The severe acute respiratory syndrome (SARS) pandemic caught the world by surprise in 2003 and spread rapidly within a relatively short period of time. Hence, randomised placebo-controlled clinical trials on the treatment of SARS were not possible. Our understanding was obtained from observational, cohort studies, case series and reports. Nevertheless, such information is useful in providing clinical management guidelines and directing future research in case SARS recurs. Early in the pandemic, a combination of ribavirin and corticosteroids was adopted as the standard treatment in Hong Kong, Canada and elsewhere because of the apparent good results of the first few patients. Subsequent reports showed that ribavirin was associated with a high rate of toxicity and lacked in vitro antiviral effect on SARS-coronavirus (SAR-CoV). The timing and dosage regimens of steroid in the treatment of SARS are controversial. Pulse methylprednisolone 250 to 500 mg/day for 3 to 6 days has been reported to have some efficacy in a subset of patients with "critical SARS", i.e., critically ill SARS patients with deteriorating radiographic consolidation, increasing oxygen requirement with PaO2 <10 kPa or SpO2 <90% on air, and respiratory distress (rate of 30/min). Prolonged therapy with high-dose steroids, in the absence of an effective antimicrobial agent, could predispose patients to complications such as disseminated fungal infection, and avascular necrosis. Kaletra (400 mg ritonavir and 100 mg lopinavir), a protease inhibitor used in the treatment of human immunodeficiency virus infection, may be considered for early treatment of SARS patients, preferably in a randomised double-blind placebo-controlled clinical trial setting. Interferon (IFN) is not recommended as standard therapy in SARS. However, there are enough data on in vitro activity of IFN preparations and a few clinical studies for these products to support a controlled trial if SARS recurs. Many other experimental treatments have been tried in an uncontrolled manner, and they should not be recommended as standard therapy.
Adrenal Cortex Hormones ; pharmacology ; therapeutic use ; Antiviral Agents ; pharmacology ; therapeutic use ; Clinical Competence ; Disease Outbreaks ; prevention & control ; Global Health ; Humans ; Immunoglobulins ; pharmacology ; therapeutic use ; Immunologic Factors ; pharmacology ; therapeutic use ; Interferons ; pharmacology ; therapeutic use ; Lopinavir ; Practice Guidelines as Topic ; Protease Inhibitors ; pharmacology ; therapeutic use ; Pyrimidinones ; pharmacology ; therapeutic use ; Ribavirin ; pharmacology ; therapeutic use ; SARS Virus ; drug effects ; Severe Acute Respiratory Syndrome ; drug therapy ; epidemiology

Severe acute respiratory syndrome (SARS) was an unknown disease barely 3 years ago. After the World Health Organization declared the world SARS-free on 5 July 2003, there were episodic recurrences of SARS between September 2003 and May 2004, including 4 cases of laboratory-acquired SARS. SARS posed a mammoth challenge because of the impact of nosocomial transmission on healthcare manpower and facilities, and the resources needed for controlling and preventing further spread. Through worldwide scientific collaboration, the medical community has made much progress in unraveling its enigma, though much more needs to be discovered. This paper highlights how we can apply our knowledge of its epidemiology, mode of transmission, clinical course, ICU admission, complications, predictors of poor outcome, treatment and infection control to help us avert a catastrophic outbreak, and to manage our resources and patients. SARS preparedness and response planning must be flexible and dynamic so that appropriate measures can be implemented as an outbreak progresses. Even if SARS does not reemerge, the experience gained from such planning is valuable in preparing for threats of bioterrorism or a global avian influenza A (H5N1) virus pandemic.
Cross Infection ; prevention & control ; Disease Outbreaks ; prevention & control ; Disease Transmission, Infectious ; prevention & control ; Global Health ; Humans ; Severe Acute Respiratory Syndrome ; epidemiology

Severe acute respiratory syndrome (SARS) is a new infectious disease that emerged in mid- November 2002 in Guangdong, southern China. The global pandemic began in late February 2003 in Hong Kong. By the time SARS was declared contained on 5 July 2003 by the World Health Organization (WHO), it had afflicted 8096 patients in 29 countries. No other disease had had such a phenomenal impact on healthcare workers (HCWs), who formed about 21% of SARS patients. In Vietnam, Canada and Singapore, HCWs accounted for 57%, 43% and 41% of SAR patients, respectively. At the beginning of the outbreak, there was practically no information on this disease, which did not even have a name until 16 March 2003, except that it was infectious and could result in potentially fatal respiratory failure. Indeed, HCWs had lost their lives to SARS. Understandably, some HCWs refused to look after SARS patients or even resigned. Initially, much negative publicity was given to such HCWs. It was a very trying time for HCWs as many were also ostracised by the society which they served. They were perceived to be a potential source of infection in the community because of their contact with SARS patients, whom they risked their lives looking after. Subsequently, as we learnt more about the disease and educated the public about the plight of the frontline HCWs, the public gave the frontline HCWs tremendous support and even honoured them as heroes. Being in the medical profession, caring for patients is one of our expected responsibilities. On the other hand, as public citizens, HCWs have the right to resign when they feel that their responsibility to their families should take priority over that to their patients. As a result of this scourge, each HCW learnt to decide if caring for patients is their chosen profession and vocation. Many chose to live up the Hippocratic oath.
Delivery of Health Care ; standards ; Disease Outbreaks ; prevention & control ; Global Health ; Humans ; Severe Acute Respiratory Syndrome ; epidemiology

INTRODUCTIONParacetamol overdose is the most common drug overdose worldwide. To our knowledge, the maximum number of paracetamol tablets ingested reported in the literature is 45 g.

CLINICAL PICTUREWe describe a 21-year-old patient who acutely ingested 120 tablets, each 500 mg paracetamol (i.e., 60 g equivalent to 1200 mg/kg body weight) in a suicidal attempt. Our patient also drank 2 bottles of codeine-based cough syrup equivalent to 360 mg of codeine. At 6 hours post ingestion, her serum paracetamol level was 207 mg/L. The poor prognostic factors for paracetamol overdose in our patient included massive paracetamol ingestion (confirmed by blood levels), codeine co-ingestion and elevated serum amylase (189 U/L).

TREATMENTShe was treated with a 3-day modified regimen of intravenous N-acetylcysteine.

OUTCOMEThe liver function tests and the prothrombin time remained normal over the second and third day of admission and the patient was discharged without complications on the fifth day.

CONCLUSIONFrom this experience we feel that in very severe paracetamol poisoning, a modified regime of intravenous N- acetylcysteine for 3 days is safe and efficacious.

Acetaminophen ; blood ; poisoning ; Acetylcysteine ; administration & dosage ; Adult ; Amylases ; blood ; Antidotes ; administration & dosage ; Codeine ; poisoning ; Drug Overdose ; Female ; Humans ; Liver Function Tests ; Narcotics ; poisoning ; Suicide, Attempted ; Tablets ; Time Factors