sars: prognosis, outcome and sequelae

Respirology

(2003)

8

S36ndashS40

Blackwell Science LtdOxford UKRESRespirology1323-77992003 Blackwell Science Asia Pty LtdNovember 20038S1S36S40Original Article

SARS prognosis outcome and sequelaeKS Chan

et al

Correspondence KS Chan United Christian HospitalHong Kong SAR China Email chankshaorghk

SARS prognosis outcome and sequelae

KS

CHAN

1

JP

ZHENG

2

YW

MOK

3

YM

LI

2

Y-N

LIU

4

CM

CHU

1

AND

MS

IP

5

1

United Christian Hospital Hong Kong SAR China

2

Guangzhou Institute of Respiratory Medicine Guangzhou China

3

Kowloon Hospital Hong Kong SAR China

4

Beijing 301 Hospital Beijing China

5

University of Hong Kong SAR China


KS CHAN JP ZHENG YW MOK YM LI Y-N LIU CM CHU MS IP

Respirology

2003

8

S36ndashS40Severe acute respiratory syndrome (SARS) is associated with considerable morbidity and mortality inthe acute phase Worldwide case fatality rate is 11 (range 7 to 27) for the most severely affectedregions Several adverse prognostic factors have been identified including advanced age presence ofcomorbidity higher lactose dehydrogenase levels and initial neutrophil count but the impact of viraland other host factors on outcome is unknown Published data on sequelae of SARS are limited Clin-ical follow-up of patients who recovered from SARS has demonstrated radiological functional andpsychological abnormalities of varying degrees In the early rehabilitation phase many complainedof limitations in physical function from general weakness andor shortness of breath In a smallseries of subjects who underwent CT scan of the chest over half showed some patchy changes con-sistent with pulmonary fibrosis Lung function testing at 6ndash8 weeks after hospital discharge showedmild or moderate restrictive pattern consistent with muscle weakness in 6ndash20 of subjects Milddecrease in carbon monoxide diffusing capacity was detected in a minority of subjects Preliminaryevidence suggests that these lung function abnormalities will improve over time Psychobehaviouralproblems of anxiety andor depression were not uncommon in the early recovery phase andimproved over time in the majority of patients Avascular necrosis of the hip has been reported asanother complication The long-term sequelae of SARS are still largely unknown It is important tofollow up these patients to detect and appropriately manage any persistent or emerging long-termsequelae in the physical psychological and social domains

Key words

prognosis sequelae severe acute respiratory syndrome

Severe acute respiratory syndrome (SARS) has causedmultinational outbreaks affecting 8422 individualswith 916 deaths within a period of 6 months

1

OUTCOMES

Severe acute respiratory syndrome patients maypresent with a spectrum of disease severity rangingfrom relatively asymptomatic infection to fulminantpneumonitis and death Several studies havereported on short-term outcomes in adult patients upto about one month of the onset of illness Variousoutcome measures have been examined includingadmission to intensive care unit (ICU) developmentof acute lung injury (ALI) adult respiratory distresssyndrome (ARDS) and mortality

About one-third of patients have prompt resolutionof fever and pneumonitis with treatment

2

and evenwithout specific treatment in a minority However theremaining run a much more stormy course ndash 19 to34 of SARS patients required admission to ICU 13 to26 required assisted ventilation 20 to 226developed ALI or ARDS and 36 to 101 died atday 21 to day 28 (Table 1)

2ndash9

Protracted ventilation isnot uncommon for SARS-induced respiratory failure

9

This has posed considerable strain on critical careresources in the affected regions Even with vigoroussupport and treatment half of those who requiredmechanical ventilation eventually died

9

The reportedmortality in ICU was 34 at 28 days

8

and 522 at13 weeks

9

As the SARS epidemic abates a clearer picture ofthe mortality of the disease is emerging The mostrecent WHO update

1

indicated that the worldwidecase fatality rate (CFR) is 11 and ranged from 7 to27 for the most severely affected regions (Table 2)Most deaths were attributed to complications relatedto sepsis ARDS and multiorgan failure

8

which


S37

Tab

le 1

Ou

tco

me

stu

die

s in

SA

RS

Stu

dy

No

of

pat

ien

tsV

iro

logi

cal

do

cum

enta

tio

nFo

llow

up

du

rati

on

En

d-p

oin

tsP

rogn

ost

ic f

acto

rs im

plic

ated

ICU

ad

mis

sio

nVe

nti

lati

on

su

pp

ort

Mo

rtal

ity

Lee

et a

l

3

13

8N

RN

R32

(23

2)

19 (

138

)

36

(21

-day

)A

ge p

eak

LDH

neu

tro

ph

il co

un

t ab

ove

no

rmal

Bo

oth

et a

l

4

14

4N

R21

day

s29

(20

)

20 (

14

)6

5 (

21-d

ay)

Co

mo

rbid

ity

(Dia

bet

es)

Wo

ng

et a

l

5

15

787

9

Med

ian

26

day

sN

RN

RN

RA

ge i

nit

ial L

DH

leve

l lo

w in

itia

l CD

4 C

D8

cou

nt

Ch

an

et a

l

6

11

589

M

edia

n 6

2 d

ays

39 (

34

)30

(26

)

10

(21

-day

)A

ge c

om

orb

idit

y (D

iab

etes

hea

rt d

isea

se)

Pei

ris

et a

l

7

7593

24

day

s24

(32

)

19 (

25

) (A

RD

S 2

0)

67

(21

-day

)A

ge c

om

orb

idit

y (h

epat

itis

B)

Tsu

i

et a

l

2

32

389

lt

5 w

eeks

67 (

21

)42

(13

)

NR

Age

in

itia

l LD

H n

eutr

op

hil

cou

nt

Lew

et a

l

8

19

9N

R28

day

s46

(23

)

39 (

195

)

(ALI

AR

DS

22

6)

101

(

28-d

ay)

APA

CH

E I

I sc

ore

bas

elin

e Pa

O

2

FiO

2

rat

ioFo

wle

r

et a

l

9

196

NR

28 d

ays

38 (

19

)29

(14

8

)6

6 (

28-d

ay)

Age

Dia

bet

es b

ilate

ral l

un

g in

filt

rate

s

ICU

in

ten

sive

car

e u

nit

ALI

acu

te lu

ng

inju

ry A

RD

S a

cute

res

pir

ato

ry d

istr

ess

syn

dro

me

NR

no

t re

po

rted

Tab

le 2

Sum

mar

y ta

ble

of

SAR

S ca

ses

by

cou

ntr

y 1

Nov

emb

er 2

002mdash

7 A

ugu

st 2

003

1

Cu

mu

lati

ve n

um

ber

of

case

sSt

atu

s

Are

asFe

mal

eM

ale

Tota

lM

edia

n a

ge (

ran

ge)

No

cas

es c

urr

entl

yh

osp

ital

ized

No

cas

esre

cove

red

No

dea

ths

No

hea

lth

car

ew

ork

ers(

)

CF

Rdagger

()

Can

ada

151

100

251

49 (

1ndash98

) 10

200

4110

8 (4

3)

17C

hin

a53

2729

4949

349

1002

(19

)7

Ch

ina

Ho

ng

Ko

ng

Spec

ial A

dm

inis

trat

ive

Reg

ion

977

778

1755

40 (

0ndash10

0)7

1448

300

386

(22)

17

Ch

ina

Tai

wan

349

3

319

3

665

46 (

2ndash79

) 10

475

180

86 (

13)

27Si

nga

po

re16

177

238

35 (

1ndash90

) 0

205

3397

(41

) 14

Vie

tnam

3924

6343

(20

ndash76)

0

585

36 (

57)

8U

nit

ed S

tate

s16

1733

36 (

0ndash83

)7

260

1 (3

) 0

dagger

Cas

e fa

tali

ty b

ased

on

cas

es w

ith

kn

ow

n o

utc

om

e an

d ir

resp

ecti

ve o

f im

med

iate

cau

se o

f d

eath

S38

KS Chan

et al

occurred commonly in the elderly with comorbidi-ties There were notable differences in case-mixamong different regions (ie differences in distribu-tion of age sex disease severity as reflected by surro-gate markers such as LDH level proportion ofinfected healthcare workers (HCW) and the propor-tion of SARS confirmed by virological tests) The CFRof HCW in Hong Kong was 2 (8 out of 386) It is note-worthy that in the United States only 8 out of 47 prob-able cases and none of the 162 suspected cases havehad virological confirmation of SARS-CoV infection

10

The variation in CFR across different regions has to beinterpreted in the light of these differences

11

PROGNOSTIC FACTORS

Prognostic factors examined were essentially patientcharacteristics and laboratory findings Few studiesreported prognosis in relation to drug treatment andlittle is known about the differences in host responsecaused by SARS-coronavirus

Age and comorbidity (eg diabetes mellitus heartdisease) were consistently found to be significantindependent predictors of various adverse out-comes in SARS Initial experience suggests thatchildren with SARS have better prognosis thanadults

1213

Three studies reported that LDH level(two on the initial LDH level

25

and one on the peakLDH level

3

) was a predictive factor Two studiesreported the initial neutrophil count

23

and onestudy reported the initial CD4 CD8 count

5

as pre-dictive of outcome The analysis by the SARS Collab-orative Group of the Hong Kong Hospital Authorityon 889 patients has identified the following as riskfactors for death advanced age male sex presenceof comorbidity higher peak LDH level and higherinitial neutrophil count

1415

The mortality rate was6 for patients aged between 25 and 44 in contrastto 60 for age over 65 The use of ribavirin did notappear to have an independent favourable or dele-terious effect on patient outcome

111415

Unpub-lished data in Hong Kong suggested that initial viralload obtained from the nasopharyngeal aspiratemight be an additional predictor of ARDS and ulti-mate mortality in addition to the known risk fac-tors (KY Yuen pers comm)

Old age and comorbidity are well establishedadverse risk factors in pneumonia but they are non-modifiable Parameters such as LDH level and neu-trophil count might serve as surrogate markers of dis-ease severity to guide treatment plans in individualsIt is important to have more understanding of otherpotentially modifiable prognostic factors such as therelationship of the viral load or transmission routeand the host response so that treatment can bepromptly tailored to the needs of the individuals andhopefully improve their eventual outcome

SEQUELAE AND FOLLOW UP

Although published data on the sequelae of SARS arelimited patients who have recovered from SARS have

been noted to manifest radiological functional andpsychological abnormalities to varying degrees

In the early rehabilitation phase many patientscomplained of limitation in physical function fromgeneral weakness andor shortness of breath In aseries from United Christian Hospital (UCH) in HongKong comprising 42 patients with a mean age of40 years seen at about one month after hospital dis-charge about one-third of patients had moderate tosevere degree of dyspnoea on exertion or general mal-aise and felt that their performance of householdtasks or at work was moderately or severely impaired(E Wong pers comm)

Computerized tomography of the thorax in24 patients at about 5 weeks after discharge from hos-pital showed that changes consistent with pulmonaryfibrosis occurred in 62 (15 of 24 patients) whotended to be older and had more severe disease dur-ing the acute phase

16

However the fibrosis waspatchy and not extensive in the majority and hope-fully would not have a significant impact on lungfunction

In a series of 46 patients from Queen Elizabeth Hos-pital (QEH) in Hong Kong who were examined at6 weeks postdischarge about 20 were found to havea mild restrictive defect (PMY Lau pers comm) Inanother series of patients from Prince of Wales Hos-pital (PWH) the inspiratory and expiratory pressureswere below normal range while carbon monoxide dif-fusing capacity measurements were not markedlydecreased (D Hui pers comm) Similarly a study at6ndash8 weeks after hospital discharge in 43 patients atthe Guangzhou Institute of Respiratory Diseasesshowed that forced vital capacity and total lungcapacity were mildly decreased at 85

plusmn

11 and81

plusmn

8 of predicted respectively and residual vol-ume was markedly reduced at 63

plusmn

10 of predictedwhile carbon monoxide diffusing capacity correctedfor lung volume (DLCOVA) was normal at 109

plusmn

18of predicted

17

The findings suggested that respiratorymuscle weakness rather than parenchymal lung dam-age was the major factor for the restrictive lung func-tion defect In addition 50 of the patients from theQEH series have a decrease in hand grip strength Theobserved weakness of respiratory and skeletal musclecould be due to several factors including the previoususe of high dose steroids prolonged bed rest physicaldeconditioning or residual systemic effect of theacute disease

Lung function studies carried out on 258 patientsfrom Xiaotangshan Hospital in Beijing 2 months afterdischarge showed that 21 patients (54 of 258patients) had evidence of impaired diffusion (D

L

CO

lt

80pred) while 6 (16 of 258 patients) had restrictiveventilatory defect (VC

lt

80pred)

18

Fifty-one of54 patients had lung function tests repeated onemonth later D

L

CO was found to improve in 804patients (41 of 51 patients) and FVC in 813 patients(13 of 16 patients) (Table 3) These findings suggestthat lung function abnormality caused by SARS mightimprove spontaneously over time

Severe acute respiratory syndrome patients mayshow a decrease in their aerobic capacity in the earlyrehabilitation period In the QEH series 41 (19 of


S39

46) of patients have diminished VO

2

max as measuredby the Chester Strep test Among 33 of the 42 patientsin UCH 97 had a 6 minute walking distance below2 standard deviations of normal control (E Wongperscomm) Possible contributing of factors for theirdiminished cardiopulmonary fitness include muscleweakness residual lung damage anaemia and phys-ical deconditioning

Patients who have recovered from SARS showsymptoms of psychological trauma In the earlyrecovery phase about 5 weeks from onset of illnessone out of four (27 of 101) and one out of seven (16 of101) inpatients in Wong Tai Sin Hospital in Hong Kongshowed moderate to severe degrees of anxiety anddepression respectively (SP Lam pers comm) It isassumed this psychological aftermath will probablyimprove over time as suggested by data from anotherseries of 75 patients in QEH who were evaluated atone to two months after hospital discharge Only 5of these patients were reported to have moderate tosevere anxiety and depressive symptoms (A Au perscomm) Other than anxiety or depression post-SARSpatients suffered from some impairment of health-related quality of life Using the validated MOS 36-items Short Form Health Survey the QEH seriesshowed a decrease in health-related quality of lifescores particularly in the domains of physical func-tioning role physical social functioning and bodilypain Isolated cases of steroid-induced psychosishave also been reported

Clinical experience showed that SARS sequelae inother systems have also been encountered to varyingextents although systematic data is not yet availablefor reporting Mild degree of anaemia was commonlyseen in patients at the early follow-up period Lym-phocyte count appeared to have returned to the nor-mal range for most patients but it is not known if bodyimmune defence has been fully restored and studiesrelating to lymphocyte subset or lymphocyte functionmay shed light on this aspect Side-effects of high-dose steroids such as avascular necrosis of femoralhead have been reported in a few patients and furtherfollow-up for subclinical effects on bone or pituitary-adrenal axis is warranted Neurological and psy-chobehavioural problems such as lack of concentra-tion or poor memory have been reported by somepatients and warrant further follow-up It is also pru-dent to be alert to any potential problems that mayarise in the long term from the use of unconventionaltreatment such as convalescent plasma

In summary SARS is associated with considerablemorbidity and mortality in the acute phase A signif-

icant proportion of patients who survive the acute ill-ness have impairment in their overall functionalcapacity and health status in the first few months ofrecovery However the long-term sequelae are stilllargely unknown It is necessary to follow up thesepatients and perform comprehensive assessments fordetection and appropriate management of any per-sistent or emerging long-term sequelae in the physi-cal psychological and social domains

REFERENCES

1

World Health Organization Summary table of SARScases by country 1 November 2002ndash7 August 2003[Cited 29 August 2003] Available from URL httpwwwwhointcsrsarscountryencountry2003_08_15pdf

2

Tsui PT Kwok ML Yuen H Lai ST Severe acute respira-tory syndrome clinical outcome and prognosticcorrelates [Cited 29 August 2003] Available from URLhttpwwwcdcgovncidodEIDvol9no903- 0362htm

3

Lee N Hui D Wu A

et al

A major outbreak of severeacute respiratory syndrome in Hong Kong

N Engl JMed

2003

348

1986ndash94

4

Booth CM Matukas LM Tomlinson GA

et al

Clinical fea-tures and short-term outcomes of 144 patients with SARSin the greater Toronto area

JAMA

2003

289

2801ndash9

5

Wong RS Wu A To KF

et al

Haematological manifesta-tions in patients with severe acute respiratory syndromeretrospective analysis

BMJ

2003

326

1358ndash62

6

Chan JW Ng CK Chan YH

et al

Short term outcome andrisk factors for adverse clinical outcomes in adults withsevere acute respiratory syndrome (SARS)

Thorax

2003

58

686ndash9

7

Peiris JS Chu CM Cheng VC

et al

Clinical progressionand viral load in a community outbreak of coronavirus-associated SARS pneumonia a prospective study

Lan-cet

2003

361

1767ndash72

8

Lew TWK Kwek TK Tai D

et al

Acute respiratory distresssyndrome in critically ill patients with severe acute res-piratory syndrome

JAMA

2003

290

374ndash80

9

Fowler RA Lapinsky SE Hallet D

et al

Critically illpatients with severe acute respiratory syndrome

JAMA

2003

290

367ndash73

10

Centres for Disease Control and Prevention Updatesevere acute respiratory syndromemdashUnited States 2003

MMWR

Morb Mortal Wkly Rep

2003

52

616

11

Hospital Authority of Hong Kong

Medical ServicesDevelopment committee paper (MSDC-P172) ClinicalManagement and outcome of SARS 25 August 2003

Hos-pital Authority of Hong Kong Hong Kong 2003

Table 3

Changes in lung function test of SARS patients after discharge from Xiaotangshan Hospital (

Χ

plusmn

S)

VC(L)

FEV

1

(L)FEV

1

FVC()

D

L

CO(mlminmmHg)

D

L

COV

A

(LminmmHg)

Second month 310

plusmn

068 247

plusmn

060 797

plusmn

009 158

plusmn

28 412

plusmn

060Third month 333

plusmn

063 264

plusmn

057 798

plusmn

009 177

plusmn

29 435

plusmn

059

t

-test 57132 50470 00521 68197 39212

P

-value 0000 0000 0958 0000 0000

S40

KS Chan

et al

12

Hon KLE Leung CW Cheng WTF

et al

Clinical presen-tations and outcome of severe acute respiratorysyndrome in children

Lancet

2003

361

1701ndash3

13

Chiu WK Cheung PCH Ng KL

et al

Severe acute respi-ratory syndrome in children experience in a regionalhospital in Hong Kong

Pediatr Crit Care Med

2003

4

279ndash83

14

Taam Wong V

Prognostic indicators and disease patternProceeding of WHO workshop July 13 2003

WHO HongKong 2003

15

Sung J Clinical diagnosis and management of SARSWHO workshop June 17ndash18 Malaysia [Cited 29 August2003] Available from URL httpwwwwhointcsr

sarsconferencejune_materialspresentationsenclinical_diagnosispdf

16

Antonio GE Wong KT Hui DS

et al Thin-section CT inpatients with severe acute respiratory syndrome follow-ing hospital discharge preliminary experience Radiol-ogy 2003 228 810ndash5

17 Zheng JP Wang HY An JY et al Pulmonary function inthe rehabilitation period of severe acute respiratorysyndome (SARS) Chin J Tuberc Respir Dis 2003 inpress

18 Liu Y-N Severe acute respiratory syndrome diagnosistreatment and follow up Chinese Medical Forum 2ndConference 8ndash12 September 2003 Beijing China


S37

Tab

le 1

Ou

tco

me

stu

die

s in

SA

RS

Stu

dy

No

of

pat

ien

tsV

iro

logi

cal

do

cum

enta

tio

nFo

llow

up

du

rati

on

En

d-p

oin

tsP

rogn

ost

ic f

acto

rs im

plic

ated

ICU

ad

mis

sio

nVe

nti

lati

on

su

pp

ort

Mo

rtal

ity

Lee

et a

l

3

13

8N

RN

R32

(23

2)

19 (

138

)

36

(21

-day

)A

ge p

eak

LDH

neu

tro

ph

il co

un

t ab

ove

no

rmal

Bo

oth

et a

l

4

14

4N

R21

day

s29

(20

)

20 (

14

)6

5 (

21-d

ay)

Co

mo

rbid

ity

(Dia

bet

es)

Wo

ng

et a

l

5

15

787

9

Med

ian

26

day

sN

RN

RN

RA

ge i

nit

ial L

DH

leve

l lo

w in

itia

l CD

4 C

D8

cou

nt

Ch

an

et a

l

6

11

589

M

edia

n 6

2 d

ays

39 (

34

)30

(26

)

10

(21

-day

)A

ge c

om

orb

idit

y (D

iab

etes

hea

rt d

isea

se)

Pei

ris

et a

l

7

7593

24

day

s24

(32

)

19 (

25

) (A

RD

S 2

0)

67

(21

-day

)A

ge c

om

orb

idit

y (h

epat

itis

B)

Tsu

i

et a

l

2

32

389

lt

5 w

eeks

67 (

21

)42

(13

)

NR

Age

in

itia

l LD

H n

eutr

op

hil

cou

nt

Lew

et a

l

8

19

9N

R28

day

s46

(23

)

39 (

195

)

(ALI

AR

DS

22

6)

101

(

28-d

ay)

APA

CH

E I

I sc

ore

bas

elin

e Pa

O

2

FiO

2

rat

ioFo

wle

r

et a

l

9

196

NR

28 d

ays

38 (

19

)29

(14

8

)6

6 (

28-d

ay)

Age

Dia

bet

es b

ilate

ral l

un

g in

filt

rate

s

ICU

in

ten

sive

car

e u

nit

ALI

acu

te lu

ng

inju

ry A

RD

S a

cute

res

pir

ato

ry d

istr

ess

syn

dro

me

NR

no

t re

po

rted

Tab

le 2

Sum

mar

y ta

ble

of

SAR

S ca

ses

by

cou

ntr

y 1

Nov

emb

er 2

002mdash

7 A

ugu

st 2

003

1

Cu

mu

lati

ve n

um

ber

of

case

sSt

atu

s

Are

asFe

mal

eM

ale

Tota

lM

edia

n a

ge (

ran

ge)

No

cas

es c

urr

entl

yh

osp

ital

ized

No

cas

esre

cove

red

No

dea

ths

No

hea

lth

car

ew

ork

ers(

)

CF

Rdagger

()

Can

ada

151

100

251

49 (

1ndash98

) 10

200

4110

8 (4

3)

17C

hin

a53

2729

4949

349

1002

(19

)7

Ch

ina

Ho

ng

Ko

ng

Spec

ial A

dm

inis

trat

ive

Reg

ion

977

778

1755

40 (

0ndash10

0)7

1448

300

386

(22)

17

Ch

ina

Tai

wan

349

3

319

3

665

46 (

2ndash79

) 10

475

180

86 (

13)

27Si

nga

po

re16

177

238

35 (

1ndash90

) 0

205

3397

(41

) 14

Vie

tnam

3924

6343

(20

ndash76)

0

585

36 (

57)

8U

nit

ed S

tate

s16

1733

36 (

0ndash83

)7

260

1 (3

) 0

dagger

Cas

e fa

tali

ty b

ased

on

cas

es w

ith

kn

ow

n o

utc

om

e an

d ir

resp

ecti

ve o

f im

med

iate

cau

se o

f d

eath

S38

KS Chan

et al


10


11

PROGNOSTIC FACTORS



1213


25


3


23


5


1415


111415








16



plusmn

11 and81

plusmn


plusmn


plusmn

18of predicted

17



L

CO

lt


lt

80pred)

18


L




S39


2






REFERENCES

1


2


3

Lee N Hui D Wu A

et al


N Engl JMed

2003

348

1986ndash94

4


et al


JAMA

2003

289

2801ndash9

5

Wong RS Wu A To KF

et al


BMJ

2003

326

1358ndash62

6


et al


Thorax

2003

58

686ndash9

7


et al


Lan-cet

2003

361

1767ndash72

8


et al


JAMA

2003

290

374ndash80

9


et al


JAMA

2003

290

367ndash73

10


MMWR


2003

52

616

11




Table 3


Χ

plusmn

S)

VC(L)

FEV

1

(L)FEV

1

FVC()

D

L

CO(mlminmmHg)

D

L

COV

A

(LminmmHg)

Second month 310

plusmn

068 247

plusmn

060 797

plusmn

009 158

plusmn

28 412

plusmn

060Third month 333

plusmn

063 264

plusmn

057 798

plusmn

009 177

plusmn

29 435

plusmn

059

t

-test 57132 50470 00521 68197 39212

P

-value 0000 0000 0958 0000 0000

S40

KS Chan

et al

12


et al


Lancet

2003

361

1701ndash3

13


et al



2003

4

279ndash83

14

Taam Wong V


WHO HongKong 2003

15



16





S38

KS Chan

et al


10


11

PROGNOSTIC FACTORS



1213


25


3


23


5


1415


111415








16



plusmn

11 and81

plusmn


plusmn


plusmn

18of predicted

17



L

CO

lt


lt

80pred)

18


L




S39


2






REFERENCES

1


2


3

Lee N Hui D Wu A

et al


N Engl JMed

2003

348

1986ndash94

4


et al


JAMA

2003

289

2801ndash9

5

Wong RS Wu A To KF

et al


BMJ

2003

326

1358ndash62

6


et al


Thorax

2003

58

686ndash9

7


et al


Lan-cet

2003

361

1767ndash72

8


et al


JAMA

2003

290

374ndash80

9


et al


JAMA

2003

290

367ndash73

10


MMWR


2003

52

616

11




Table 3


Χ

plusmn

S)

VC(L)

FEV

1

(L)FEV

1

FVC()

D

L

CO(mlminmmHg)

D

L

COV

A

(LminmmHg)

Second month 310

plusmn

068 247

plusmn

060 797

plusmn

009 158

plusmn

28 412

plusmn

060Third month 333

plusmn

063 264

plusmn

057 798

plusmn

009 177

plusmn

29 435

plusmn

059

t

-test 57132 50470 00521 68197 39212

P

-value 0000 0000 0958 0000 0000

S40

KS Chan

et al

12


et al


Lancet

2003

361

1701ndash3

13


et al



2003

4

279ndash83

14

Taam Wong V


WHO HongKong 2003

15



16






S39


2






REFERENCES

1


2


3

Lee N Hui D Wu A

et al


N Engl JMed

2003

348

1986ndash94

4


et al


JAMA

2003

289

2801ndash9

5

Wong RS Wu A To KF

et al


BMJ

2003

326

1358ndash62

6


et al


Thorax

2003

58

686ndash9

7


et al


Lan-cet

2003

361

1767ndash72

8


et al


JAMA

2003

290

374ndash80

9


et al


JAMA

2003

290

367ndash73

10


MMWR


2003

52

616

11




Table 3


Χ

plusmn

S)

VC(L)

FEV

1

(L)FEV

1

FVC()

D

L

CO(mlminmmHg)

D

L

COV

A

(LminmmHg)

Second month 310

plusmn

068 247

plusmn

060 797

plusmn

009 158

plusmn

28 412

plusmn

060Third month 333

plusmn

063 264

plusmn

057 798

plusmn

009 177

plusmn

29 435

plusmn

059

t

-test 57132 50470 00521 68197 39212

P

-value 0000 0000 0958 0000 0000

S40

KS Chan

et al

12


et al


Lancet

2003

361

1701ndash3

13


et al



2003

4

279ndash83

14

Taam Wong V


WHO HongKong 2003

15



16





S40

KS Chan

et al

12


et al


Lancet

2003

361

1701ndash3

13


et al



2003

4

279ndash83

14

Taam Wong V


WHO HongKong 2003

15



16





sars: prognosis, outcome and sequelae

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