatremia (OR=26.667, CI=2.242 to 317.147, P=0.009), and elevation of serum creatinine levels (OR=111.932, CI=6.096 to 2 055.252, P=0.001). CONCLUSION: More attention should be paid to deal with these risk factors and to prevent the development of serious complications associated with SARS.

[Clinical therapy of severe acute respiratory syndrome: 38 cases retrospective analysis].

OBJECTIVE: To analyze the clinical features and therapy experience of severe acute respiratory syndrome (SARS). METHODS: From December 2002 to April 2003 in Guangzhou Institute of Respiratory Disease, 38 patients with severe SARS were retrospectively studied to evaluate the relationship between treatment strategy and prognosis. RESULTS: Thirty-eight cases of severe SARS were diagnosed. Comprehensive measures most commonly included corticosteroids, antibiotics, antivirotics, nutritional support and mechanical ventilation. Thirty cases were cured (78.9%), of them 11 cases had pulmonary fibrosis (36.7%), 8 patients died (21.1%) in all cases. CONCLUSION: Severe SARS might develop rapidly. In addition to early diagnosis, prompt isolation, and emergency therapy, appropriate use of corticosteroid and noninvasive ventilation should be recommended.

[Efficacy and safety of cefditoren pivoxil in treatment of respiratory infections, a clinical study].

OBJECTIVE: To evaluate the efficacy and safety of cefditoren pivoxil in treatment of respiratory infections. METHODS: 199 cases of respiratory infection confirmed by etiological and clinical examinations were treated with cefditoren pivoxil tablets taken orally. Therapeutic evaluation was conducted among 196 cases and safety evaluation was conducted among 199 cases. RESULTS: The total effective rate was 94.9%, and the causative bacteria -elimination rate was 96.7%. Clinical adverse events, including moderate diarrhea, mild nausea and vomiting, and stomach discomfort, were seen in 9 cases with an incidence rate of 4.5%. Laboratory adverse events, including increase of with an incidence rate of 3.5%. CONCLUSION: Cefditoren pivoxil is effective and safe in treatment of mild and moderate respiratory infections. The resistance rate to cefditoren pivoxil of pathogens of respiratory infections and the efficacy of cefditoren pivoxil show no difference from those tested 7 years ago.

[Effect of tumor necrosis factor-alpha and interleukin-1beta on bovine pulmonary arterial endothelial cell apoptosis].

OBJECTIVE: To investigate the effect of tumor necrosis factor-alpha (TNF-alpha) and interleukin-1beta (IL-1beta) on apoptosis of bovine pulmonary arterial endothelial cells (BPEC). METHODS: BPECs were incubated with TNF-alpha, IL-1beta or the combination of TNF-alpha and IL-1beta. BEPCs were also pretreated with TNF-alpha monoclonal antibody or Ac-DEVD-CHO (caspase-3 inhibitor), and followed by incubation with TNF-alpha. The apoptotic rate was measured by flow cytometry (Annexin V-FITC and PI staining). RESULTS: (1) TNF-alpha induced apoptosis in a dose-dependent manner after a 24 h incubation. With the increase of the TNF-alpha (500, 1,000, 2,000 U/ml respectively), the BPEC apoptotic rate [(8.21 +/- 0.70)%, (9.63 +/- 0.71)%, (17.43 +/- 1.99)%, respectively] was significantly higher than that of the control group [(3.09 +/- 0.08)%, P < 0.05]. (2) TNF-alpha induced apoptosis was time dependent. After incubated with TNF-alpha 2,000 U/ml, the BPEC apoptotic rate [(6.72 +/- 0.38)%, (7.72 +/- 1.66)%, (12.95 +/- 0.32)%, (17.70 +/- 1.79)%, P < 0.05] increased significantly with time [6, 12, 24, 36 h, respectively] of TNF-alpha incubation. (3) The BPEC apoptotic rate of anti-TNF-alpha monoclonal antibody group [(7.78 +/- 0.21)%] or the Ac-DEVD-CHO group [(7.32 +/- 0.11)%] was significantly higher than the TNF-alpha group alone [(10.59 +/- 0.49)%, P < 0.01], but the combination of TNF-alpha and IL-1beta group had no such significant effect (P > 0.05). CONCLUSIONS: It is TNF-alpha but not IL-1beta that induces pulmonary arterial endothelial cell apoptosis in acute lung injury (ALI). There is no synergistic effect between IL-1beta and TNF-alpha in the induction of BPEC apoptosis.