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1.  Pro/con clinical debate: Isolation precautions for all intensive care unit patients with methicillin-resistant Staphylococcus aureus colonization are essential 
Critical Care  2004;8(3):153-156.
Antibiotic-resistant bacteria are an increasingly common problem in intensive care units (ICUs), and they are capable of impacting on patient outcome, the ICU's budget and bed availability. This issue, coupled with recent outbreaks of illnesses that pose a direct risk to ICU staff (such as SARS [severe acute respiratory syndrome]), has led to renewed emphasis on infection control measures and practitioners in the ICU. Infection control measures frequently cause clinicians to practice in a more time consuming way. As a result it is not surprising that ensuring compliance with these measures is not always easy, particularly when their benefit is not immediately obvious. In this issue of Critical Care, two experts face off over the need to isolate patients infected with methicillin-resistant Staphylococcus aureus.
doi:10.1186/cc2817
PMCID: PMC468889  PMID: 15153232
hand-washing; infection control; intensive care; isolation; methicillin-resistant Staphylococcus aureus
2.  Adiponectin, retinol-binding protein 4, and leptin in protracted critical illness of pulmonary origin 
Critical Care  2009;13(4):R112.
Introduction
Critically ill patients requiring intensive care uniformly develop insulin resistance. This is most pronounced in patients with sepsis. Recently, several hormones secreted by adipose tissue have been identified to be involved in overall insulin sensitivity in metabolic syndrome-related conditions. However, little is known about these adipokines in critical illness.
Methods
We studied circulating levels of the adipokines adiponectin, retinol-binding protein 4 (RBP4), and leptin during critical illness, and the impact of intensive insulin therapy, a therapy shown to affect insulin sensitivity, in serum samples from prolonged critically ill patients with a respiratory critical illness (n = 318). For comparison, we studied healthy subjects (n = 22) and acutely stressed patients (n = 22).
Results
During acute critical illness, circulating levels of adiponectin, RBP4, and leptin were low. Patients with sepsis had lower levels of leptin and RBP4 than did nonseptic patients. When critical illness was sustained, adipokine levels returned to normal reference values. Insulin therapy enhanced adiponectin, blunted the rise of RBP4, and did not alter leptin levels.
Conclusions
Acute critical illness is associated with immediate, but transiently low serum adipokine levels. Adiponectin and RBP4 are associated with altered insulin resistance in critical illness.
doi:10.1186/cc7956
PMCID: PMC2750156  PMID: 19589139
3.  Management of Critically Ill Patients with Severe Acute Respiratory Syndrome (SARS) 
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.
PMCID: PMC1074505  PMID: 15912185
SARS; severe acute respiratory syndrome; critically ill patients; management; treatment and control.
4.  Statins in the critically ill 
The use or misuse of statins in critically ill patients recently attracted the attention of intensive care clinicians. Indeed, statins are probably the most common chronic treatment before critical illness and some recent experimental and clinical data demonstrated their beneficial effects during sepsis, acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), or after aneurismal subarachnoidal hemorrhage (aSAH). Due to the heterogeneity of current studies and the lack of well-designed prospective studies, definitive conclusions for systematic and large-scale utilization in intensive care units cannot be drawn from the published evidence. Furthermore, the extent of statins side effects in critically ill patients is still unknown. For the intensive care clinician, it is a matter of individually identifying the patient who can benefit from this therapy according to the current literature. The purpose of this review is to describe the mechanisms of actions of statins and to synthesize the clinical data that underline the relevant effects of statins in the particular setting of critical care, in an attempt to guide the clinician through his daily practice.
doi:10.1186/2110-5820-2-19
PMCID: PMC3488539  PMID: 22709377
Mevalonate; HMG-CoA reductase; Sepsis; Acute lung injury; Acute respiratory distress syndrome; Subarachnoid hemorrhage
5.  The Impact of Severe Acute Respiratory Syndrome on Medical House Staff 
OBJECTIVE
To explore the impact of severe acute respiratory syndrome (SARS) on a medical training program and to develop principles for professional training programs to consider in dealing with future, similar crises.
DESIGN
Qualitative interviews analyzed using grounded theory methodology.
SETTING
University-affiliated hospitals in Toronto, Canada during the SARS outbreak in 2003.
PARTICIPANTS
Medical house staff who were allocated to a general internal medicine clinical teaching unit, infectious diseases consultation service, or intensive care unit.
RESULTS
Seventeen medical residents participated in this study. Participants described their experiences during the outbreak and highlighted several themes including concerns about their personal safety and about the negative impact of the outbreak on patient care, house staff education, and their emotional well-being.
CONCLUSION
The ability of residents to cope with the stress of the SARS outbreak was enhanced by the communication of relevant information and by the leadership of their supervisors and infection control officers. It is hoped that training programs for health care professionals will be able to implement these tenets of crisis management as they develop strategies for dealing with future health threats.
doi:10.1111/j.1525-1497.2005.0099.x
PMCID: PMC1490116  PMID: 15963157
medical house staff; severe acute respiratory distress syndrome; training program; outbreak
6.  Atypical clinic presentation of pandemic influenza A successfully rescued by extracorporeal membrane oxygenation – Our experience and review of the literature 
The novel pandemic influenza A (H1N1) caused an epidemic of critical illness, and some patients developed severe acute respiratory distress syndrome (ARDS) or severe cardiopulmonary failure despite the use of conventional management. Extracorporeal membrane oxygenation (ECMO) support may successfully rescue these severely ill patients. We demonstrate the causative role of H1N1 in refractory ARDS of a previously healthy 15-year-old man who presented to the intensive care unit with a hypoxic and persistent cardiogenic shock refractory to conventional management as the leading symptom of influenza A. Because of compromised cardiopulmonary function, venovenous ECMO was applied 24 h after admission. Despite that the patient was manifesting heart failure, we decided the placement of venovenous ECMO because we believed that the real problem was the uncontrollable hypoxia and hypercapnia. A normal left ventricular ejection fraction was documented on a 2D echocardiography on day 2. The patient, after 6 days of ECMO, recovered completely and was successfully weaned from the mechanical ventilator on the 9th day after admission. The patient was discharged from the hospital on the 15th day. This experience showed that ECMO can be lifesaving for severe H1N1 infection also in patients with atypical clinical presentation of influenza.
doi:10.1556/IMAS.5.2013.4.7
PMCID: PMC3873598  PMID: 24381738
extra-corporeal life support; H1N1-flu; lung recovery; myocardial recovery; resuscitation
7.  Statin therapy as prevention against development of acute respiratory distress syndrome: An observational study* 
Critical care medicine  2012;40(5):1470-1477.
Objectives
The 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (“statins”) have anti-inflammatory properties and are associated with improved outcomes in critically ill patients. We investigated whether previous statin therapy affects outcomes in patients at risk for acute respiratory distress syndrome.
Design
Patients were followed-up for the primary outcome of acute respiratory distress syndrome and secondary outcomes of intensive care unit and 60-day mortality, organ dysfunction, and ventilator-free days in a secondary analysis of a prospective cohort study. Receipt of statin therapy was recorded. Propensity score matching was used to adjust for confounding by indication.
Setting
Intensive care units at a tertiary care academic medical center.
Patients
Critically ill patients (2,743) with acute respiratory distress syndrome risk factors.
Interventions
None.
Measurements and Main Results
Acute respiratory distress syndrome developed in 738 (26%) patients; 413 patients (15%) received a statin within 24 hrs of intensive care unit admission. Those who had received a statin within 24 hrs had a lower rate of development of acute respiratory distress syndrome (odds ratio 0.56; 95% confidence interval 0.43–0.73; p < .0001). After multivariate adjustment for potential confounders, this association remained significant (odds ratio 0.69; 95% confidence interval 0.51–0.92; p = .01). However, after propensity score matching, the association was not statistically significant (odds ratio 0.79; 95% confidence interval 0.57–1.10; p = .16). Statin use was not associated with reduced acute respiratory distress syndrome mortality, organ dysfunction, or ventilator-free days. Results of the study were presented in accordance with STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.
Conclusions
Statin therapy at the time of intensive care unit admission was not associated with a lower rate of development of acute respiratory distress syndrome after matching for patient propensity to receive statins. Statin therapy was not associated with improvements in acute respiratory distress syndrome mortality, organ failure, or days free from mechanical ventilation.
doi:10.1097/CCM.0b013e3182416d7a
PMCID: PMC3939937  PMID: 22430234
ALI/ARDS; critical illness; statin
8.  A fresh look at paralytics in the critically ill: real promise and real concern 
Neuromuscular blocking agents (NMBAs), or “paralytics,” often are deployed in the sickest patients in the intensive care unit (ICU) when usual care fails. Despite the publication of guidelines on the use of NMBAs in the ICU in 2002, clinicians have needed more direction to determine which patients would benefit from NMBAs and which patients would be harmed. Recently, new evidence has shown that paralytics hold more promise when used in carefully selected lung injury patients for brief periods of time. When used in early acute respiratory distress syndrome (ARDS), NMBAs assist to establish a lung protective strategy, which leads to improved oxygenation, decreased pulmonary and systemic inflammation, and potentially improved mortality. It also is increasingly recognized that NMBAs can cause harm, particularly critical illness polyneuromyopathy (CIPM), when used for prolonged periods or in septic shock. In this review, we address several practical considerations for clinicians who use NMBAs in their practice. Ultimately, we conclude that NMBAs should be considered a lung protective adjuvant in early ARDS and that clinicians should consider using an alternative NMBA to the aminosteroids in septic shock with less severe lung injury pending further studies.
doi:10.1186/2110-5820-2-43
PMCID: PMC3519794  PMID: 23062076
Neuromuscular blocking agents; Neuromuscular nondepolarizing agents; Polyneuropathies; Respiratory distress syndrome; Adult; Cisatracurium; Status asthmaticus; Shock; Septic
9.  Laboratory Diagnosis of SARS 
Emerging Infectious Diseases  2004;10(5):825-831.
The virologic test results of 415 patients with severe acute respiratory syndrome (SARS) were examined. The peak detection rate for SARS-associated coronavirus occurred at week 2 after illness onset for respiratory specimens, at weeks 2 to 3 for stool or rectal swab specimens, and at week 4 for urine specimens. The latest stool sample that was positive by reverse transcription–polymerase chain reaction (RT-PCR) was collected on day 75 while the patient was receiving intensive care. Tracheal aspirate and stool samples had a higher diagnostic yield (RT-PCR average positive rate for first 2 weeks: 66.7% and 56.5%, respectively). Pooled throat and nasal swabs, rectal swab, nasal swab, throat swab, and nasopharyngeal aspirate specimens provided a moderate yield (29.7%–40.0%), whereas throat washing and urine specimens showed a lower yield (17.3% and 4.5%). The collection procedures for stool and pooled nasal and throat swab specimens were the least likely to transmit infection, and the combination gave the highest yield for coronavirus detection by RT-PCR. Positive virologic test results in patient groups were associated with mechanical ventilation or death (p < 0.001), suggesting a correlation between viral load and disease severity.
doi:10.3201/eid1005.030682
PMCID: PMC3323215  PMID: 15200815
coronavirus; diagnosis; reverse-transcription–polymerase chain reaction; SARS; virus isolation; viral shedding
10.  Clinical review: Use of helium-oxygen in critically ill patients 
Critical Care  2006;10(6):241.
Use of helium-oxygen (He/O2) mixtures in critically ill patients is supported by a reliable and well understood theoretical rationale and by numerous experimental observations. Breathing He/O2 can benefit critically ill patients with severe respiratory compromise mainly by reducing airway resistance in obstructive syndromes such as acute asthma and decompensated chronic obstructive pulmonary disease. However, the benefit from He/O2 in terms of respiratory mechanics diminishes rapidly with increasing oxygen concentration in the gaseous mixture. Safe use of He/O2 in the intensive care unit requires specific equipment and supervision by adequately experienced personnel. The available clinical data on inhaled He/O2 mixtures are insufficient to prove that this therapy has benefit with respect to outcome variables. For these reasons, He/O2 is not currently a standard of care in critically ill patients with acute obstructive syndromes, apart from in some, well defined situations. Its role in critically ill patients must be more precisely defined if we are to identify those patients who could benefit from this therapeutic approach.
doi:10.1186/cc5104
PMCID: PMC1794472  PMID: 17210068
11.  Severe acute respiratory syndrome and its impact on professionalism: qualitative study of physicians' behaviour during an emerging healthcare crisis 
BMJ : British Medical Journal  2004;329(7457):83.
Objective To explore issues of medical professionalism in the context of severe acute respiratory syndrome (SARS), a new emerging health threat.
Design Qualitative interviews analysed with grounded theory methodology.
Setting University hospitals in Toronto, Canada, during the SARS outbreak in 2003.
Participants 14 staff physicians from divisions of infectious diseases, general internal medicine, and critical care medicine.
Results Of 14 attending physicians, four became ill during the outbreak. Participants described their experiences during the outbreak and highlighted several themes about values inherent to medical professionalism that arose during this crisis including the balance between care of patients and accepted personal risk, confidentiality, appropriate interactions between physicians and patients, ethical research conduct, and role modelling of professionalism for junior doctors.
Conclusion Despite concerns raised by professional societies about the erosion of professionalism, participants in this study amply demonstrated the necessary qualities during the recent healthcare crisis. However, there were several examples of strained professional behaviour witnessed by the participants and these examples highlight aspects of medical professionalism that medical educators and professional organisations should address in the future, including the balance between personal safety and duty of care.
doi:10.1136/bmj.38127.444838.63
PMCID: PMC449811  PMID: 15175231
12.  On the delivery of intensive care. 
A 12-bed medical-surgical intensive care unit in a provincial, university-affiliated teaching hospital had 810 admissions during an 18-month period. Most patients were admitted under the care of a family physician. Quality care in the ICU was maintained by the efforts of dedicated unit managers, specialists and house staff. The overall mortality in the ICU of 8.1%, when added to the post-ICU mortality of 2.7% (giving a total hospital mortality of 10.8%), compares favourably with the best reported figures. Strong emphasis on selection of patients with potentially reversible disease, prompted in part by the limited facilities, may have played a role in yielding such favourable statistics. It is possible to retain participation of all members of the health care team during the brief phase of severe illness requiring intensive care.
PMCID: PMC1956035  PMID: 1109726
13.  Eight-Year Trend of Acute Respiratory Distress Syndrome 
Rationale: Significant progress has been made in understanding the pathogenesis of acute respiratory distress syndrome (ARDS). Recent advances in hospital practice may have reduced the incidence of this lethal syndrome.
Objectives: To observe incidence trends and associated outcomes of ARDS.
Methods: This population-based cohort study was conducted in Olmsted County, Minnesota. Using a validated screening protocol, investigators identified intensive care patients with acute hypoxemia and bilateral pulmonary infiltrates. The presence of ARDS was independently confirmed according to American-European Consensus Conference criteria. The incidence of ARDS and associated outcomes were compared over the 8-year study period (2001–2008).
Measurements and Main Results: Over the 8-year period, critically ill Olmsted County residents presented with increasing severity of acute illness, a greater number of comorbidities, and a higher prevalence of major predisposing conditions for ARDS. The ARDS incidence decreased significantly from 82.4 to 38.9 per 100,000 person-years during the study period (P < 0.001). A decline in hospital-acquired ARDS (P < 0.001) was responsible for the fall in the incidence density with no change on admission (P = 0.877). Overall, mortality and hospital and intensive care unit lengths of stay decreased over time (P < 0.001), whereas the ARDS case-fatality did not change significantly.
Conclusions: Despite an increase in patients' severity of illness, number of comorbidities, and prevalence of major ARDS risk factors, the incidence of ARDS in this suburban community decreased by more than half. Correlation of the observed findings with changes in health care delivery may have important implications for the planning of acute care services in other regions.
doi:10.1164/rccm.201003-0436OC
PMCID: PMC3040394  PMID: 20693377
epidemiology; incidence; acute respiratory distress syndrome
14.  Computerized Clinical Protocols in an Intensive Care Unit: How Well Are They Followed? 
Computerized protocols were created to direct the management of arterial hypoxemia in critically ill patients with adult respiratory distress syndrome (ARDS) and have now been applied routinely, 24 hours a day, in the care of 36 such patients. We evaluated the performance of the protocols by measuring how often the clinical staff followed protocol instructions. Since compliance with the protocols could also vary depending on the type of therapy, we assessed compliance with the protocols as a function of 1) the method of artificially ventilating the patients, 2) whether the protocol instruction was to increase or decrease the intensity of therapy or to wait for an interval of time and 3) whether the computer instruction was “correct” or “incorrect.” A total of 7,663 instructions were evaluated. The clinical staff followed protocol instructions 63.8% of the time in the first 8 patients and 90.8% of the time in the subsequent patients. Instructions to wait were more likely to be followed than instructions to change therapy. There was no difference in compliance between instructions to increase and those to decrease the intensity of therapy. “Incorrect” instructions were followed 27% of the time. These instructions may not have been clinically important. The mode of ventilation therapy did not affect compliance with protocol instructions. We conclude that protocols can direct the clinical care of critically ill patients in a manner that is acceptable to experienced clinicians.
PMCID: PMC2245562
15.  Neonatal respiratory distress: potential for prevention. 
Canadian Medical Association Journal  1979;120(9):1076-1080.
A prospective study was conducted of 100 consecutive admissions to the neonatal intensive care unit of the Hospital for Sick Children, Toronto, of infants with respiratory distress syndrome or transient tachypnea of the newborn. It was found that in 15% of cases the illness was completely preventable, being the result of unintentionally premature termination of pregnancy. Significant intrapartum asphyxia occurred in 44% of the infants in whom respiratory distress syndrome developed. Factors placing the pregnancy at high risk were present antenatally in most cases, and most of the deliveries took place in hospitals without adequate facilities or staff, or both, for the requirements of the infant at and following birth.
PMCID: PMC1819281  PMID: 445301
16.  Diagnosis of Severe Acute Respiratory Syndrome (SARS) by Detection of SARS Coronavirus Nucleocapsid Antibodies in an Antigen-Capturing Enzyme-Linked Immunosorbent Assay 
Journal of Clinical Microbiology  2003;41(12):5781-5782.
Recombinant severe acute respiratory syndrome (SARS) coronavirus nucleocapsid protein was employed to establish an antigen-capturing enzyme-linked immunosorbent assay (ELISA). Antinucleocapsid protein antibodies could be detected in 68.4% of probable SARS patients 6 to 10 days after illness and in 89.6% of the patients 11 to 61 days after illness. No false-positive results were observed in 20 non-SARS fever patients, 24 non-SARS respiratory illness patients, and 20 health care workers. Among 940 other non-SARS clinical serum samples, only 1 was found to be weakly positive. This method provides a new, sensitive, and specific approach for SARS diagnosis.
doi:10.1128/JCM.41.12.5781-5782.2003
PMCID: PMC309018  PMID: 14662982
17.  Clinical course and management of SARS in health care workers in Toronto: a case series 
Background
Severe acute respiratory syndrome (SARS) has only recently been described. We provide individual patient data on the clinical course, treatment and complications experienced by 14 front-line health care workers and hospital support staff in Toronto who were diagnosed with SARS, and we provide follow-up information for up to 3 weeks after their discharge from hospital.
Methods
As part of the initial response to the SARS outbreak in Toronto, our health care centre was asked to establish a SARS unit for health care workers who were infected. Patients were admitted to this unit and were closely monitored and treated until they were well enough to be discharged. We prospectively compiled information on their clinical course, management and complications and followed them for 3 weeks after discharge.
Results
The 11 women and 3 men described here (mean age 42 [standard deviation {SD} 9] years) were all involved in providing medical or ancillary hospital services to patients who were later found to have SARS. Onset of symptoms in 4 of our patients who could clearly identify only a single contact with a patient with SARS occurred on average 4 (SD 3) days after exposure. For the remaining 10 patients with multiple patient contacts, symptom onset followed exposure by a mean of 3.5 (SD 3) days after their exposure. All patients were treated with ribavirin, and all patients received levofloxacin. Many experienced major complications. Dyspnea was present in 12 patients during their stay in hospital, and all developed abnormalities on chest radiograph; 3 patients developed severe hypoxemia (PaO2 < 50 mm Hg). All patients experienced a drop in hemoglobin. Nine patients had hemolytic anemia. Three patients experienced numbness and tingling in their hands and feet, and 2 developed frank tetany. All 3 had magnesium levels that were less than 0.1 mmol/L. All patients recovered and were discharged home. At a follow-up examination 3 weeks after discharge (5 weeks after onset of illness), all patients were no longer weak but continued to become fatigued easily and had dyspnea on minimal exertion. For 5 patients, chest radiographs still showed residual disease.
Interpretation
SARS is a very serious illness even in healthy, relatively young people. The clinical course in our patients, all of whom met the case definition for SARS (which requires pulmonary involvement), resulted in dyspnea and, in some individuals, severe hypoxemia. Severe hemolytic anemia may be a feature of SARS or may be a complication of therapy, possibly with ribavirin.
PMCID: PMC161610  PMID: 12821618
18.  Late-Onset Ornithine Carbamoyltransferase Deficiency Accompanying Acute Pancreatitis and Hyperammonemia 
Case Reports in Medicine  2013;2013:903546.
Hyperammonemia related to urea cycle disorders is a rare cause of potentially fatal encephalopathy that is encountered in intensive care units (ICUs). Left undiagnosed, this condition may manifest irreversible neuronal damage. However, timely diagnosis and treatment initiation can be facilitated simply by increased awareness of the ICU staff. Here, we describe a patient with acute severe pancreatitis who developed hyperammonemia and encephalopathy without liver disease. Urea cycle disorder was suspected and hemodialysis was initiated. Following reduction of ammonia levels, subsequent treatment included protein restriction and administration of arginine and sodium benzoate. The patient was discharged to home after 47 days with plasma ammonia within normal range and without neurological symptoms. In clinical care settings, patients with neurological symptoms unexplained by the present illness should be assessed for serum ammonia levels to disclose any urea cycle disorders to initiate timely treatment and improve outcome.
doi:10.1155/2013/903546
PMCID: PMC3773375  PMID: 24073003
19.  Combining Clinical and Epidemiologic Features for Early Recognition of SARS 
Emerging Infectious Diseases  2004;10(2):327-333.
Early recognition and rapid initiation of infection control precautions are currently the most important strategies for controlling severe acute respiratory syndrome (SARS). No rapid diagnostic tests currently exist that can rule out SARS among patients with febrile respiratory illnesses. Clinical features alone cannot with certainty distinguish SARS from other respiratory illnesses rapidly enough to inform early management decisions. A balanced approach to screening that allows early recognition of SARS without unnecessary isolation of patients with other respiratory illnesses will require clinicians not only to look for suggestive clinical features but also to routinely seek epidemiologic clues suggestive of SARS coronavirus exposure. Key epidemiologic risk factors include 1) exposure to settings where SARS activity is suspected or documented, or 2) in the absence of such exposure, epidemiologic linkage to other persons with pneumonia (i.e., pneumonia clusters), or 3) exposure to healthcare settings. When combined with clinical findings, these epidemiologic features provide a possible strategic framework for early recognition of SARS.
doi:10.3201/eid1002.030741
PMCID: PMC3322910  PMID: 15030706
SARS; Coronavirus; diagnosis; epidemiology; clinical features; SARS-CoV
20.  Factors associated with nosocomial SARS-CoV transmission among healthcare workers in Hanoi, Vietnam, 2003 
BMC Public Health  2006;6:207.
Background
In March of 2003, an outbreak of Severe Acute Respiratory Syndrome (SARS) occurred in Northern Vietnam. This outbreak began when a traveler arriving from Hong Kong sought medical care at a small hospital (Hospital A) in Hanoi, initiating a serious and substantial transmission event within the hospital, and subsequent limited spread within the community.
Methods
We surveyed Hospital A personnel for exposure to the index patient and for symptoms of disease during the outbreak. Additionally, serum specimens were collected and assayed for antibody to SARS-associated coronavirus (SARS-CoV) antibody and job-specific attack rates were calculated. A nested case-control analysis was performed to assess risk factors for acquiring SARS-CoV infection.
Results
One hundred and fifty-three of 193 (79.3%) clinical and non-clinical staff consented to participate. Excluding job categories with <3 workers, the highest SARS attack rates occurred among nurses who worked in the outpatient and inpatient general wards (57.1, 47.4%, respectively). Nurses assigned to the operating room/intensive care unit, experienced the lowest attack rates (7.1%) among all clinical staff. Serologic evidence of SARS-CoV infection was detected in 4 individuals, including 2 non-clinical workers, who had not previously been identified as SARS cases; none reported having had fever or cough. Entering the index patient's room and having seen (viewed) the patient were the behaviors associated with highest risk for infection by univariate analysis (odds ratios 20.0, 14.0; 95% confidence intervals 4.1–97.1, 3.6–55.3, respectively).
Conclusion
This study highlights job categories and activities associated with increased risk for SARS-CoV infection and demonstrates that a broad diversity of hospital workers may be vulnerable during an outbreak. These findings may help guide recommendations for the protection of vulnerable occupational groups and may have implications for other respiratory infections such as influenza.
doi:10.1186/1471-2458-6-207
PMCID: PMC1562405  PMID: 16907978
21.  The psychological effect of severe acute respiratory syndrome on emergency department staff 
Background
The severe acute respiratory syndrome (SARS) outbreak in 2003 affected 29 countries. The SARS outbreak was unique in its rapid transmission and it resulted in heavy stress in first‐line healthcare workers, particularly in the emergency department.
Aim
: To determine the influence of SARS on the psychological status, including post‐traumatic stress disorder (PTSD) symptoms, of the staff in the emergency department.
Methods
To investigate whether different working conditions in the hospital led to different psychological effects on healthcare workers, the psychological effect on emergency department staff in the high‐risk ward was compared with that on psychiatric ward staff in the medium‐risk ward. Davidson Trauma Scale‐Chinese version (DTS‐C) and Chinese Health Questionnaire‐12 (CHQ‐12) items were designed to check the psychological status of the staff in the month after the end of the SARS outbreak.
Results
86 of 92 (93.5%) medical staff considered the SARS outbreak to be a traumatic experience. The DTS‐C scores of staff in the emergency department and in the psychiatric ward were significantly different (p = 0.04). No significant difference in CHQ score was observed between the two groups. Emergency department staff had more severe PTSD symptoms than staff in the psychiatric ward.
Conclusion
SARS was a traumatic experience for healthcare providers in Taiwan. Most staff in the emergency department and in the psychiatric ward had PTSD. Emergency department staff had more severe PTSD symptoms than staff in the psychiatric ward.
doi:10.1136/emj.2006.035089
PMCID: PMC2658141  PMID: 17183035
22.  Laboratory diagnosis of SARS. 
The emergence of new viral infections of man requires the development of robust diagnostic tests that can be applied in the differential diagnosis of acute illness, or to determine past exposure, so as to establish the true burden of disease. Since the recognition in April 2003 of the severe acute respiratory syndrome coronavirus (SARS-CoV) as the causative agent of severe acute respiratory syndrome (SARS), enormous efforts have been applied to develop molecular and serological tests for SARS which can assist rapid detection of cases, accurate diagnosis of illness and the application of control measures. International progress in the laboratory diagnosis of SARS-CoV infection during acute illness has led to internationally agreed World Health Organization criteria for the confirmation of SARS. Developments in the dissection of the human immune response to SARS indicate that serological tests on convalescent sera are essential to confirm SARS infection, given the sub-optimal predictive value of molecular detection tests performed during acute SARS illness.
doi:10.1098/rstb.2004.1493
PMCID: PMC1693399  PMID: 15306394
23.  Challenging beliefs and ethical concepts: the collateral damage of SARS 
Critical Care  2003;7(4):269-271.
The recent SARS (severe acute respiratory syndrome) outbreak exploded on an unsuspecting public and functionally paralyzed health care delivery systems in many countries. Cancer treatments were deferred and elective surgeries, clinic visits and diagnostic tests were postponed. Other collateral damage includes the devastating psychological distress suffered by patients who were isolated from their families, those same families who could not visit their ill loved ones, patients awaiting access to various aspects of the health care system, and health care workers. We are all starting to dig out, and this process will take many months at a minimum and we may never completely return to the way we were. This commentary addresses the implications of a modern-day epidemic like SARS, focusing on the intensive care unit setting, with special attention given to the effect on health care workers. We explore some of the ethical challenges posed to relationships, professional integrity and resource allocation.
PMCID: PMC270701  PMID: 12930546
critical care; ethical issues; intensive care unit; SARS
24.  Surviving Critical Illness: The Acute Respiratory Distress Syndrome as Experienced by Patients and Their Caregivers 
Critical care medicine  2009;37(10):2702-2708.
Objective
Survivors of the acute respiratory distress syndrome (ARDS), a systemic critical illness, often report poor quality of life based on responses to standardized questionnaires. However, the experiences of ARDS survivors have not been reported. Our objective was to characterize the effects of critical illness in the daily lives and functioning of ARDS survivors.
Design, Setting, and Patients
We recruited consecutively 31 ARDS survivors and their informal caregivers from medical and surgical intensive care units of an academic medical center and a community hospital. Eight patients died before completing interviews. We conducted semi-structured interviews with 23 ARDS survivors and 24 caregivers three to nine months after ICU admission, stopping enrollment after thematic saturation was reached. Transcripts were analyzed using Colaizzi’s qualitative methodology to identify significant ways in which survivors’ critical illness experience impacted their lives.
Measurements and Main Results
Participants related five key elements of experience as survivors of ARDS: pervasive memories of critical care, day to day impact of new disability, critical illness defining the sense of self, relationship strain and change, and ability to cope with disability. Survivors described remarkable disability that persisted for months. Caregivers’ interviews revealed substantial strain from caregiving responsibilities, as well as frequent symptom minimization by patients.
Conclusions
The diverse and unique experiences of ARDS survivors reflect the global impact of severe critical illness. We have identified symptom domains important to ARDS patients that are not well represented in existing health outcomes measures. These insights may aid the development of targeted interventions to enhance recovery and return of function after ARDS.
doi:10.1097/CCM.0b013e3181b6f64a
PMCID: PMC2771584  PMID: 19865004
Respiratory Distress Syndrome, Adult; Qualitative Research; Quality of Life
25.  Patient Contact Recall after SARS Exposure 
Emerging Infectious Diseases  2005;11(4):625-628.
We reinterviewed healthcare workers who had been exposed to a patient with severe acute respiratory syndrome (SARS) in an intensive care unit to evaluate the effect of time on recall reliability and willingness to report contact activities and infection control precautions. Healthcare workers reliably recalled events 6 months after exposure.
doi:10.3201/eid1104.040648
PMCID: PMC3320347  PMID: 15829207
dispatch; SARS; occupational exposure; intensive care unit; recall; reliability

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