key: cord-0008010-dw6269m7
authors: Sun, Hsin-Yun; Fang, Chi-Tai; Wang, Jann-Tay; Chen, Yee-Chun; Chang, Shan-Chwen
title: Treatment of severe acute respiratory syndrome in health-care workers
date: 2003-12-13
journal: Lancet
DOI: 10.1016/s0140-6736(03)15036-2
sha: b88869f3ca38180a666c106e01f2f6b6b577cb14
doc_id: 8010
cord_uid: dw6269m7

nan

influenza vaccinee was a healthy 28-year-old woman who, unlike the other volunteers, had not received yearly influenza vaccinations, but had a clinical history of a severe influenza-like syndrome 3 years before scanning. Her 5-day post-vaccination scan (figure) revealed extensive bilateral node activation throughout the chest external to the mediastinum. She was completely free of signs or symptoms during the ensuing extensive negative work-up for occult disease, and has remained completely healthy over the subsequent 6 years. We interpret this massive activation of upper torso nodes, in part, as a physical reflection of recall responses to non-vaccine strains-the "original antigenic sin" phenomenon, which is well described for influenza. It is also consistent with the finding that the secondary immune response to influenza infection exceeds the primary response by 1000-fold in terms of responding cell numbers. 3 It hints at greater potential protection by natural infection than by yearly vaccination in the setting of a major antigenic shift in influenza.

Furthermore, somewhat similar patterns of FDG uptake have been seen in some cancer patients, and clearly attributed to metabolically active brown fat. 4, 5 Such uptake can be present in the absence of tumour (unpublished data), and can be differentiated from lymph node or muscle activity by use of combined PET and computed tomography (PET/CT). 

Sir--There is still no proven therapy for severe acute respiratory syndrome (SARS). The protocol reported by Loletta So and colleagues 1 emphasised the combination use of ribavirin and high-dose corticosteroid. However, if given very early in the course of the disease, this approach could suppress the generation of host immunity to the novel coronavirus. We observed a biphasic pattern of illness in SARS and postulated that the first stage represents a viraemic phase and the second phase is an immune phase. 2 Acute respiratory distress syndrome seems to be a complication in the second phase. 2 If this hypothesis is true, antiviral agents will be most beneficial in the first phase, whereas corticosteroids should be delayed until the onset of the second phase to maximise benefit and keep the negative effects of immune suppression to a minimum. We, therefore, developed a treatment protocol 3 that emphasises early use of ribavirin but delayed introduction of corticosteroids until the second week, if possible. One oral 2000 mg loading dose of ribavirin was given to patients as soon as they received medical attention, followed by 600 mg ribavirin twice daily for patients with a bodyweight greater than 75 kg or 1000 mg daily for those with a bodyweight of 75 kg or less (400 mg in morning, 600 mg in evening) for 10 days. For patients who developed pneumonia, intravenous methylprednisolone (2 mg/kg daily for 5 days) was started on day 8 of fever or later. If rapid deterioration occurred before day 8, steroid treatment was started upon development of dyspnoea. If respiratory distress was not responsive to this dose, 500 mg methylprednisolone daily for 3 days was given. Upon improvement, the dose of steroid was tapered off over the next 2 weeks as recovery warranted.

In Taipei between April 23 and May 31, 2003, 17 health-care workers at our hospital contracted SARS. 4 PCR of serum or nasopharyngeal swab proved positive in seven of the 17 health-care workers, and convalescent serum antibodies were positive in 13 health-care workers. All 17 health-care workers received our treatment protocol (table) . The median starting day of ribavirin was day 2 of fever (range 1-7 days). Only one health-care worker needed subsequent intubation and respiratory support. All 17 individuals recovered without major sequelae or subsequent relapse. With prompt identification THE LANCET • Vol 362 • December 13, 2003 • www.thelancet.com CORRESPONDENCE Culture and medical terms: help or headache?

Sir-As an aid to comprehension and memory, medical teachers sometimes use common objects to describe the appearance of various pathological conditions-eg, horse-shoe kidney. This is a valuable technique, but only if the student is familiar with the object of comparison.

After World War II, Anglo-American medicine led the way in many countries. Overwhelmed by the might and sophistication of western science, traditional medical texts in developing countries were soon replaced by western books. And that is where the problem arose. People living in some of these countries have their own culture. Terms such as "Swiss cheese appearance", "doughnut mastopexy", "Champagne glass appearance", "cottage loaf sign", "scalloped meat sign", "pig-tail catheter", and "jack-in-the-box" might be completely meaningless to many medical students training in countries where such items are not available. Students studying medicine in these countries face two obstacles: understanding the scientific content of the lessons, and deciphering terms that were originally coined to make their lessons more understandable. Whereas for a student growing up in a western culture, a particular lesion might look like a doughnut, for a student living in a country unacquainted with these confectionery products, a doughnut will look like that particular lesion.

In the short term, we believe that medical academies should prepare illustrated dictionaries to describe these unfamiliar words; in the long term, they should research and apply appropriate equivalents on the basis of native cultures. 

Sir-AŠrámek and colleagues' interpretation (Aug 2, p 351), 1 that the variably reduced concentrations of clotting factors VIII and IX in carriers of haemophilia A and B, respectively, and associated favourable effects on blood haemostasis and atherothrombosis contributes to cardiovascular protection, is obvious and well founded. Another protective mechanism not considered by Srámek and colleagues, however, could also be of relevance.

Carriers of haemophilia are at raised risk of recurrent bleeding, both major (see table 3 of article) and minor, which results in a lowering of body iron stores. Decreased ferritin-a reliable laboratory measure of stored tissue iron-lowered haemoglobin concentrations, and depletion of iron stores by repeated phlebotomy or non-voluntary blood loss (surgery, gastrointestinal bleedings, etc) have all been associated with decreased risk of atherosclerosis, myocardial infarction, and ischaemic stroke. [2] [3] [4] Cardiovascular protection potentially afforded by low iron stores was attributed to decreased iron-induced oxidation of LDL cholesterol, blood viscosity, and reperfusion injury. 3, 4 Reduction of iron stores in the setting of a controlled prospective intervention trial, such as FeAST, 5 could help to ascertain the validity of the iron hypothesis and clarify whether iron depletion contributes to the findings of Š rámek and co-workers.

Austria (e-mail: stefan.kiechl@uibk.ac.at) 1Šrámek A, Kriek M, Rosendaal FR. Decreased mortality of ischaemic heart disease among carriers of haemophilia

Cohort study of relation between donating blood and risk of myocardial infarction in 2682 men in eastern Finland

Body iron stores and the risk of carotid atherosclerosis: prospective results from the Bruneck Study

The iron paradigm of ischemic heart disease

The Iron (Fe) and Atherosclerosis Study (FeAST): a pilot study of reduction of body iron stores in atherosclerotic peripheral vascular disease