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Background: In patients with schizophrenia, Diankuang Mengxing Decoction with antipsychotics is one of the treatments for it. However, little information is available regarding the difference between the therapeutic effect of Diankuang Mengxing Decoction with antipsychotics and other treatments. Systematic evaluation is conducted to assess the efficacy and safety of Diankuang Mengxing Decoction and other antipsychotics, which are used to treat schizophrenia., Methods: We performed a systematic review (PROSPERO ID: CRD42023414603). This entailed a computerized search of several research databases from their respective dates of establishment until April 11, 2023, which collected clinical randomized controlled trials of Diankuang Mengxing Decoction combined with antipsychotics. The databases that contributed to this study were PubMed, Web of Science, Embase, EBSCOhost, Cochrane, Scopus, and Google Scholar. Each publication was screened according to defined inclusion and exclusion criteria, and appropriate literature was extracted and evaluated for quality, for which meta-analysis was performed using RevMan 5.4., Results: A literature review of 456 publications resulted in the inclusion of 18 randomized controlled trials with data collected from a total of 1636 patients. Meta-analytical results showed combination with risperidone, olanzapine, chlorpromazine, clozapine, ziprasidone, or aripiprazole increased the overall effectiveness of Diankuang Mengxing Decoction when treating schizophrenia (P < . 00001), among whom olanzapine demonstrated the greatest enhancement (Z = 3.65, odds ratio = 4.26, 95% CI: 1.96-9.28, P = .0003). The 4-week/30-day treatment (P = .0003) and a dosage of 400 mL/d of Diankuang Mengxing Decoction (P = .0004) were more effective. Also, there were widespread reductions to the Positive And Negative Syndrome Scale (PANSS) total scores, PANSS-positive symptom scores, PANSS-negative symptom scores, general psychopathology scores (P < .05 for all), as well as the incidence of adverse effects (Z = 2.79, odds ratio = 0.34, 95% CI: 0.16-0.73, P = .005) in patients with schizophrenia., Conclusion: The combination of Diankuang Mengxing Decoction with different antipsychotics can improve the overall prognosis of patients with schizophrenia; Diankuang Mengxing Decoction combined olanzapine, a dosage of 400 mL/d and a duration of 4 weeks/30 days being the best in this regard, by alleviating the symptoms and diminishing the disorder's adverse effects. To build on this work, more large-sample, multi-center, and high-quality clinical studies in the future would help to further validate our findings., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

This cross-sectional study assessed the risk factors for infection in 150 diabetic foot patients admitted to the Xiamen University Hospital between October 2020 and October 2022. Patients were categorised as infected (n = 80) or uninfected (n = 70) cohorts. The diabetic foot was evaluated using the American Diabetic Foot Grading system, whereas ulcers were categorised using Wagner's method. Analysed were patient-specific information, clinical data and risk factors including neuropathy, arterial disease and foot deformities. Our findings revealed no statistically significant differences between infected and uninfected cohorts concerning age, body mass index, gender, duration of diabetes or ankle-brachial index values (p > 0.05). However, infected group had a higher proportion of smokers and reduced socio-economic status (p < 0.05). Wagner grades indicated a greater severity in the infected group, with grade 3, grade 4 and grade 5 differing significantly (p < 0.05). Comparative analysis of ulcer characteristics revealed no statistically significant differences in ulcer surface area and depth, but the infected group had a higher prevalence of osteomyelitis and a greater number of ulcers (p > 0.05). Blood vessel complications, retinopathy, the presence of three or more ulcers, osteomyelitis and diabetic nephropathy were substantially more prevalent in the infected group, as determined by univariate analysis (p < 0.05). Subsequent multivariate logistic analysis revealed that patients with blood vessel complications, retinopathy, osteomyelitis, diabetic nephropathy and three or more ulcers were at increased risk for infection (p < 0.05). In addition, lifestyle factors, such as smoking, sedentary behaviour, inadequate foot hygiene, obesity and poor glycaemic control, were also associated with higher infection rates. A multivariate analysis of foot wound factors revealed that deeper, longer and recurrent lesions increased the likelihood of infection. Escherichia coli was the most frequently isolated bacterium from the infected group's bacterial culture, followed by Pseudomonas aeruginosa and Staphylococcus aureus. The study enhanced our comprehension of the multifactorial risk factors associated with infections in diabetic foot patients, highlighting the need for thorough clinical evaluation, lifestyle modification and vigilant infection control., (© 2023 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Purpose: We aimed to compare the outcomes of primary anastomosis (PA) and enterostomy as treatments for intestinal atresia in neonates to identify the factors influencing the choice of modality., Methods: We conducted a retrospective single-centre analysis of all neonates with intestinal atresia between 2000 and 2020 and measured the clinical outcomes. We performed logistic regression to identify factors that influenced the choice of surgical approach., Results: Of 62 intestinal atresia neonates, 71% received PA. There were no significant differences in gestation, gender, age at operation, birth weight, or body weight at operation between the PA and enterostomy groups. PA reoperation was not required for 78% of patients, and the PA group had shorter hospital stays. Complications, operative time, duration on parenteral nutrition, time to full enteral feeding were comparable in both groups. Upon multivariate regression analysis, surgeons favoured PA in proximal atresia [Odds ratio (OR) 38.5, 95% Confidence Interval (CI) 2.558-579] while enterostomy in smaller body size [OR 2.75, CI 0.538-14.02] and lower Apgar score [OR 1.1, CI 0.07-17.8]. Subgroup analysis in these patient groups demonstrated comparable outcomes with both surgical approaches., Conclusion: Both surgical approaches achieved comparable outcomes, but PA was associated with short hospital stays and the avoidance of stoma-related complications, and reoperation was generally not required. This surgical approach was suitable for patients with proximal atresia, but enterostomy remained a sensible choice for patients with smaller body sizes and lower Apgar scores., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Persistent air leak (PAL) is common in secondary spontaneous pneumothorax (SSP), with risk factors only been determined for post-pulmonary resection PAL. Information about its risk factors and long-term outcome is, however, necessary to enable selection of treatment modalities for elderly SSP patients with comorbid conditions., Methods: A retrospective observational study was performed on chest drain-treated SSP patients from 2009 to 2018. The risk factors, long-term recurrent pneumothorax, and mortality rates of those with and without PAL were evaluated., Results: Of 180 non-surgical SSP patients, PAL prevalence for >2 days and >7 days were 81.1% and 43.3%, respectively. Bulla was associated with PAL >7 days (OR: 2.32; P: 0.027) and serum albumin negatively associated (OR: 0.94; P: 0.028). PAL resulted in longer hospitalization in the index episode (P: <0.01). PAL >7 days was associated with a higher pneumothorax recurrence rate in three months (HR: 2.65; P: 0.041), one year (HR: 2.50; P: 0.040) and two-year post-discharge (HR: 2.40; P: 0.029). Patients treated with medical pleurodesis were significantly older (P: <0.01), had higher Charlson Co-morbidity index scores (P: <0.01), and 77.8% of those who had PAL >7 days were considered unfit for surgery. Of these, pneumothorax had not recurred in 69.4% after two years (HR: 0.47; P: 0.044)., Conclusion: Bulla was positively associated with PAL over seven days in SSP patients while albumin was negatively associated. PAL over seven days increased future recurrent pneumothorax risks, while elderly SSP patients unfit for surgery had acceptable recurrence rates after medical pleurodesis., Competing Interests: No potential conflict of interest was reported by the authors., (© 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

In this paper, the ultraviolet protection factor (UPF) of plain knitted fabrics made from 20Ne cotton yarns, Coolmax yarn and their combinations in wet, relaxed and stretched states were studied. According to the fiber composition, fabric samples are divided into three groups including Group I (single cotton yarn), Group II (cotton/cotton combination) and Group III (Coolmax/cotton combination) for discussion. In order to study the effect of wet condition on the UPF of different plain knitted fabrics, five wetting solutions, namely: (i) chlorinated pool water; (ii) sea water, (iii) acidic perspiration; (iv) alkaline perspiration and (v) deionized water (DI water) were prepared and the fabrics were wetted with different percentages of 50%, 75% and 100%. The UPF of the plain knitted fabrics in wet, relaxed and stretched states was measured and the results were discussed. In addition, yarn and fabric properties such as yarn tenacity, yarn strength, fiber combination and water vapor transmission, which affect the corresponding UPF values, were used for generating a prediction model in order to determine UPF. Verification of the prediction model was also conducted.

In this paper, the ultraviolet protection factor (UPF) of weft knitted fabrics made from 20Ne cotton yarn, Coolmax yarn and their blends in dry, relaxed and stretched states were studied. According to the fibre composition, samples were divided into three groups: Group I (single cotton yarn); Group II (cotton/cotton combination); and Group III (Coolmax/cotton combination) for discussion. In addition, yarn and fabric properties such as yarn tenacity, yarn strength, fibre combination and water vapour transmission that affect the corresponding UPF values are used for formulating a prediction model in order to determine UPF. Generally speaking, when samples are measured under stretched conditions in a dry state, they exhibit a remarkable reduction in ultraviolet protective power, as pores are opened up and UV radiation can easily penetrate through these pores. In addition, greater stretch percentage came along with greater reduction in UPF. This can be explained by the fact that the amount and the size of pores increase when samples are subjected to greater tension.

CD209 (DC-SIGN) is an important C-type lectin which acts a receptor of many pathogens. The single nucleotide polymorphism (SNP) -336A>G in the CD209 promoter has been demonstrated to regulate promoter activity and to be associated with several important infectious diseases, such as human immunodeficiency virus-1 (HIV-1), Mycobacterium tuberculosis, and Dengue fever. CD209 facilitates severe acute respiratory syndrome (SARS)-coronavirus spike protein-bearing pseudotype driven infection of permissive cells in vitro. In keeping with previously published findings, our in vitro studies confirmed that this SNP modulates gene promoter activity. Genetic association analysis of this SNP with clinico-pathologic outcomes in 824 serologic confirmed SARS patients showed that the -336AG/GG genotype SARS patients was associated with lower standardized lactate-dehydrogenase (LDH) levels compared with the -336AA patients (p = 0.014, odds ratio = 0.40). High LDH levels are known to be an independent predictor for poor clinical outcome, probably related to tissue destruction from immune hyperactivity. Hence, SARS patients with the CD209 -336 AA genotype carry a 60% chance of having a poorer prognosis. This association is in keeping with the role of CD209 in modulating immune response to viral infection. The relevance of these findings for other infectious diseases and inflammatory conditions would be worth investigating., (Copyright 2010 American Society for Histocompatibility and Immunogenetics. Published by Elsevier Inc. All rights reserved.)

Background and Objective: The burden of lung disease in Hong Kong is not known. This study determined the mortality and hospitalization rates of respiratory diseases in Hong Kong in 2005, their trend in the past decade and their incidence/prevalence., Methods: Mortality data were obtained from the Department of Health and hospitalization data from the Hospital Authority, Hong Kong. Incidence/prevalence data were obtained from local registries or local studies. Trends of mortality and hospitalization rates of various respiratory diseases from 1997 and 2005 were calculated after age standardization and were tested for significance using negative binomial regression analysis. Age standardized mortality rates in Hong Kong were compared with those of the UK and globally., Results: Respiratory disease was the most common cause of mortality and hospitalization in Hong Kong in 2005. Globally and in the UK, cardiovascular disease ranked first in mortality. Respiratory infections ranked first in respiratory mortality, followed by respiratory tract cancer and chronic obstructive lung disease. Respiratory infections also ranked first followed by chronic obstructive lung disease in the utilization of respiratory inpatient bed-days. While mortality rates from all respiratory diseases decreased in the past decade, hospitalization rates remained unchanged. Unlike other respiratory diseases, mortality from respiratory infections have increased since 2001. Smoking is the most important risk factor in non-communicable respiratory diseases., Conclusions: Respiratory disease is responsible for the highest health-care burden locally. Increased efforts in improving management and prevention of these diseases, including tobacco control, improving air quality and vaccination against influenza and pneumococci, are necessary.

A 53-year-old lady with blood-stained sputum and pleuritic pain had a lingular opacity on CXR which failed to resolve. A bronchial aspirate and transbronchial biopsy revealed features of bronchocentric granulomatosis with dichotomous branching hyphae suggestive of Aspergillus infection. However, subsequent fungal culture grew Pseudallescheria boydii. This case demonstrates the similarity of clinical and histological features caused by these two fungi. This appears to be the first reported case of pulmonary pseudallescheria with a bronchocentric granulomatous response.

Purposes: To estimate the prevalence of undiagnosed airflow obstruction (AFO) in Hong Kong smokers with no previous diagnosis of respiratory disease, and to assess its variability when applying different prediction equations and diagnostic criteria., Methods: A multicenter, population-based, cross-sectional prevalence study was performed in smokers aged 20 to 80 years. Three different criteria (fixed 70% [Global Initiative for Chronic Obstructive Lung Disease and British Thoracic Society], fixed 75%, and European Respiratory Society [ERS]) were applied to define a lower limit of normal (LLN) of the FEV(1)/FVC ratio to compare with the Hong Kong Chinese reference equation (criterion 1), which had used a distribution-free method to obtain the lower fifth percentile of FEV(1)/FVC ratio as the LLN., Results: In 525 male patients, using criterion 1 (local internal prediction equation) and defining AFO as FEV(1)/FVC less than LLN, the overall prevalence of AFO was 13.7%: 8.3% in age > or = 20 to 40 years, 14.0% in age > or = 40 to 60 years, and 17.8% in age > or = 60 to 80 years. When the local internal prediction equation was used as the comparison reference, the fixed-ratio methods tended to miss AFO in younger age groups and overdiagnose AFO in old age, while the ERS criteria, which uses an almost lower fifth percentile-equivalent method, showed less of such a trend but still only showed moderate agreement with criterion 1., Conclusions: Undiagnosed AFO was prevalent in Hong Kong smokers. Estimated prevalence rates were highly affected by the criteria used to define AFO. The predicted lower fifth percentile values calculated from a local reference equation as the LLN of FEV(1)/FVC ratio should be used for the diagnosis of AFO.

Nosocomial outbreaks of infectious diseases in psychiatric facilities are not uncommon but the implementation of infection control measures is often difficult. Here, we report an outbreak of an acute respiratory illness in a psychiatric ward between 29 July and 20 August 2005 involving 31 patients. Human metapneumovirus was detected in seven (23%) patients by reverse transcription-polymerase chain reaction and nucleotide sequencing. A review of outbreak surveillance records showed that six nosocomial outbreaks occurred in the year 2005, of which four (67%) were confirmed or presumably related to a respiratory viral infection. Directly observed deliveries of alcohol hand rub 4-hourly during daytime to all psychiatric patients was instituted in December 2005. Only one nosocomial respiratory viral outbreak occurred in the following year. The total number of patients and staff involved in nosocomial outbreaks due to presumed or proven respiratory virus infections decreased significantly from 60 to six (P<0.001), whereas those due to all types of nosocomial outbreaks also decreased from 70 to 24 (P=0.004). Alcohol hand rub has been shown to have potent bactericidal and virucidal activity against a wide range of nosocomial pathogens. Regular use of directly observed alcohol hand rub may decrease the incidence and scale of nosocomial outbreaks due to enveloped respiratory viruses especially in mentally incapacitated patients.

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.

Background: Patients with mild to moderate obstructive sleep apnoea (OSA) may be managed with different treatment options. This study compared the effectiveness of three commonly used non-surgical treatment modalities., Methods: Subjects with mild to moderate OSA were randomised to one of three treatment groups for 10 weeks: conservative measures (sleep hygiene) only, continuous positive airways pressure (CPAP) in addition to conservative measures or an oral appliance in addition to conservative measures. All overweight subjects were referred to a weight-reduction class. OSA was assessed by polysomnography. Blood pressure was recorded in the morning and evening in the sleep laboratory. Daytime sleepiness was assessed with the Epworth Sleepiness Scale. Health-related quality of life (HRQOL) was assessed with the 36-Item Short-Form Health Survey (SF-36) and Sleep Apnoea Quality of Life Index (SAQLI)., Results: 101 subjects with a mean (SEM) apnoea-hypopnoea index (AHI) of 21.4 (1.1) were randomised to one of the three groups. The severity of sleep-disordered breathing was decreased in the CPAP and oral appliance groups compared with the conservative measures group, and the CPAP group was significantly better than the oral appliance group. Relief from sleepiness was significantly better in the CPAP group. CPAP was also better than the oral appliance or conservative measures in improving the "bodily pain" domain, and better than conservative measures in improving the "physical function" domain of SF-36. Both CPAP and the oral appliance were more effective than conservative measures in improving the SAQLI, although no difference was detected between the CPAP and oral appliance groups. CPAP and the oral appliance significantly lowered the morning diastolic blood pressure compared with baseline values, but there was no difference in the changes in blood pressure between the groups. There was also a linear relationship between the changes in AHI and body weight., Conclusion: CPAP produced the best improvement in terms of physiological, symptomatic and HRQOL measures, while the oral appliance was slightly less effective. Weight loss, if achieved, resulted in an improvement in sleep parameters, but weight control alone was not uniformly effective.

Background: The patterns of corticosteroids usage in severe acute respiratory syndrome (SARS) and associated treatment outcomes in Hong Kong were studied., Method: Patients> or =18 years old who either had not received corticosteroid or had taken corticosteroids within 14 days from symptom onset were included. Patients receiving corticosteroids beyond 15 days or other investigational treatment within 21 days from symptom onset were excluded. Of 1313 eligible patients, 1287 with major corticosteroid dosage-type combinations were analysed., Results: Crude death rate was lower among 1188 steroid-treated patients compared to 99 patients in Group No Steroid (17.0% vs. 28.3%). Among four corticosteroid groups studied, mortality was lowest in the low-dose oral prednisolone (Group P) and high-dose methylprednisolone (Group MP) groups. On multivariate analysis of the corticosteroid groups, independent factors related to death were: corticosteroid group, older age, co-morbidity, worse chest X-ray score, worse respiratory status at Days 8-10 and higher admission white cell count. Again Groups P and MP had significantly lower adjusted odds ratios for death and lower bacterial and fungal culture rates. Despite worse chest X-ray scores and higher cumulative corticosteroid dosages in Group MP compared to Group P, fewer patients required rescue pulsed corticosteroid. Patients on hydrocortisone (Group HC) had the highest positive culture rates., Conclusion: We speculate that corticosteroid with higher in-vitro inflammatory potency administered at timing and dosages commensurate with disease severity may be conducive to better outcome from SARS as a consequence of more effective control of immunopathological lung damage.

The objective of this study was to evaluate long-term dentofacial changes in Chinese obstructive sleep apnea (OSA) patients treated with a mandibular advancement device (MAD). Lateral cephalograms in natural head posture were obtained from 67 consecutive OSA patients (mean age = 46.9 +/- 8.9 years) treated with an MAD. The cephalograms were obtained at start of treatment (T0), after 1 year (T1), 2 years (T2), and 3 years (T3) of treatment. The lateral cephalograms were digitized twice, and the average of two readings was used for statistical analyses. Small, but statistically significant changes occurred in some dentofacial variables. The lower anterior facial height steadily increased during the observation period, and this increase was significant for the T0-T1 and T1-T2 periods and marginally significant for the T2-T3 period. A significant increase in the mandibular plane angle was observed during the T0-T1 and T2-T3 periods only. Significant reductions in the overjet and overbite were observed for the T0-T1 period but not thereafter. Statistically significant dentofacial changes were observed in this study, but they were of small magnitude. The overjet and overbite changes observed mainly occurred at the initial stage of treatment.

Background: Severe acute respiratory syndrome is frequently complicated by respiratory failure requiring ventilatory support. We aimed to compare the efficacy of non-invasive ventilation against invasive mechanical ventilation treating respiratory failure in this disease., Methods: Retrospective analysis was conducted on all respiratory failure patients identified from the Hong Kong Hospital Authority Severe Acute Respiratory Syndrome Database. Intubation rate, mortality and secondary outcome of a hospital utilizing non-invasive ventilation under standard infection control conditions (NIV Hospital) were compared against 13 hospitals using solely invasive ventilation (IMV Hospitals). Multiple logistic regression analyses with adjustments for confounding variables were performed to test for association between outcomes and hospital groups., Results: Both hospital groups had comparable demographics and clinical profiles, but NIV Hospital (42 patients) had higher lactate dehydrogenase ratio and worse radiographic score on admission and ribavirin-corticosteroid commencement. Compared to IMV Hospitals (451 patients), NIV Hospital had lower adjusted odds ratios for intubation (0.36, 95% CI 0.164 - 0.791, P = 0.011) and death (0.235, 95% CI 0.077 - 0.716, P = 0.011), and improved earlier after pulsed steroid rescue. There were no instances of transmission of severe acute respiratory syndrome among health care workers due to the use of non-invasive ventilation., Conclusion: Compared to invasive mechanical ventilation, non-invasive ventilation as initial ventilatory support for acute respiratory failure in the presence of severe acute respiratory syndrome appeared to be associated with reduced intubation need and mortality.

Severe acute respiratory syndrome (SARS) is a highly contagious disease that has led to large hospital and community outbreaks, necessitating stringent infection control in its management. Among 90 SARS patients in our institution in the 2003 outbreak, 2 underwent cardiac catheterization. We report the personal respiratory protection and environmental control measures implemented to minimize the risk of droplets spread during these procedures, including re-engineering of the ventilation system of the cardiac catheterization laboratory (CCL). The report highlights the importance of collaboration of CCL personnel with relevant hospital engineering and management teams to develop a contingency infection control plan to prepare for future outbreaks of SARS or other epidemics.

Objective: To identify anxiety levels among front-line health care workers during the 2003 severe acute respiratory syndrome outbreak., Design: Questionnaire survey., Setting: Regional hospital, Hong Kong., Participants: All hospital staff were given a questionnaire; administrative staff who had not had any patient contact served as controls., Main Outcome Measures: Levels of contact with patients who had severe acute respiratory syndrome were measured and correlated with anxiety levels as determined by the State-Trait Anxiety Inventory., Results: Of 4252 questionnaires distributed between May and June 2003, 2040 (48.0%) were returned and 1926 (45.3%) were valid for analysis. Overall, 534 (27.7%) respondents had had contact with patients with severe acute respiratory syndrome. Anxiety scores ranged from 20 to 80, and mean (standard deviation) scores were higher among staff who had had contact with patients with severe acute respiratory syndrome than among those who had not (52.6 [10.5] versus 49.8 [10.1], respectively; P<0.01). Mean anxiety levels were higher among workmen, health care assistants, and nurses than among administrative staff controls or doctors (P<0.01). Anxiety scores were correlated with burnout scores (Pearson's correlation coefficient, 0.52-0.59) and with discomfort from wearing protective gear (0.21-0.32)., Conclusion: Severe acute respiratory syndrome has likely stressed the public health care system. Prediction and early identification of adverse factors in a crisis situation would allow early implementation of interventions to reduce and counteract the impact of this stress.

Objectives: To study the effectiveness of noninvasive positive pressure ventilation (NIPPV) in the treatment of acute respiratory failure (ARF) in severe acute respiratory syndrome (SARS), and the associated infection risk., Methods: All patients with the diagnosis of probable SARS admitted to a regional hospital in Hong Kong from March 9 to April 28, 2003, and who had SARS-related respiratory distress complications were recruited for NIPPV usage. The health status of all health-care workers working in the NIPPV wards was closely monitored, and consent was obtained to check serum for coronavirus serology. Patient outcomes and the risk of SARS transmission to health-care workers were assessed., Results: NIPPV was applied to 20 patients (11 male patients) with ARF secondary to SARS. Mean age was 51.4 years, and mean acute physiology and chronic health evaluation II score was 5.35. Coronavirus serology was positive in 95% (19 of 20 patients). NIPPV was started 9.6 days (mean) from symptom onset, and mean duration of NIPPV usage was 84.3 h. Endotracheal intubation was avoided in 14 patients (70%), in whom the length of ICU stay was shorter (3.1 days vs 21.3 days, p < 0.001) and the chest radiography score within 24 h of NIPPV was lower (15.1 vs 22.5, p = 0.005) compared to intubated patients. Intubation avoidance was predicted by a marked reduction in respiratory rate (9.2 breaths/min) and supplemental oxygen requirement (3.1 L/min) within 24 h of NIPPV. Complications were few and reversible. There were no infections among the 105 health-care workers caring for the patients receiving NIPPV., Conclusions: NIPPV was effective in the treatment of ARF in the patients with SARS studied, and its use was safe for health-care workers.

Objective: Severe acute respiratory syndrome (SARS) is a newly emergent disease due to a novel coronavirus, which caused outbreaks worldwide., Methodology: We report a SARS patient who had developed recurrent chest pain and acute T-wave inversion over the precordial leads on electrocardiography (ECG)., Results: She developed progressive subcutaneous emphysema a few days later. Her CXR showed features suggestive of pneumomediastinum, which was confirmed by high-resolution CT scan of the thorax., Conclusion: Pneumomediastinum should be considered in SARS patients as a possible cause of chest pain and ECG changes that mimic acute coronary syndrome.

Objective: There is so far no consensus on the optimal treatment strategy for the coronavirus-associated severe acute respiratory syndrome (SARS). We aimed to analyse the outcomes of a standard treatment strategy comprising antibiotics, a combination of ribavirin, a 3-week step-down course of corticosteroids, and the possibility of pulsed methylprednisolone rescue in the event of deterioration., Methodology: This was a prospective cohort study performed at a major public-funded hospital in Hong Kong. Eighty-eight World Health Organisation/Centers for Disease Control and Prevention probable cases of SARS (97% laboratory-confirmed) were treated with a standard protocol previously reported. Seventy-one patients treated de novo were analysed in detail with regard to time to clinical stabilization after combination treatment, requirement of additional therapy (pulsed methylprednisolone; assisted ventilation); and final outcomes (recovery, mortality)., Results: The mean age was 42. Twenty-one patients (24%) had comorbidities. Three of 71 treated de novo recovered with antibiotics alone. The remaining 68 received combination treatment at a mean of 5.8 days after symptom onset, of whom 30 subsequently required pulsed methylprednisolone rescue (independent predictors: older age and higher LDH) and 18 required assisted ventilation (independent predictors: older age, higher oxygen requirement and creatinine level). Their median time to clinical stabilization was 8.0 days after combination treatment (independent predictor for longer time to stabilization: median age of 41 or above). Common complications were hyperglycaemia (58%), pneumo-mediastinum/thoraces (13%), psychiatric manifestations (7%) and ventilator-associated pneumonia (2%). One patient (1%) died of SARS-related respiratory failure. All-cause mortality was 3.4%, occurring in patients aged > 65 years only. None of the discharged survivors required continuation of oxygen therapy., Conclusions: This standard treatment protocol resulted in overall satisfactory outcomes. Randomized controlled trial is suggested to confirm its efficacy.

Study Objective: Microalbuminuria in diabetes mellitus is a risk factor for cardiovascular disease. We hypothesized that microalbuminuria in type 2 diabetic patients is related to impaired cardiopulmonary function during exercise, and that the severity of impairment is correlated with the degree of microalbuminuria., Design: Twenty of each of the following categories of subjects performed symptom-limited cardiopulmonary exercise testing on a cycle ergometer: (1) type 2 diabetic patients with normoalbuminuria (daily urinary albumin excretion [UAE] < 30 mg/d); (2) type 2 diabetic patients with microalbuminuria (daily UAE, 30 to 300 mg/d); and (3) normal control subjects., Measurements and Results: Oxygen consumption (VO(2)) of patients with microalbuminuria was lower than that of control subjects at anaerobic threshold (AT) [p < 0.001], and was lower than both control subjects (p < 0.001) and patients with normoalbuminuria (p = 0.015) at peak exercise. There was a progressive worsening in gas exchange efficiency at the lungs, as measured by minute ventilation (VE)/carbon dioxide production (VCO(2)) at AT or DeltaVE/DeltaVCO(2) slope, (p = 0.006 and p = 0.019, respectively) going from control subjects to patients with normoalbuminuria and then to patients with microalbuminuria. Left ventricular ejection fractions and BP were similar in patients with normoalbuminuria and microalbuminuria. More patients with microalbuminuria (n = 9) than with normoalbuminuria (n = 2) demonstrated diastolic dysfunction (p = 0.013). These 11 patients had lower peak VO(2) values (p = 0.001) and higher daily UAE (p = 0.028). An inverse linear relationship was found between peak VO(2) and log(10) daily UAE (r = - 0.57, r(2) = 0.29, p < 0.001)., Conclusions: Abnormalities reflecting reduced oxygen transport and impaired gas exchange efficiency were found during exercise, and were especially profound in patients with microalbuminuria. These changes could be secondary to pulmonary microangiopathy and myocardial interstitial changes. Increases in capillary permeability to proteins may take place in the myocardium as they do in the kidneys, and contribute to impaired myocardial distensibility and hence diastolic dysfunction.

Cases of severe acute respiratory syndrome (SARS) were investigated for SARS coronavirus (SARS-CoV) through RNA tests, serologic response, and viral culture. Of 537 specimens from patients in whom SARS was clinically diagnosed, 332 (60%) had SARS-CoV RNA in one or more clinical specimens, compared with 1 (0.3%) of 332 samples from controls. Of 417 patients with clinical SARS from whom paired serum samples were available, 92% had an antibody response. Rates of viral RNA positivity increased progressively and peaked at day 11 after onset of illness. Although viral RNA remained detectable in respiratory secretions and stool and urine specimens for >30 days in some patients, virus could not be cultured after week 3 of illness. Nasopharyngeal aspirates, throat swabs, or sputum samples were the most useful clinical specimens in the first 5 days of illness, but later in the illness viral RNA could be detected more readily in stool specimens.

Severe acute respiratory syndrome (SARS) is frequently complicated with acute respiratory failure. In this article, we aim to focus on the management of the subgroup of SARS patients who are critically ill. Most SARS patients would require high flow oxygen supplementation, 20-30% required intensive care unit (ICU) or high dependency care, and 13-26% developed acute respiratory distress syndrome (ARDS). In some of these patients, the clinical course can progress relentlessly to septic shock and/or multiple organ dysfunction syndrome (MODS). The management of critically ill SARS patients requires timely institution of pharmacotherapy where applicable and supportive treatment (oxygen therapy, noninvasive and invasive ventilation). Superimposed bacterial and other opportunistic infections are common, especially in those treated with mechanical ventilation. Subcutaneous emphysema, pneumothoraces and pneumomediastinum may arise spontaneously or as a result of positive ventilatory assistance. Older age is a consistently a poor prognostic factor. Appropriate use of personal protection equipment and adherence to infection control measures is mandatory for effective infection control. Much of the knowledge about the clinical aspects of SARS is based on retrospective observational data and randomized-controlled trials are required for confirmation. Physicians and scientists all over the world should collaborate to study this condition which may potentially threaten human existence.

Objective: We retrospectively reviewed high-resolution CT (HRCT) examinations of the lungs performed in 27 confirmed cases of severe acute respiratory syndrome (SARS). The HRCT findings at different phases of the illness were analyzed., Conclusion: A defined pattern of HRCT findings is observed in different phases of SARS, which is characterized by focal ground-glass and crazy paving patterns in a scattered distribution at presentation, followed by development of interstitial thickening, consolidation, pleural reaction, and scarring. Spontaneous pneumomediastinum is a distinct complication during the course of the illness.

Severe acute respiratory syndrome (SARS) is an emerging infection caused by a novel coronavirus. It is characterised by a highly infectious syndrome of fever and respiratory symptoms, and is usually associated with bilateral lung infiltrates. The clinical syndrome of SARS often progresses to varying degrees of respiratory failure, with about 20% of patients requiring intensive care. Despite concern about potential aerosol generation, non-invasive ventilation (NIV) has been reported to be efficacious in the treatment of SARS-related ARF without posing infection risks to health care workers (HCW). Spontaneous pneumomediastinum and pneumothorax in SARS is common. The incidence of NIV-associated barotrauma ranged from 6.6% to 15%. Patients who fail to tolerate NIV or fail NIV with progressive dyspnoea, tachypnoea and hypoxaemia should be intubated and mechanically ventilated. Mortality rates in intensive care units for SARS patients were high: 34-53% at 28 days, when some patients were still being ventilated. Strict adherence to infection control measures including isolation, use of appropriate personal protective equipment and negative pressure environment had been reported to eliminate cross-infection to HCW.

A series of 31 patients with probable SARS, diagnosed from WHO criteria, were treated according to a treatment protocol consisting of antibacterials and a combination of ribavirin and methylprednisolone. Through experience with the first 11 patients, we were able to finalise standard dose regimens, including pulsed methylprednisolone. One patient recovered on antibacterial treatment alone, 17 showed rapid and sustained responses, and 13 achieved improvement with step-up or pulsed methylprednisolone. Four patients required short periods of non-invasive ventilation. No patient required intubation or mechanical ventilation. There was no mortality or treatment morbidity in this series.

The aim of this study was to assess the clinical spectrum of peripartum tuberculosis from the perspective of immunorestitution disease. Of 29 patients with peripartum tuberculosis, 27 (93.1%) had extrapulmonary tuberculosis, 20 (69%) of whom were affected in the central nervous system. Twenty-two (75.9%) patients had no clinical features suggestive of tuberculosis during pregnancy. The median time from delivery to the onset of immunorestitution was 4 days, but treatment with anti-tuberculous therapy was delayed for a median time of 27 days after the onset of symptoms. Despite therapy, 11 (38%) patients died and 4 (13.8%) had residual functional deficits. Peripartum tuberculosis is an important differential diagnosis of postpartum fever (of unknown origin) without localized signs.

Background: An outbreak of severe acute respiratory syndrome (SARS) has been reported in Hong Kong. We investigated the viral cause and clinical presentation among 50 patients., Methods: We analysed case notes and microbiological findings for 50 patients with SARS, representing more than five separate epidemiologically linked transmission clusters. We defined the clinical presentation and risk factors associated with severe disease and investigated the causal agents by chest radiography and laboratory testing of nasopharyngeal aspirates and sera samples. We compared the laboratory findings with those submitted for microbiological investigation of other diseases from patients whose identity was masked., Findings: Patients' age ranged from 23 to 74 years. Fever, chills, myalgia, and cough were the most frequent complaints. When compared with chest radiographic changes, respiratory symptoms and auscultatory findings were disproportionally mild. Patients who were household contacts of other infected people and had older age, lymphopenia, and liver dysfunction were associated with severe disease. A virus belonging to the family Coronaviridae was isolated from two patients. By use of serological and reverse-transcriptase PCR specific for this virus, 45 of 50 patients with SARS, but no controls, had evidence of infection with this virus., Interpretation: A coronavirus was isolated from patients with SARS that might be the primary agent associated with this disease. Serological and molecular tests specific for the virus permitted a definitive laboratory diagnosis to be made and allowed further investigation to define whether other cofactors play a part in disease progression.

A rare case of pyothorax-associated large B-cell lymphoma occurring in Hong Kong is reported. The patient was a 64-year-old Chinese male who presented with shortness of breath and pleuritic pain. Radiological examination revealed left pleural thickening associated with bilateral pleural effusion. Open biopsy of the thickened parietal pleura revealed occasional large malignant lymphoid cells of B lineage admixed with fibrin and hyalinised fibrous tissue. These lymphoma cells were shown to harbour both Epstein-Barr virus and human herpesvirus type 8 by in situ hybridisation and immunohistochemical study, respectively. There was no associated lymphadenopathy and hepatosplenomegaly. The clinicoradiological presentation and pathological findings thus fulfilled the criteria of the so-called pyothorax-associated large B-cell lymphoma. Awareness of this rare entity, together with diligent histological examination and proper application of ancillary investigative techniques, are essential for making a correct diagnosis. The co-infection with Epstein-Barr virus and human herpesvirus type 8 in this case also suggests a possible pathogenetic relationship between pyothorax-associated large B-cell lymphoma and primary effusion lymphoma.

A retrospective study was carried out in a Hong Kong regional hospital with 24-h emergency service, to study the factors associated with shorter time to re-admission after acute exacerbation of chronic obstructive pulmonary disease (COPD). From 1 January 1997 to 31 December 1997, the first admission (index admission) of each patient through the emergency room with COPD/chronic bronchitis/emphysema was included. A total of 551 patients fulfilled the inclusion criteria. The total acute and rehabilitative length of stay (mean +/- SD) was 9.41+/-11.67 days. Within 1 year after discharge, 327 patients (59 35%) were re-admitted at least once. Median time to first re-admission after discharge was 240 days. By Cox regression analysis, the following factors were independently associated with shorter time to re-admission: hospital admission within 1 year before index admission, total length of stay in index admission > 5 days, nursing home residency, dependency in self-care activities, right heart strain pattern on electrocardiogram, on high dose inhaled corticosteroid and actual bicarbonate level > 25 mmol l(-1). These factors may be relevant in the future planning of healthcare utilization for COPD patients.

Objective: To study the effectiveness and safety of non-invasive positive-pressure ventilation in the management of acute respiratory failure., Design: Prospective study., Setting: Regional public hospital, Hong Kong., Patients: One hundred and eighty-nine haemodynamically stable adult Chinese patients with acute respiratory failure (119 men and 70 women; mean age, 71.2 years [range, 18-92 years]) who were treated with non-invasive positive-pressure ventilation as the primary mode of ventilatory assistance from 1 January 1996 to 31 December 1998., Main Outcome Measures: Arterial blood gas measurements, respiratory rate, airway pressures used, use of endotracheal intubation, and standardised mortality ratio., Results: Fifty-two patients had hypoxaemic respiratory failure (group I); 97 had hypercapnic respiratory failure (group II); and 40 had either type with advanced co-morbidities and were not planned to receive endotracheal intubation (group III). For groups I and II, the overall mean duration of non-invasive positive-pressure ventilation was 56.2 hours. Improvements in gas exchange were seen in approximately 71% of these patients, endotracheal intubation was not needed for 82%, and the standardised mortality ratio was 0.86. The hospital survival rate was approximately 93% in non-intubated patients and 41% in intubated patients. Predictors of success were reduction in respiratory rate within 6 hours (P<0.005), and (for hypercapnic respiratory failure) increased pH and reduced arterial carbon dioxide tension within 24 hours (P<0.005). Patients with pneumonia had significantly higher failure rates (P<0.05). Group III patients were older, had higher Acute Physiology and Chronic Health Evaluation II scores, and required longer ventilatory support, but their gas exchange response rate was 68%. The only complication of treatment was minor facial skin abrasions., Conclusion: Non-invasive positive-pressure ventilation is effective in treating haemodynamically stable patients with acute respiratory failure and causes few and minor complications.

OBJECTIVE: To review the donor and recipient selection criteria, surgical techniques, perioperative and post-operative management, and complications of lung/heart-lung transplantation. DATA SOURCES: Medline and non-Medline search of the relevant English literature, local data, and personal experience. STUDY SELECTION: Studies containing supporting evidence were selected. DATA EXTRACTION: Data were extracted and analysed independently by the authors. DATA SYNTHESIS: Lung/heart-lung transplantations are considered only for patients who have progressively disabling and end-stage disease. Numerous investigations of the recipient and rigorous matching between the donor and recipient are required. Factors such as maintaining the donor's haemodynamic stability, graft preservation, effective perioperative immunosuppression, and careful postoperative monitoring are key to a successful transplantation. Follow-up should include the home-monitoring of body weight, temperature, and spirometry, as well as regular chest X-rays, pulmonary function tests, and blood tests. So far, two double and two single lung transplantations, and one heart-lung transplantation have been performed in Hong Kong. CONCLUSION: Lung transplantation is an invaluable treatment modality for patients with end-stage lung disease.

Systemic lupus erythematosus (SLE) is a chronic systemic inflammatory disease associated with the production of various autoantibodies and involvement of multiple organs. Necropsy findings in a 65 year old woman with SLE who had multiple aortic aneurysms and dissections, as well as other unusual manifestations, are described. The case illustrates the occurrence of and the difficulties encountered in the diagnosis of several diseases, namely aortic aneurysm, aortic dissection, acute pancreatitis, and Penicillium marneffei infection.

Rheumatoid arthritis is the commonest connective tissue disease associated with bronchiolitis obliterans, a clinico-pathologic entity of bronchiolar inflammation and fibrosis reflecting injury to the small airways, and presenting with symptoms and signs of small airways obstruction. It may arise de novo or as a complication of therapy due to d-penicillamine, when a distinct histologic picture of bronchiolar constriction without intraluminal inflammatory polyps appeared to be predominant in most reported cases. This condition is associated with a high morbidity and mortality, and apart from cessation of d-penicillamine, there are no standard recommendations for treatment. Response to various immunosuppressive agents, including corticosteroid, azathioprine, and cyclophosphamide, had been variable and unsatisfactory. We report a case of bronchiolitis obliterans in a Chinese female treated with d-Penicillamine for rheumatoid arthritis with the first documented response to corticosteroid alone, and review the literature on this subject.

Significant ischaemic tracheal damage from endotracheal intubation is uncommon when the lateral wall pressure exerted by the cuff does not exceed the mean capillary perfusion pressure of the mucosa. This is facilitated by the modern endotracheal tubes with high-volume-low-pressure cuffs. We report a case of tracheal rupture due to an incorrectly positioned softcuffed tube. The need to review tube position radiologically and to make immediate adjustment cannot be overemphasised.

A total of 108 patients with duodenal ulcers were divided into 4 groups in a double-blind study controlled by endoscopic examinations. Patients in each group were given either an antacid mixture or sulpiride alone, antacid mixture plus sulpiride, or a placebo. The highest complete recovery rate (84 per cent) was noted in the antacid mixture plus sulpiride group, while partial healing (more than 50 per cent reduction in ulcer size) was highest in the sulpiride group (84,6 per cent). As sulpiride has both healing effects on the ulcer and an analgesic effect against pain it can be prescribed in association with antacid mixtures for the treatment of duodenal ulcers.

The effect of aluminum-magnesium hydroxide tablets (800 mg seven times per day) and that of sulpiride, a hypothalamic neurolaptic, were studied in 101 patients with duodenal ulcer in a double-blind controlled 4-wk trial. Significantly more of the patients treated with antacid, sulpiride, or antacid-sulpiride combination showed a greater than 50% reduction in ulcer size than did the patients treated with placebo. However, only in the antacid- and antacid-sulpiride-treated groups did the ulcer, with and without residual inflammation, disappear statistically more often than in the placebo-treated group. Furthermore, only in the antacid-sulpiride-treated group did complete healing, with no trace of inflammation, occur statistically more often than in the placebo-treated group. Disappearance of ulcer pain was likewise statistically more frequent in the antacid-sulpiride group than in the placebo-treated group. Antacid therapy with aluminum-magnesium hydroxide tablets appears to accelerate the rate of ulcer healing. Sulpiride appears to have a minor but definite synergism with antacids. Cigarette smoking affected ulcer healing adversely; on the other hand, factors favorable to healing were the early onset age of ulcer symptoms and acid hypersecretion. Male patients also healed more favorably than females.