International experts in infectious disease and epidemiology consider it likely that there will be a recurrent outbreak of severe acute respiratory syndrome (SARS) or other newly emerging and serious transmissible respiratory pathogens, according to the published conclusions of a workshop on the highly infectious disease. Writing in the first issue for March 2005 of the American Thoracic Society's peer-reviewed American Journal of Respiratory and Critical Care Medicine, an expert panel developed recommendations concerning the care and treatment of patients with SARS based on prior clinical experience. According to the report, 8,098 persons in 29 countries developed probable SARS between November 1, 2002, and August 7, 2003. The heaviest burden of illness was felt in China, Hong Kong, Taiwan, Singapore, Viet Nam, and Canada. About 23 to 32 percent of SARS patients become critically ill, with acute lung injury affecting 16 percent of all patients with SARS and 80 percent of critically ill patients with the disease. The worldwide fatality rate among all SARS outbreaks was 9.6 percent, but those suffering from SARS-related critical illness died at a 50 percent rate. Worldwide, children were relatively protected from this severe illness. The report notes that the first symptom of SARS is often fever followed by diffuse muscle pain (myalgia), headache, nonproductive cough, and breathlessness (dyspnea). Rapid breathing (tachypnea) and rapid heart rate (tachycardia) are also common early symptoms. Lower respiratory problems, including cough and shortness of breath, typically begin 2 to 7 days after symptoms onset. The average time from exposure to symptom onset is approximately one week. Infection from patients to healthcare workers in the hospital has been a "prominent and worrisome feature of SARS outbreaks. In Singapore and Toronto, healthcare workers have accounted for half of all SARS cases and 20 percent of all critically ill SARS cases." The Workshop report noted: "An urgent need exists for antiviral drugs to prevent and treat SARS. During the first global outbreak, various interventions were used in management, including antivirals like ribavirin, interferon, and protease inhibitors, as well as host immunomodulary agents, particularly systemic corticosteroids. However, the uncontrolled nature of these observations and the uncertain natural history of untreated SARS mean that no drug interventions of proven therapeutic or prophylactic value have been established to date." Because the clinical and pathologic mechanisms of SARS are indistinguishable from acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), the clinical management of severe SARS should be similar to that for ALI and ARDS. In these illnesses, mechanical ventilation with a low tidal volume strategy here has been shown to improve survival in these patients.
OVERWEIGHT IS SIGNIFICANTLY ASSOCIATED WITH ASTHMA IN FEMALES
In a cohort of New Zealand children who were followed from birth to age 26, overweight, expressed as higher body mass index, was significantly associated with asthma wheeze in females, but not in males. The investigators found that the association between high body mass index (BMI) and asthma occurred in females who became overweight during late adolescence and early adulthood. At age 9, there was no evidence of an association, but by 26 it was statistically significant. Analysis of data was performed in 1,037 children at ages 9, 11, 13, 15, 18, 21, and 26. Information on asthma and measurements of lung function, airway responsiveness, and atopy (inherited tendency toward allergic reaction) were obtained on each of these occasions. At each age checked, investigators calculated the young person's age, height, and weight in light clothing without shoes to determine BMI. The association between raised BMI and asthma appeared to emerge in late adolescence, according to the investigators. The participants were part of the Dunedin Multidisciplinary Health and Development Study which involved children (52 percent male) who were born between April 1971 and March 1973. At age 26, 980 (96 percent of the 1,019 living study members were still participating. The research is published in the first issue for March 2005 of the American Thoracic Society's peer-reviewed American Journal of Respiratory and Critical Care Medicine.
POSTOPERATIVE PULMONARY COMPLICATIONS AFTER NONTHORACIC SURGERY
Of the approximately 45 million North Americans who will undergo nonthoracic surgery during the next year, over 1 million will experience a postoperative pulmonary complication, an event which could have enormous implications for both the patient and health care system. Canadian investigators checked 1,055 consecutive patients attending a presurgical admission clinic at a university hospital to uncover risk factors for pulmonary complications after elective nonthoracic surgery. According to the authors, pulmonary complications after nonthoracic surgery are more frequent than cardiac complications and are associated with a greater increase in hospital length of stay. Of the 1,055 patients in the study, 28 (2.7 percent) suffered a postoperative pulmonary complication within 7 days after surgery. Thirteen patients developed respiratory failure requiring ventilatory support, 9 contracted pneumonia, 5 had collapse of lung tissue (atelectasis) requiring bronchoscopic intervention, and 1 suffered a collection of air or gas in the pleural cavity causing the lung to collapse. One patient who had pneumonia subsequently died. The length of stays for patients with postsurgical pulmonary complications were almost 28 days, as contrasted with 4.5 days for patients who had no postsurgical complications. The four factors associated with an increased risk for pulmonary complications following nonthoracic surgery were: age over 65; a positive cough test (meaning the patient continued to cough after taking a deep breath and providing a voluntary cough); placement of a nasogastric tube at the time of the operation; and long-duration anesthesia (2.5 hours or longer). The researchers called for steps to minimize perioperative intubation unless it is judged very necessary on clinical grounds. The research is published in the first issue for March 2005 of the American Thoracic Society's peer-reviewed American Journal of Respiratory and Critical Care Medicine
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