Effect on muscle strength after blood flow restriction resistance exercise in early in-patient rehabilitation of post-chronic obstructive pulmonary disease acute exacerbation, a single blinded, randomized controlled study.

BACKGROUND: Early commencement of rehabilitation might counteract the loss of muscle strength due to a chronic obstructive pulmonary disease acute exacerbation (COPDAE). Blood flow restriction resistance exercise (BFR-RE) using a low intensity of training load has demonstrated muscle strength gain in varieties of clinical populations. This trial aimed at studying the efficacy and acceptability of BFR-RE in patients with post-COPDAE which was not reported before. METHOD: A prospective, assessor blinded, randomized controlled study with 2-week in-patient rehabilitation program with BFR-RE was compared to a matched program with resistance exercise without BFR in patients with post-COPDAE. The primary outcome was the change of muscle strength of knee extensor of dominant leg. The secondary outcomes included changes of hand grip strength (HGS), 6-minute walk test (6MWT) distance, short physical performance battery (SPPB) scores, COPD assessment test (CAT) scores; acceptability and feasibility of BFR-RE; and 1-month unplanned re-admission rate. RESULTS: Forty-Five post-COPDAE patients (mean age = 76 ± 10, mean FEV1%=49% ± 24%) were analyzed. After training, BFR-RE group and control group demonstrated a statistically significant median muscle strength gain of 20 (Interquartile range (IQR) 3 to 38) Newton(N) and 12 (IQR -9 to 30) N respectively. BFR-RE group showed a significant change in SPPB scores, but not in 6MWT distance and HGS after training. Between groups did not have statistically significant different in all primary and secondary outcomes, though with similar acceptability. Drop-out rate due to training-related discomfort in BFR-RE group was 3.7%. CONCLUSION: BFR-RE is feasible and acceptable in patients with post-COPDAE. A 2-week inpatient pulmonary rehabilitation with BFR-RE improved muscle strength of knee extensors, but not a greater extent than the same rehabilitation program with resistance exercise without BFR. Further studies could be considered with a longer training duration and progression of resistance load. [ClinicalTrials.gov Identifier: NCT04448236].

Outcomes of community-based and home-based pulmonary rehabilitation for pneumoconiosis patients: a retrospective study.

BACKGROUND: Pneumoconiosis patients receive community-based or home-based pulmonary rehabilitation (PR) for symptom management and enhancement of physical and mental well-being. This study aimed to review the clinical benefits of community-based rehabilitation programmes (CBRP) and home-based rehabilitation programmes (HBRP) for PR of pneumoconiosis patients. METHODS: Archival data of pneumoconiosis patients who participated in CBRP and HBRP between 2008 and 2011 was analysed. There were 155 and 26 patients in the CBRP and HBRP respectively. The outcome measures used in the pre- and post-tests were Knowledge, Health Survey Short Form-12 (SF-12), Hospital Anxiety and Depression Scale (HADS), 6-Min Walk Test (6MWT), and Chronic Respiratory Questionnaire (CRQ). Paired t-tests and the Analysis of Covariance (ANCOVA) using the patients' baseline lung functions as the covariates were performed to examine the changes in the outcomes after completing the programmes. Hierarchical multiple regression analyses were used to examine the relationships between patient's programme participation factors and different scores of the outcome measures. RESULTS: After controlling for patients' baseline lung capacities, significant improvements were revealed among patients participated in CBRP in the scores of the 6MWT, Knowledge, HADS, SF-12 PCS, and CRQ emotion and mastery. The different scores in the Knowledge and HADS were correlated with the patients' levels of programme participation. In contrast, significant improvements were only found in the scores of the Knowledge and 6MWT among patients who participated in HBRP. The gain scores of the 6MWT were correlated with the patients' levels of programme participation. CONCLUSIONS: Both CBRP and HBRP benefited patients' levels of exercise tolerance and knowledge about the disease. CBRP provided greater benefits to patients' mental and psychosocial needs. In contrast, HBRP was found to improve patients' physical function, but did not have significant impacts on patients' mental health and health-related quality of life. The attendance of patients and the participation of their relatives in treatment sessions were important factors in enhancing the positive effects of CBRP and HBRP. These positive outcomes confirm the value of pulmonary rehabilitation programmes for community-dwelling pneumoconiosis patients.

Effects of a nurse-led post-discharge advance care planning programme for community-dwelling patients nearing the end of life and their family members: A randomised controlled trial.

BACKGROUND: Although evidence increasingly demonstrates the effects of advance care planning, the relevant studies are of questionable quality, and lack consensus regarding when and with whom to initiate the conversation. OBJECTIVE: To examine the effects of a structured, nurse-led post-discharge advance care planning programme on congruence between the end-of-life care preferences of the patient and family members, decisional conflicts and the documentation of care preferences. DESIGN: A two-arm parallel-group randomised controlled trial. PARTICIPANTS: A total of 230 dyads comprising community-dwelling patients screened by the Gold Standards Framework Prognostic Indicator Guidance and their designated family members. METHODS: Patients in the experimental group participated in a structured advance care planning programme administered by a trained nurse during three weekly home visits following hospital discharge. In contrast, the post-discharge home visits provided to the control group focused on self-care management as attention control. The study outcomes were the dyadic congruence regarding end-of-life care preferences, the patients' level of decisional conflict regarding end-of-life decision-making and the documentation of these preferences at baseline and 1 and 6 months after enrolment. Generalised estimating equation models were used to compare changes in the outcomes between the groups across time. RESULTS: At baseline, few participants had ever heard of advance directives (12/460, 2.6%) and few patients had ever discussed end-of-life issues with family members (34/230, 14.8%). After six months, the experimental group exhibited a greater increase in dyadic congruence regarding various end-of-life care preferences than the control group (Ps < 0.04). The experimental group also exhibited a greater improvement in decisional conflict at 6 months relative to the control group (P = 0.003). However, the groups did not differ significantly in terms of changes in any outcomes after one month. The experimental group had significantly higher rates of completion of advance directives and electronic medical record documentation of do-not-attempt cardiopulmonary resuscitation orders than the control group. CONCLUSIONS: This study showed that a nurse-led structured advance care planning programme could effectively improve dyadic congruence regarding end-of-life care preferences, reduce patients' decisional conflict and increase the documentation of care preferences. The findings underscored the importance of supporting nurses to introduce advance care planning at an earlier time that enable patients with sufficient time to contemplate end-of-life issues, empower patients to deliberate their choices and engage patients and their family members in open discussion.

Declining Trends of Cardiovascular-Renal Complications and Mortality in Type 2 Diabetes: The Hong Kong Diabetes Database.

OBJECTIVE: Nationwide studies on secular trends of diabetes complications are not available in Asia. We examined changes in risk factor control and incidence of complications from diabetes and death in a large longitudinal cohort of Chinese adults with type 2 diabetes in Hong Kong. RESEARCH DESIGN AND METHODS: Between 1 January 2000 and 31 December 2012, 338,908 Chinese adults with type 2 diabetes underwent metabolic and complication assessment in 16 diabetes centers operated by Hong Kong Hospital Authority that provided care to a large majority of diagnosed patients. Patients were followed for incident acute myocardial infarction (AMI), stroke, end-stage renal disease (ESRD), and death until 31 December 2012. Risk factor levels between enrollment periods were compared. Incidence of clinical events, stratified by diabetes duration, was examined over time. RESULTS: Incidence of complications from diabetes and death declined over the observation period in patients at varying disease duration. Among the high-risk group with diabetes for at least 15 years, crude incidence of AMI decreased from 8.7 to 5.8, stroke from 13.5 to 10.1, ESRD from 25.8 to 22.5, and death from 29.0 to 26.6 per 1,000 person-year between the periods 2000 to 2002 and 2010 to 2012. Improvements in levels of metabolic risk factors were detected. Proportion of patients achieving HbA1c <7.0% (53 mmol/mol) was increased from 32.9 to 50.0%, blood pressure ≤130/80 mmHg from 24.7 to 30.7%, and LDL cholesterol <2.6 mmol/L from 25.8 to 38.1%. CONCLUSIONS: From this territory-wide Hong Kong Diabetes Database, we observed decreases in incidence of cardiovascular-renal complications and death and corresponding improvements in risk factor control over a 13-year period.

The meaning of hope from the perspective of Chinese advanced cancer patients in Hong Kong.

AIM: This article reports a study to examine the meaning of hope from the perspective of Chinese advanced cancer patients in Hong Kong. METHODS: Semi-structured interviews were conducted with a convenience sample of advanced cancer patients recruited from the palliative care unit of a local hospital. Data were saturated after 17 participants were interviewed. Qualitative content analysis was adopted to analyse the data. FINDINGS: Hope as experienced by the participants was found to consist of five components: living a normal life, social support, actively letting go of control, reconciliation between life and death, and wellbeing of significant others. CONCLUSIONS: While hope is related to the wellbeing of patients with advanced cancer, successful palliative care partly depends on an awareness of the importance of hope in the end-of-life context and cultural sensitivity to the meanings behind it from the patients' own perspective.

Comparing noncancer and cancer deaths in Hong Kong: a retrospective review.

This retrospective study aimed to compare noncancer deaths with cancer deaths in the following: 1) utilization of the public health care system in the last six months of life; 2) end-of-life care received; and 3) documentation of the advance care planning (ACP) process. The following sample was recruited from the deaths in 2006 in four public hospitals for analysis: 656 noncancer deaths consisting of 239 deaths from chronic renal failure (CRF), 242 deaths from chronic obstructive pulmonary disease (COPD) and 175 deaths from congestive heart failure (CHF), and 183 cancer deaths. Only 1.4% of noncancer patients received palliative care, compared with 79.2% of cancer patients. As compared with cancer, the noncancer patients were older (79.1±9.5 vs. 71.1±12.4 years, P<0.001) and had more comorbid conditions (2.3±1.4 vs. 1.6±1.4, P<0.001). Utilization of public health care was more intensive in noncancer patients, with more intensive care unit admissions, more ward admissions, more bed days occupied, and more clinic attendances. Within the last two weeks of life, the noncancer patients had more invasive interventions initiated, fewer symptoms documented, less analgesics and sedatives prescribed, less do-not-resuscitate orders in place, and more cardiopulomonary resuscitation performed. Dyspnea, edema, pain, and fatigue were among the most documented symptoms in both cancer and noncancer patients. A higher proportion of ACP discussions were first documented within three days before death in COPD and CHF patients as compared with CRF and cancer patients. There is a need to develop palliative care for noncancer patients in Hong Kong.

Health-care professionals' perspective on hope in the palliative care setting.

Hope is considered a coping strategy as well as a factor that enhances quality of life for patients with advanced cancer. Most studies on the meaning of hope are from the patients' perspective. However, the health-care professionals' view is also important since it may affect their practice. This study explored the meaning of hope to patients with advanced cancer from health-care professionals' perspective. This was a qualitative study that used a hermeneutic phenomenological approach. Five focus group interviews were conducted with 23 participants including physicians, nurses, social workers, occupational therapists, chaplains, and a physiotherapist working in the palliative care unit of a hospital in Hong Kong. Data analysis revealed four themes: expected hopelessness, a dynamic process of hope, hope-fostering strategies, and peace as the ultimate hope. It appears that health-care professionals' hopefulness contributes to the hopefulness of patients. Opportunities to reflect on their values, beliefs, and experience may help health-care professionals enhance their ability to foster hope in patients.

Healthcare professionals' perceptions of existential distress in patients with advanced cancer.

AIM: This paper is a report of an exploration of the phenomenon of existential distress in patients with advanced cancer from the perspectives of healthcare professionals. BACKGROUND: Existential distress is an important concern in patients with advanced cancer; it affects their well-being and needs to be addressed in the provision of holistic care. METHOD: Focus groups were conducted from November 2008 to February 2009 with physicians, nurses, social workers, occupational therapists, physiotherapists, and chaplains working in a palliative care unit that served patients with advanced cancer in Hong Kong. Data collection and analysis were guided by the grounded theory approach. All categories were saturated when five focus groups had been held with a total number of 23 participants. FINDINGS: We found three causal conditions of existential distress: anticipation of a negative future, failure to engage in meaningful activities and relationships, and having regrets. Three basic (caring, relating and knowing) and six specific (positive feedback, religious support, new experiences, task setting, exploring alternatives and relationship reconciliation) intervening strategies were identified. Whether the intervening strategies would be effective would depend on patients' openness and readiness; healthcare professionals' self-awareness, hopefulness, and interest in knowing the patients; and a trusting relationship between patients and healthcare professionals. A sense of peace in patients was considered a consequence of successful interventions. CONCLUSION: This paper acknowledges the lack of an accepted conceptual framework of existential distress in patients with advanced cancer. It is based on healthcare professionals' views, and further studies from the perspectives of patients and their families are needed.

The burden of lung disease in Hong Kong: a report from the Hong Kong Thoracic Society.

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.

Sex- and age-dependent association of SLC11A1 polymorphisms with tuberculosis in Chinese: a case control study.

BACKGROUND: Host genetic factors are important determinants in tuberculosis (TB). The SLC11A1 (or NRAMP1) gene has been studied extensively for genetic association with TB, but with inconsistent findings. In addition, no study has yet looked into the effect of sex and age on the relationship between SLC11A1 polymorphisms and TB. METHODS: A case-control study was conducted. In total, 278 pulmonary TB patients and 282 sex- and age-matched controls without TB were recruited. All subjects were ethnic Chinese. On the basis of linkage disequilibrium pattern, three genetic markers from SLC11A1 and one from the nearby IL8RB locus were selected and examined for association with TB susceptibility. These markers were genotyped using single strand conformation polymorphism analysis or fragment analysis of amplified products. RESULTS: Statistically significant differences in allele (P = 0.0165, OR = 1.51) and genotype (P = 0.0163, OR = 1.59) frequencies of the linked markers SLC6a/b (classically called D543N and 3'UTR) of the SLC11A1 locus were found between patients and controls. With stratification by sex, positive associations were identified in the female group for both allele (P = 0.0049, OR = 2.54) and genotype (P = 0.0075, OR = 2.74) frequencies. With stratification by age, positive associations were demonstrated in the young age group (age < or =65 years) for both allele (P = 0.0047, OR = 2.52) and genotype (P = 0.0031, OR = 2.92) frequencies. All positive findings remained significant even after correction for multiple comparisons. No significant differences were noted in either the male group or the older age group. No significant differences were found for the other markers (one SLC11A1 marker and one IL8RB marker) either. CONCLUSION: This study confirmed the association between SLC11A1 and TB susceptibility and demonstrated for the first time that the association was restricted to females and the young age group.

Scanning laser polarimetry in pulmonary tuberculosis patients on chemotherapy.

INTRODUCTION: The aim of this study was to analyse the thickness of the retinal nerve fibre layer (RNFL) of pulmonary tuberculosis patients on ethambutol and isoniazid. MATERIALS AND METHODS: This was a prospective cohort study where patients with newly diagnosed pulmonary tuberculosis requiring chemotherapy, including ethambutol and isoniazid, were imaged using scanning laser polarimetry. Their mean baseline RNFL thickness and various scanning laser polarimetry parameters of both eyes were measured 2 weeks after the commencement of chemotherapy. The measurements were repeated at 3 months and 6 months after treatment. The various parameters of the baseline and the follow-up measurements were compared using paired sample t-test with Bonferroni correction. RESULTS: Twenty-four patients (16 males and 8 females; mean age, 51.0 +/- 17.6 years) were recruited. There was no statistically significant difference between the baseline and the follow-up measurements in RNFL thickness and all other scanning laser polarimetry parameters. CONCLUSION: In this cohort of subjects, there was no subclinical change in RNFL thickness detected by scanning laser polarimetry in pulmonary tuberculosis patients on chemotherapy, including ethambutol and isoniazid, after 6 months of treatment.

Diagnostic application of genotypic identification of mycobacteria.

This study evaluated conventional methods, GLC and three molecular tests, including 16S rRNA sequencing, for the identification of mycobacteria, and the experiences of the authors with the integration of these methods into a diagnostic clinical laboratory were also recorded. Of 1067 clinical isolates of mycobacteria identified by conventional tests, 365 were tested by Accuprobe hybridization assays and PCRs specific for Mycobacterium tuberculosis (MTB) complex or Mycobacterium avium complex (MAC), 202 were tested by 16S rRNA sequencing, and 142 were tested by GLC. Three runs of all tests were performed on a weekly basis. The identifications for 209 MTB complex and 118 MAC isolates obtained by species-specific PCR were in complete agreement with AccuProbe hybridization and conventional test results. The 16S rRNA sequence-based identification, at a similarity of > or =99 %, for 132 of 142 isolates was concordant with the identifications made by the biochemical methods, and for 134 isolates was concordant with the identifications made by GLC at species, group or complex level. 16S rRNA sequencing resulted in fewer incorrectly identified or unidentified organisms than GLC or conventional tests. For the slowly growing non-tuberculous mycobacteria, the mean turnaround times for identification were 4-5 days for 16S rRNA sequencing, 14-29 days for GLC and 22-23 days for conventional methods. Considering the large proportion of some species among clinical isolates, a strategy of initial screening with species-specific PCR (or AccuProbe assays) for the MTB complex and MAC, followed by direct sequencing of the strains that yield negative results, should make 16S rRNA sequencing more affordable for routine application in diagnostic laboratories.

The validity and reliability of the functional impairment checklist (FIC) in the evaluation of functional consequences of severe acute respiratory distress syndrome (SARS).

Severe acute respiratory distress syndrome (SARS) contributed to significant mortality and morbidity worldwide. We aimed to establish the validity, reliability and responsiveness of the functional impairment checklist (FIC) as a measurement tool for physical dysfunction in SARS survivors. One hundred and sixteeen (65 females and 51 males, mean age 45.6) patients who joined the SARS rehabilitation programme were analysed. The factor analysis yielded two latent factors. The mean FIC-symptom and FIC-disability score were 24.12 (SD +/- 20.2) and 26.11 (SD +/- 27.32), respectively. Based on the item-scale correlation coefficients, the Cronbach's alpha coefficients reflecting the internal consistency reliability of scale score were 0.75 for FIC-symptom and 0.86 for FIC-disability. Test-retest reliability in 23 patients showed no statistical significant difference in the FIC scores between tests with intraclass correlation coefficient (ICC) 0.49-0.57. The FIC scales correlated both with 6 munute walking test (6MWT) distance (-0.26 and -0.38) and handgrip strength (HGS) (-0.20 and -0.27). Moreover, the FIC scales correlated with St. George's respiratory questionnaire (SGRQ) (0.19 to 0.52) and short form 36 Hong Kong (SF-36) domains (-0.19 to -0.59). Both FIC scales correlated stronger with physical component summary (PCS) (-0.41 and -0.55) than with mental component summary (MCS) (-0.30 and -0.23). FIC reduced significantly at 6 months while the SF-36 PCS and MCS did not show any change. In conclusion, the study results indicate the FIC is reliable, valid and responsive to change in symptom and disability as a consequence of SARS, suggesting it may provide a means of assessing health related quality of life (HRQOL) outcomes in a longitudinal follow up.

Assessing quality of life of patients with advanced chronic obstructive pulmonary disease in the end of life.

Given the limitations of existing health-related quality-of-life (QOL) measures in capturing the end-of-life experience of patients with advanced chronic diseases, an empirically grounded instrument, the quality-of-life concerns in the end of life questionnaire (QOLC-E), was developed. Though it was built on the McGill quality of life questionnaire (MQOL), its sphere is more holistic and culturally specific for the Chinese patients in Hong Kong. One hundred and forty-nine patients with advanced chronic obstructive pulmonary disease (COPD) or metastatic cancer completed the questionnaire. Seven factors (28 items) which emerged from the factor analysis were grouped into four positive (support, value of life, food-related concerns, and healthcare concerns) and four negative (physical discomfort, negative emotions, sense of alienation, and existential distress) subscales. Good internal consistency and concurrent validity were shown. The results also revealed that these two groups of patients had similar QOL concerns. The validity of applying QOLC-E as an outcome measure to evaluate the effectiveness of palliative and psychoexistential interventions has yet to be tested.

Retrospective analysis of antibiotic use and survival in advanced cancer patients with infections.

Infection is common among advanced cancer patients. This study was undertaken to review the pattern of use of antibiotics and to identify potential factors that could affect outcomes after infection. The medical records of all patients with advanced cancer who were enrolled into the palliative care service of a district hospital during the period January, 2002 to July, 2002 were retrospectively reviewed for infections and the use of antibiotics. Among the eligible 87 patients, 17 did not have any infective episode and 70 had at least one infective episode and accounted for a total of 120 episodes. Sixty-eight episodes were associated with survival for >14 days, and 52 episodes were associated with survival of < or =14 days. The most frequent sites of infection were chest (n=63, 52.5%), urinary tract (n=35, 29.2%), and skin/wound (n=6, 5%). Antibiotics were prescribed for 97.5% (n=117) episodes. The use of second-line antibiotics was 16.2% (n=19). By multivariate logistic regression analysis, dyspnea [odds ratio (OR)=2.6, 95% confidence interval (CI)=1.1-6.3], antibiotic utilization pattern [empirical therapy (OR=4.8, 95% CI=1.7-13.2) vs. therapy according to antibiotic sensitivity], and route of administration [parenteral route (OR=3.3, 95% CI=1.3-8.2) vs. oral route] were identified as independent determinants affecting survival after infection. Dyspnea was possibly associated with poor prognosis during the treatment of infections in patients with advanced cancer, and antibiotic therapy according to sensitivity was associated with better prognosis. Further studies are encouraged to verify this. The bioethical principles on the use of antibiotics as a life-sustaining treatment should always be followed.

Viral load distribution in SARS outbreak.

An unprecedented community outbreak of severe acute respiratory syndrome (SARS) occurred in the Amoy Gardens, a high-rise residential complex in Hong Kong. Droplet, air, contaminated fomites, and rodent pests have been proposed to be mechanisms for transmitting SARS in a short period. We studied nasopharyngeal viral load of SARS patients on admission and their geographic distribution. Higher nasopharyngeal viral load was found in patients living in adjacent units of the same block inhabited by the index patient, while a lower but detectable nasopharyngeal viral load was found in patients living further away from the index patient. This pattern of nasopharyngeal viral load suggested that airborne transmission played an important part in this outbreak in Hong Kong. Contaminated fomites and rodent pests may have also played a role.

Initial viral load and the outcomes of SARS.

BACKGROUND: Severe acute respiratory syndrome (SARS) is caused by a novel coronavirus. It may progress to respiratory failure, and a significant proportion of patients die. Preliminary data suggest that a high viral load of the SARS coronavirus is associated with adverse outcomes in the intensive care unit, but the relation of viral load to survival is unclear. METHODS: We prospectively studied an inception cohort of 133 patients with virologically confirmed SARS who were admitted to 2 general acute care hospitals in Hong Kong from Mar. 24 to May 4, 2003. The patients were followed until death or for a minimum of 90 days. We used Cox proportional hazard modelling to analyze potential predictors of survival recorded at the time of presentation, including viral load from nasopharyngeal specimens (measured by quantitative reverse transcriptase polymerase chain reaction [PCR] of the SARS-associated coronavirus). RESULTS: Thirty-two patients (24.1%) met the criteria for acute respiratory distress syndrome, and 24 patients (18.0%) died. The following baseline factors were independently associated with worse survival: older age (61-80 years) (adjusted hazard ratio [HR] 5.24, 95% confidence interval [CI] 2.03-13.53), presence of an active comorbid condition (adjusted HR 3.36, 95% CI 1.44-7.82) and higher initial viral load of SARS coronavirus, according to quantitative PCR of nasopharyngeal specimens (adjusted HR 1.21 per log10 increase in number of RNA copies per millilitre, 95% CI 1.06-1.39). INTERPRETATION: We found preliminary evidence that higher initial viral load is independently associated with worse prognosis in SARS. Mortality data for patients with SARS should be interpreted in light of age, comorbidity and viral load. These considerations will be important in future studies of SARS.

An empirical analysis of the decision-making of limiting life-sustaining treatment for patients with advanced chronic obstructive pulmonary disease in Hong Kong, China.

OBJECTIVES: To understand the prognostic and quality-of-life considerations surrounding life-sustaining treatment decisions for patients with advanced chronic obstructive pulmonary disease (COPD) in Hong Kong China. METHODS: A documentary review of 49 COPD patients and 19 patient case studies from the medical departments of 2 hospitals were undertaken to examine the practices of DNI decision-making (do not perform mechanical ventilation and cardiopulmonary resuscitation). Statistical, event, and thematic analyses were conducted to delineate the prognostic and quality-of-life factors that shaped the not for intubation and mechanical ventilation (DNI) decisions. RESULTS: Three major treatment-limiting decision-making patterns existed in practice: 1) Patient-initiated and shared decision-making with physician (n = 14); 2) Physician-initiated and shared decision-making with the patient/family members (n = 24); and 3) Physician-initiated DNI decision-making with patient family, but without patient participation due to mental incapacity (n = 11). Prognostic considerations include physiological parameters, performance status, concomitant diseases, therapeutic regimens, and the utilization of medical services. Three major themes were delineated regarding the way in which the patients evaluated their life quality in the context of DNI status. They are prognostic awareness, illness burdens, and existential concerns. DISCUSSION: A decision-making framework used by patients/families/physicians to limit life-sustaining treatments in patients with advanced COPD is delineated. Observations regarding how treatment limiting decision-making for patients with advanced chronic illnesses can be improved in Hong Kong are discussed.