Quality Assessment of Clinical Practice Guidelines for Respiratory Diseases in China: A Systematic Appraisal.

BACKGROUND: There has been a significant increase in the publication of clinical practice guidelines (CPGs) for respiratory diseases in China. However, little is known about the quality and potential impacts of these CPGs. Our objective was to critically evaluate the quality of Chinese CPGs for respiratory diseases that were published in peer-reviewed medical journals. METHODS: A systematic search of scientific literature published between 1979 and 2013 was undertaken to identify and select CPGs that were related to respiratory diseases. Four Chinese databases (the Chinese Biomedical Literature database [CBM], the China National Knowledge Infrastructure [CNKI], the VIP database, and the WANFANG database) were used. The quality of eligible guidelines was assessed independently by four reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. The overall agreement among reviewers was evaluated using an intraclass correlation coefficient. RESULTS: A total of 109 guidelines published in 27 medical journals from 1979 to 2013 were evaluated. The overall agreement among reviewers was considered good (intraclass correlation coefficient, 0.838; 95% CI, 0.812-0.862). The scores of the six AGREE domains were low: 57.3% for scope and purpose (range, 4.2%-80.5%), 23.8% for stakeholder involvement (range, 2.8%-54.2%), 7.7% for rigor of development (range, 0%-27.1%), 59.8% for clarity and presentation (range, 22.2%-80.6%), 10.9% for applicability (range, 0%-22.9%), and 0.6% for editorial independence (range, 0%-16.7%). Scores for all guidelines were below 60%, and only three guidelines (2.8%) were recommended for clinical practice with modifications. CONCLUSIONS: The quality of the guidelines was low, and stakeholder involvement, rigor of development, applicability, and editorial independence should be considered in the future development of CPGs for respiratory diseases in China.

[Effects of cyclic stretch on the induction of the transdifferentiation in human lung epithelial cells].

OBJECTIVE: To investigate the effect of mechanical stretch induced epithelial-mesenchymal transition in human lung epithelial cells BEAS-2B in vitro. METHODS: The human lung epithelial cells BEAS-2B were subjected to cyclic stretch by the FX-5000T system at 0.33 Hz of 10% or 20% elongation for 24, 48 and 72 hours respectively. The morphologic changes were observed by microscopy. The mRNA and protein expressions of E-cadherin, Cytokeratin-8 (CK-8), α-smooth muscle actin (α-SMA) and Vimentin were evaluated by immunofluorescence before and after mechanical stretch and fluorescent quantitation reverse transcription-polymerase chain reaction (qRT-PCR). RESULTS: (1) When stretch by 20% elongation for 48 hours, the morphological changes in BEAS-2B cells from cobblestone-like structure to elongated shape and obviously when stretch for up to 72 hours, while 10% elongation showed no significant morphological changes comparing to control. (2) Decreasing E-cadherin and CK-8 protein expression was associated with increased immunostaining for α-SMA protein at 72 hours after 20% mechanical stretch. (3) Expression of E-cadherin mRNA was decreased to 0.388±0.056 and 0.247±0.064 after 20% mechanical stretch for 48 hours and 72 hours compared with control without stretch (set 1, both P<0.05), expression of CK-8 mRNA was decreased to 0.436±0.060 at 72 hours after 20% mechanical stretch (P<0.01), α-SMA mRNA was increased to 1.437±0.267 (48 hours) and 1.261±0.247 (72 hours) after 20% mechanical stretch (both P<0.05), and Vimentin mRNA was increased to 1.679±0.172 (48 hours) after 20% mechanical stretch (P<0.05). Expression of E-cadherin mRNA was decreased to 0.387±0.081 at 72 hours after 10% mechanical stretch (P<0.05), Vimentin mRNA was increased to 1.688±0.179 at 48 hours after 10% mechanical stretch while other markers showed no significant changes comparing with control. CONCLUSIONS: Excessive mechanical stretch could induce epithelial-mesenchymal transition in lung epithelial cells BEAS-2B in vitro.

[Effects of cyclic stretch on expression of cytokines and intercellular adhesion molecule-1 in human pulmonary artery endothelial cell].

OBJECTIVE: To observe the effects of cyclic stretch on expression of cytokines and adhesion molecules in human pulmonary artery endothelial cells (HPAECs), herein to provide a theoretical basis to ventilator-induced lung injury (VILI). METHODS: HPAECs were subjected to cyclic stretch by the Flexcell FX-5000T system at 0.5 Hz of 10% or 20% elongation for 3, 6, 12, 24 hours respectively. The mRNA and protein expression of interleukin (IL-6, IL-8), monocyte chemotactic protein-1 (MCP-1) and intercellular adhesion molecule-1 (ICAM-1) was determined by fluorescent quantitation reverse transcription-polymerase chain reaction (qRT-PCR), enzyme linked immunosorbent assay (ELISA) or Western blotting. RESULTS: Increasing the stretch force, the mRNA and protein expression of IL-8, MCP-1, ICAM-1 were up regulated with increasing stretch time. Compared with the control (set 1), after 20% cyclic stretch for 24 hours, IL-8 mRNA expression was up regulated to 1.58±0.10, MCP-1 mRNA expression was up regulated to 2.85±0.52, and ICAM-1 mRNA expression was up regulated to 1.90±0.14 (all P<0.05). Compared with control group, after 20% cyclic stretch for 24 hours, the protein expression of IL-8 and MCP-1 in HPAEC was significantly increased (IL-8: 3401.08±439.60 ng/L vs. 1422.60±66.98 ng/L, MCP-1: 1117.64±237.54 ng/L vs. 307.88±80.84 ng/L, both P<0.05), ICAM-1 protein expression was up regulated to 2.15±0.40 (P<0.05), while the expression of IL-6 mRNA and protein had no statistic difference compared with control group. CONCLUSIONS: Cyclic stretch enhanced the expression of IL-8, MCP-1 and ICAM-1 in an intensity-dependent fashion, so it may be involved in the pathogenesis of lung injury induced by mechanical ventilation.

[Lipopolysaccharide induced expression of peroxiredoxin 1 in airway epithelial cell].

OBJECTIVE: To investigate the effect of lipopolysaccharide (LPS) on expression of peroxiredoxin 1 (prdx1) in airway epithelial cells. METHODS: The airway epithelium cell line BEAS-2B was cultivated, and the cells were stimulated with 0, 1, and 10 mg/L of LPS for 12 hours and 24 hours, and then were harvested for prdx1 expression detection. The mRNA expression of prdx1 was detected by reverse transcription-polymerase chain reaction (RT-PCR).The airway epithelium cells were stimulated with 0, 0.1 , 0.5, 1 , 5, and 10 mg/L of LPS for 12 hours, and were collected for determination of prdx 1 protein expression by Western blotting. RESULTS: RT-PCR results showed that the prdx1 mRNA expression was significantly increased within 12 hours of stimulation with elevation of the dosage of LPS. The prdx1 mRNA expression at 12 hours of stimulation by 10 mg/L LPS was significantly higher than that in control group (2.014 ± 0.197 vs. 0.644 ± 0.178, P<0.05). However, with prolongation of LPS stimulation time, the prdx1 mRNA expression at 24 hours was slightly declined. Western blotting results showed that the prdx1 protein expression was gradually increased with elevation of dosage of LPS. The prdx1 protein expression at 12 hours of stimulation with 5 mg/L LPS was significantly higher than that in control group (1.069 ± 0.175 vs. 0.328 ± 0.010, P<0.05), and the expression remained at high level at 12 hours of stimulation with 10 mg/L LPS (0.984 ± 0.220 ). CONCLUSION: 10 mg/Lof LPS can induce the mRNA and protein expression of prdx1 in BEAS-2B cell after 12 hours of stimulation.

[Isolation and characterization of human alveolar type II cells and phenotypes maintaining study].

OBJECTIVE: To establish a method of isolate, purify, primary culture and identify human alveolar type II cells (AT II ) in vitro, as well as its possible maintaining phenotype characteristics. METHODS: The marginal lung tissue was collected. AT II cells were isolated with trypsin and elastase, purified by a series of steps, such as, cell sieve filtration, differential adhesion, gradient separation and anti-CD14 beads separation. AT II cells were identified with immunofluorescence of human pro-surfactant-associated protein C (pro-SP-C), Green DND-26 probe and electron microscope. The purity of AT II cells was measured by immunofluorescence of human pro-SP-C and Green DND-26 probe. The viability of AT II cells was measured by trypan blue staining. The phenotypes (SP-A, SP-B,SP-C, SP-D) were monitored with reverse transcription-polymerase chain reaction (RT-PCR) at different time points. RESULTS: The output of AT II cells from lung tissue was (5-10) x 105/g, and the cell viability was (93 ± 2)% with trypan blue staining, the cell purity was about 98% with pro-SP-C immunofluorescence and Green DND-26 fluorescent probe, the lamellar bodies were clearly observed with transmission electron microscope. In the aspect of phenotypes maintaining, the time of surfactant expression was about 24 days [SP-A: 0.52 + 0.03 (day 16), 0.35 + 0.02 (day 20),0.26 ± 0.01 (day 24), 0.10 + 0.08 (day 28); SP-C: 0.68 0.16 (day l6), 0.31 + 0.04 (day 20), 0.18 + 0.06 (day 24), 0.14 + 0.09 (day 28)], and the longest one was more than 28 days [SP-B: 1.05 + 0.17 (day 16), 0.76 + 0.35(day 20), 0.55 0.15 (day 24), 0.36 0.19 (day 28); SP-D: 0.52 0.19 (day 16), 0.33 + 0.12 (day 20), 0.31 +0.04 (day 24), 0.23 ± 0.02 (day 28)). CONCLUSION: We successfully established a procedure to separate, purify,identify of AT II cells, which retain primary phenotypic characteristics over long period.

[Intrathoracic blood volume index as an indicator of fluid management in septic shock].

OBJECTIVE: To investigate the value of intrathoracic blood volume index (ITBVI) monitoring in fluid management strategy in septic shock patients. METHODS: In a prospective study, 33 patients who were diagnosed to be suffering from septic shock in the intensive care unit (ICU) were enrolled . Seventeen patients who received pulse indicator continuous cardiac output (PiCCO) monitoring, and ITBVI was used as indicator of fluid management, were enrolled into ITBVI group; 16 patients who received traditional fluid management strategy [directed by central venous pressure (CVP)] were enrolled into control group. Acute physiology and chronic health evaluation II (APACHEII) score, sepsis related organ failure assessment (SOFA) score and vasopressor score were compared between 1 day and 3 days of treatment. The characteristics of fluid management were recorded and compared within 72 hours. RESULTS: (1)In 3 days of treatment, APACHEII, SOFA and vasopressor score were significantly lower in ITBVI group compared with that of in 1 day of treatment[21.3±6.2 vs. 25.4±7.2, 6.1±3.4 vs. 9.0±3.5, 5 (0, 8.0) vs. 20.0 (8.0, 35.0), respectively, all P<0.01], whereas there were no changes in control group. (2)Although fluid output (ml) was higher in ITBVI group during 48-72 hours period (2 421± 868 vs. 1 721±934, P=0.039), there was no difference in fluid intake, fluid output or fluid balance (ml) within 0-72 hours between two groups (fluid intake: 9 918±137 vs. 10 529±1 331, fluid output : 6 035±1 739 vs. 5 827±2 897, fluid balance: 3 882±1 889 vs. 4 703±2 813, allP>0.05). (3)Comparing the fluid volume (ml) used for fluid replacement period, except that there was no significance in fluid challenge with colloid during 0-6 hours between two groups [ml: 250 (125, 500) vs. 250 (69,250), P>0.05], more fluid intake (ml) was found in ITBVI group [0-6 hours crystalloid: 250(150,250) vs. 125 (105,125), 6-72 hours crystalloid: 125 (125, 250) vs. 100 (56, 125), 0-72 hours crystalloid: 250(125, 250) vs. 125 (75, 125), 6-72 hours colloid: 125 (106, 250) vs. 75 (50, 125), 0-72 hours colloid: 200 (125, 250) vs. 100 (50, 125),all P<0.01]. CONCLUSION: Clinical picture in patients with septic shock is improved after 3 days of treatment than 1 day of treatment under fluid management directed by ITBVI, compared with by CVP. This improvement may be attributable to accurate assessment of preload and appropriate infusion rate in fluid challenge.

[Study on the natural ligand(s) of triggering receptor expressed on myeloid cell-1 on bacteria cell wall].

OBJECTIVE: To look for the natural ligand(s) of human triggering receptor expressed on myeloid cell-1 (TREM-1), in order to provide the theoretical basis for elucidation of the pathogenesis of sepsis. METHODS: Neutrophils and monocytes isolated from human peripheral blood were treated with heat-inactivated Staphylococcus aureus, Pseudomonas aeruginosa, Mycobacterium tuberculosis, Staphylococcus aureus L-form or Pseudomonas aeruginosa L-form respectively for 24 hours. The cell wall was extracted from Staphylococcus aureus, Pseudomonas aeruginosa and Mycobacterium tuberculosis by ultrasound. Neutrophils and monocytes were isolated and treated with the cell wall respectively for 24 hours. Neutrophils and monocytes were isolated and treated with three main components from bacterial cell wall (polysaccharides, lipids and proteins) respectively for 24 hours. The level of TREM-1 mRNA was measured with fluorescent quantitative polymerase chain reaction (PCR), and the concentrations of tumor necrosis factor-alpha (TNF-alpha) and interleukin-1 beta (IL-1 beta) were measured with enzyme-linked immunosorbent assay (ELISA). RESULTS: The TREM-1 mRNA level and the concentrations of TNF-alpha and IL-1 beta in cell supernatant of neutrophils and monocytes were upgraded when treated with cell, cell wall and cell wall polysaccharides of Staphylococcus aureus and Pseudomonas aeruginosa. Compared with the blank control group, the TREM-1 mRNA level of neutrophils and monocytes was upgraded to (3.86+/-0.20)-fold and (5.15+/-0.56)-fold respectively when treated with cell wall polysaccharides of Staphylococcus aureus (both P<0.05); the TREM-1 mRNA level of neutrophils and monocytes was upgraded to (4.03+/-0.15)-fold and (7.22+/-0.73)-fold respectively when treated with cell wall polysaccharides of Pseudomonas aeruginosa (both P<0.05). The effect could be attenuated by the addition of LP17 which could bind TREM-1 ligand. This attenuating effect was not found when the cells were treated with cell, cell wall or cell wall polysaccharides of Mycobacterium tuberculosis. CONCLUSION: The study provides the evidence that TREM-1 natural ligand(s) is present on cell wall of bacteria including Staphylococcus aureus and Pseudomonas aeruginosa, and it might be polysaccharides.

[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.

[Changes in pulmonary function in severe acute respiratory syndrome patients during convalescent period].

OBJECTIVE: To investigate the changes and pattern of pulmonary function in severe acute respiratory syndrome (SARS) patients during convalescent period. METHODS: Pulmonary function tests were performed in 26 SARS convalescent patients regularly every 3 months after their discharge from hospital. The significance of changes in pulmonary function indexes was analyzed. RESULTS: Restrictive pulmonary ventilation function and diffusing dysfunction of the lung were found in one third of the patients during third to sixth month from onset. There was a little improvement in forced vital capacity (FVC), one second forced expiratory volume (FEV(1.0)), functional residual capacity (FRC) and residual volume (RV) as convalescent period was prolonged, but no difference was found between different stages (3-6 months, 6-9 months, 9-12 months, 12-15 months and 15-17 months). Meanwhile, the FEV(1.0)/FVC showed no significant change. However, there was an obvious improvement in total lung capacity (TLC) and diffusing capacity of the lung for carbon monoxide (DLCO) with the elapse of time, and also a significant difference was found between the later stage and the earlier stage. CONCLUSION: Pulmonary dysfunction is found among some SARS patients after convalescence presenting mainly as restrictive ventilatory function and diffusing capacity abnormality. These dysfunctions would improve gradually with the elapse of time.

[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.

[Determination of serum acute phase reaction protein in patients with severe acute respiratory syndrome].

OBJECTIVE: To study the diagnostic value of determinations of serum acute phase reaction protein, such as complement 3 (C3), complement 4 (C4), prealbumin (PA) and C-reactive protein (CRP), etc., in patients with severe acute respiratory syndrome (SARS). METHODS: Serum levels of C3, C4, PA and CRP were determined by turbidimetry in 54 cases of SARS, 20 of other pneumonia and 30 normal persons. RESULTS: Serum concentrations of C3, C4, CRP and PA were (1.18 +/- 0.42) g/L, (1.15 +/- 0.56) g/L, (10.52 +/- 8.77) mg/L and (107 +/- 54) mg/L in SARS patients, (1.30 +/- 0.46) g/L, (0.57 +/- 0.31) g/L, (0.88 +/- 0.43) mg/L and (291 +/- 76) mg/L in patients with other pneumonia, and (1.11 +/- 0.56) g/L, (0.38 +/- 0.26) g/L, (0.42 +/- 0.26) mg/L and (376 +/- 74) mg/L in normal persons, respectively. Serum level of PA was significantly lower and levels of C4 and CRP significantly in patients with SARS higher than those in patients with other pneumonia and normal persons (P < 0.01). There was no significant difference in serum level of C3 between the three groups (P > 0.05). CONCLUSION: Determination of serum level of C4, CRP and PA in suspected patients is beneficial to early differential diagnosis for SARS.

[Clinical nutrition support and relationship of blood glucose level/insulin administration with outcome in critical SARS patients].

OBJECTIVE: To evaluate the use of clinical nutritional support in critical SARS patients, and the relationship between blood glucose levels/insulin administration amount and outcome. METHODS: Twenty-one SARS patients who reached the standard of Ministry of Health's "critical level" were transferred into our ICU in an average of 11 days after onset and enrolled in this clinical trial. All patients underwent respiratory support and clinical nutrition support as scheduled. For about 60 kg patient per day 3347.2 kJ(800 kcal), 36 g protein, and 125 g carbohydrate was given intravenously; 4184 kJ(1000 kcal), 38 g protein, and 125 g carbohydrate was provided by enteral route. MCT/LCT as fat resource shared 50% calories intake. All patients received similar doses of intravenous Methylprednisolone(about 200 mg/d). Blood glucose, serum albumin, blood lymphocyte counts, and serum alanine transminase (ALT) were checked on the first admission day in ICU and on the 12th day after nutrition therapy was started. Insulin was started to pump in to maintain the blood glucose levels between 4.44-7.78 mmol/L (80-140 mg/dl) when the levels exceeded normal range. RESULTS: Upon admission into ICU, all patients had poor nutrients intake for an average of 11 days and 16 patients (76.2%) were diagnosed as malnutrition. Parenteral and enteral nutrition therapy were then offered for an average of 12 days. On the 12th day, the serum albumin increased [(28.5 +/- 2.2)] g/L vs (37.0 +/- 4.1) g/L] (P = 0.0001) and so did the lymphocytes count [(0.74 +/- 0.47)] x 10(9)/L vs (1.22 +/- 0.73) x 10(9)/L] (P = 0.02). The blood glucose maintained at lower level in the surviving patients when compared with those who died [(9.5 +/- 2.3) mmol/L vs (6.3 +/- 1.8) mmol/L] [(196 +/- 70) mg/dl vs (110 +/- 21) mg/dl] (P = 0.0002), and the abnormally high ALT levels presented in some of the patients decreased but not significantly (81.0% vs 57.1%) (P = 0.18). In order to keep blood glucose within the range 4.44-7.78 mmol/L (80-140 mg/dl), only 18.8% of the surviving patients needed insulin intervention as opposed to 80.0% of those who died (P = 0.03). The amount of insulin used in the surviving group was significant lower than that in the group who died [(24 +/- 2) IU/d vs (72 +/- 9) IU/d] (P = 0.01). CONCLUSIONS: Eleven days after SARS onset, most of the critical patients presented with malnutrition. Some improved nutrition related parameters may be associated with clinical nutritional support. The surviving patients required less insulin when compared to those who died. 80.0% of the patients who died need insulin versus only 18.8% of the surviving patients. Due to the difficulty of SARS management, this study was not a randomized controlled clinical trial. More clinical trials will be needed for checking the results of this investigation.

[Management of critical severe acute respiratory syndrome and risk factors for death].

OBJECTIVE: To investigate the management of critical severe acute respiratory syndrome (SARS) and possible risk factors for death. METHODS: Thirty-three patients with SARS referred to Guangzhou Institute of Respiratory Disease (GIRD) between December 2002 and March 2003 were studied retrospectively. Paired t-test using statistical software SPSS 10.0 was employed to compare the respiratory frequency and pulse O(2) saturation (SpO(2)) before and after noninvasive ventilation with continuous positive airway pressure (CPAP) on the 33 patients. Among them, 18 patients who presented with SpO(2) of 90% - 93% at rest under O(2) inhalation 5 L/min were further recorded for their SpO(2) during slight physical movement and CPAP. The possible death-related risk factors including age, underlying diseases, leucocytosis, thrombocytopenia, and lymphopenia were analyzed by the Mantel-Haenszel chi(2) test. RESULTS: The respiratory frequencies were significantly decreased and SpO(2) was improved in the 33 patients after one hour of noninvasive ventilation. The SpO(2) in the latter 18 patients fell during slight physical movement and improved one hour after CPAP (p < 0.01). The RRs of the five death predictors concerning thrombocytopenia, age (> 50 yrs, underlying diseases, leucocytosis, and lymphopenia were 25.83, 8.57, 6.40, 1.64, and 1.17, respectively, with the 95% CI of 3.64 - 183.59, 1.94 - 37.83, 1.75 - 23.33, 0.38 - 7.05 and 0.16 - 8.48, respectively. Management with corticosteroids effectively ameliorated and suppressed the development of pulmonary fibrosis. CONCLUSIONS: Noninvasive ventilation relieves dyspnea and SpO(2) in patients with critical SARS, and should also be employed in those with SpO(2) of 90% - 93% at rest under O(2) inhalation 5 L/min. Noninvasive as an add-on management may probably cut down on the dosage and duration of corticosteriod therapy. Among 5 possible risk factors, 3 were recognized as death-related, turning out to be thrombocytopenia, age (> 50 yrs) and underlying diseases.

[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.

[Effects of H1 blocker and inhaled corticosteroids on asthmatic patients with allergic rhinitis].

OBJECTIVE: To evaluate the therapeutic effects of H(1) blocker in combination with low dose inhaled corticosteroid on allergic asthma. METHODS: A multi-center, double blind, randomized, placebo control study was conducted in 67 patients with mild to moderate allergic asthma. Patients were randomized to receive either Loratadine 10 mg or placebo twice a day on the basis of inhaled beclomethasone dipropionate (400 microg/d for 14 days, then reduced to 200 microg/d) for 5.3 +/- 1.3 months. Symptom scores of asthma, frequencies of episode of rhinitis and common cold and doses of inhaled Salbutamol as rescue drug were recorded. Bronchial hyperresponsiveness (PD(20) FEV(1) in response to Histamine) and serum ICAM-1 and VCAM-1 were measured before and after the treatment. RESULTS: After treatment, there was much better improvement in symptom score (2.4 +/- 0.9 vs 3.1 +/- 0.9, P < 0.01), symptomatic days due to rhinitis (4.0 +/- 1.2 d/week vs 1.9 +/- 0.9 d/week, P < 0.001), episode of common cold symptom (0.8 +/- 0.5 time vs 1.1 +/- 0.4 time, P < 0.001), average doses of inhaled beta(2) agonist as rescue medication (2.6 +/- 0.9 puff/week vs 3.7 +/- 0.8 puff/week, P < 0.001) and bronchial responsiveness (P < 0.05) in Loratadine group as compared with the control group. However, there was no significant change in serum ICAM-1 and VCAM-1 levels after treatment in both groups (P > 0.05). CONCLUSIONS: On the basis of low dose inhaled corticosteroid, orally administered Loratadine significantly improves the therapeutic efficacy of asthma in patients with allergic asthma and rhinitis.