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Assessment of quality care for the respiratory disease in children
98
Tubercle and Lung Disease: Supplement
In this series, 63 % of the patients had positive cultures in at least one of the maxillary sinuses. The most common bacteria isolated were Haemophilus influenzae (51%) and Streptococcus pneumoniae (30%). Anaerobic bacteria were isolated in 20 % of the maxillary sinus secretions and fungi in 10%. Sore throat, nasal and post-nasal purulent secretions were statiscally more frequent in Group A. Complete opacification of the maxillary sinuses was the radiologic finding observed in most patients in this subset, with sensitivity of 79 % and specificity of 86%.
362 A MODEL FOR RESPIRATORY SYNCYTIAL VIRUS (RSV) INFECTION BASED ON EXPERIMENTAL AEROSOL INEECTION WITH BOVINE RSV IN CALVES Otto, P.,’ Elschner, M.,’ Reinhold, P.,’ Streckert, H.-J.,2 Werchau, H.,2 Philippou, S.3 t Institute for Veterinary Medicine of Federal Health Office, 07722 Jena, Germany; 2 Department of Virology, Ruhr-University Bochum, 44780 Bochum, Germany; 3 Department of Pathology, Ruhr-University Bochum, 44780 Bochum, Germany.
Since respiratory infections with RS virus occur naturally in humans, as well as in bovines, an infection model has been established in calves in order to clarify the mechanisms of pathogenesis and pathophysiological changes of this disease. Five conventionally kept and colostrum-fed calves aged 17-24 days were infected with the Bovine RSV strain 375 (ATCC No.: VR-1339) on either 2 or 4 consecutive days. The virus (4,5 ml, lo4 to lo5 TICDsc) was administered as an aerosol (180 to 220 htres daily) produced by means of a jet nebulizer. Each calf had to breathe the virus-containing aerosol using a tightly fitting face mask. A mouthpiece with respiration valves was used in order to filtrate the expiratory flow for virus retention. Few days after the first inhalation of RSV, a mild clinical disease could be observed in all calves characterized by cough, tears, and nasal discharge. A decrease in tidal volume and an increase in respiratory rate, as well as in expiratory flow were the main changes in lung function testing. The calves were necropsied at day 7 after the first infection. Gross findings consisted of irregularly distributed atelectasis developed both in central and peripheral regions mainly in the basal parts of the upper, middle and lower lung lobes. Viral antigen was present in the cytoplasm of epithelial cells of the collapsed bronchioli and in the vicinity of the intraluminal cellular debris. The reaction to the antibody 18FI2 (directed towards the F protein) was more intensive than the reaction to the antibody 3C4 (directed towards the P protein). The bronchial epithelium, in which there was no inflammatory reaction, showed a negative reaction. Viral antigen was also detected in the tracheal epithelium with both anti‘bodies. The infection strain of RSV has been reisolated from bronchoalveolar lavage fluid of all infected calves on bovine turbinate cells. The typical cytopathic effect due to Bovine RSV was obtained 3 to 4 days after inoculation of the cells. In conclusion, this animal model of RSV-infection was found to be suitable for further immunological and pathophysiological investigations with respect to viral respiratory infections in humans.
363 SHORT-TERM
PROSPECTIVE
STUDY
IN
CHILDREN HOSPITALIZED WITH ACUTE BRONCHIOLITIS Holgado, D., Misol, A., Halty, M., Sarachaga, M., Hortul, M., Russi, .I., Lozano, W.; Hospital Pereira Rossell, Montevideo, Uruguay
The authors report the clinical and biological findings of 36 children hospitalized with a first episode of acute bronchiolitis. A prospective study was possible in 23 of them with a follow up of 1 year. The children will be controlled yearly up to 6 years. The RSV was found in the nasopharingeal secretions in 91.3 % The total serum IgE was elevated in 44.5 % and normal in 41.7 % . There was a family history of asthma in 72.2 % Parental smoking was present in 80 % The prospective study shows that 56.5% has recurrent wheezing. The severity of the bronchiolitis does not correlate with the subsequent symptoms. There is a higher incidence of asthma in first degree relatives of those infants who developed recurrent wheezing (92.3%). There is no difference neither in the IgE values nor in the parental smoking between the group who wheezes (I) and the symptom free group (II). The compliance was below normal values in 58.1% of the group I and 57.7% of the group II. The total respiratory resistance was elevated in 42.3% of the group I and 25.8 % of the group II. After the 6th month this value was normal in the group II; being still abnormal in the 62.5% of the group I. The follow up of a control group of infants matched for sex and month of birth showed: recurrent wheezing in 26%. These children had a family history of asthma in 83.3 % The incidence of parental smoking was: 83.3% for the patients with wheezing and 64.7% in those without wheezings.
364 ASSESSMENT OF QUALITY CARE FOR THE RESPIRATORY DISEASE IN CHILDREN Duchiade, M. P., Costa, M. T.; National School of Public Health, Rua Leopold0 Bulhdes, 1480 - sala 820, CEP 21041-210, Rio de Janeiro, Brazil
Acute Respiratory Infection (ARI) is one of the chief causes of mortality in developing countries. Around twenty per cent of the estimated 2500 deaths among children under five years of age occurring each year in city of Rio de Janeiro are attribuited to ARI. The National AR1 Prog. in Brazil has been implemented since 1984. The severity and case fatality of AR1 is greater amoung young children. Acute respiratory infection, particularly during early infancy, presents a special challenge with respect to both assessment and management. A large majority of investigations have reported how good care dramatically reduced the case fatality rate from ARI. This study was conducted to asses the reliability and validity of a medical review instrument used to determine whether inpatient care was appropriate. Consensus criteria for the manegement of children admitted to a pediatric hospital with AR1 was established from questionnaires sent to pediatricians of the Infection Respiratory Diseases Commitee. A public hospital was selected for this study and the reliability of the instrument was
Tubercle and Lung Disease: Supplement determined by having it applied by two differents reviewers to each hospital record. The case record of 78 children under five years (the total number of AR1 admissions in three months in 1993) were reviewed. The judgment of a practicing pediatrian was taken as the standard for assessing validity. This study has indicated that the method used is simple and easy to use for different reviewers. Reliability and validity were found to be appropriate in mild severity cases, but this medical review instrument was considered incomplete in more severely ill admitted infants. 365 FLEXIBLE FIBEROPTIC BRONCHOSCOPY (FEB) IN INTENSIVE CARE UNITS (ICU) Kiss, K., Papai, Zs., Kis, S., Moldvay, J., Szima, B., Strausz, J.; Koranyi National Institute of Pulmonology, H-1529 Budapest, Hungary
During the last two years we have performed 115 FFB-s examining 95 patients in 9 different ICU-s and 7 critically ill patients in other departments in Budapest. Concerning the basic diseases 43 have undergone an operation because of intrathoracic malignancies, 11 were polytrauma-patients, 48 suffered from other pulmonary disorders. FFB-s were carried out mainly for atelectasis (29 % ), extended pulmonary infiltration (16 %), and retained secretions (12%). In 5 1 cases the FFB proved to be of diagnostic, in 20 cases of therapeutic value, and both in 44 cases. The FFB yielded clinical improvement in 32% of cases, and in 36% it contributed to the adequate treatment. 366 THE PHAGOCYI’OSIS AND BACTERIAL KILLING IN AIDS ALVEOLAR MACROPHAGES IS NOT RELATED TO REDUCTION OF THE LYMPHOCYTE SUBPOPULATIONS IN THE LUNG Velluti, G., Garuti, G. C., Gilioli, F., Luppi, F., De Donno, G., Bonucchi, M. E., Rossi, G., Covi, M.; Dept. of Phthisiology and Pulmonary Diseases. University of Modena - Via de1 Pozzo, 41110 Modena, Italy
Our previous study showed a reduction of phagocytosis and bacterial killing in AIDS alveolar macrophages. We tried to compare these functions with the alveolar immunological state by bronchoalveolar lavage. In the bronchoalveolar lavage of AIDS patients we assessed the T and B lymphocyte percentage, the T helper and suppressor lymphocyte percentage, the H/S ratio and the percentage of activated T lymphocytes. The table 1 shows the mean and standard deviation of these parameters:
367 PULMONARY CRYPTOCOCCOSIS ASSOCIATED WITH HUMAN IMMUNODEFICIENCY VIRUS TYPE FECTION IN RWANDA
99
1 IN-
Taelman. H.,’ Batungwanayo, J.,’ Bogaerts, J.,’ Allen, S.,’ Lucas, S.,2 Kagame, A.,’ Clerinx, J.,’ Van de Perre, P.’ et al. ’ Centre Hospitalier de Kigali, BP 780 Kigali. Rwanda; ’ University College London School of Medicine, UK; 3 National AIDS Control Programme, Kigali, Rwanda
Objectives and Methods: We retrospectively the demographics, the clinical and radiographic manifestations, the yield of various diagnostic procedures, the clinical course and therapeutic response in Rwandese patients with HIVl-associated pulmonary cryptococcosis (PC) diagnosed over a 3 year-period. Results: There were 37 HIV-l-infected
Rwandese patients (21 M, 16 F; mean age: 35; range 26-55) with PC. 29 (78%) patients had primary PC and 8 (22%) had concomitant cryptococcal meningitis. Cough (94 %), weight loss (65%), fever (51%), dyspnea (46%), thoracic pain (30%), headache (13%), hemoptysis (8%) were the predominant manifestations. A diffuse interstitial infiltrate on chest film was found in 76% of the patients, an alveolar pattern in 19%, mediastinal and/or hilar adenopathies in 11% , nodules and pleural effusion each in 5 %. With a yield of 82 %, bronchoalveolar lavage was found the most useful and sensitive diagnostic procedure. Screening of cryptococcal antigen in the serum failed to detect cases of primary PC. Twelve patients with primary PC treated with itraconazole as acute and maintenance therapy were all protected against disseminated cyryptococcal disease (DCD) while 7/10 (70%) of those who did not receive a specific anticryptococcal drug developed DCD. Conclusions:
Clinical and radiographic manifestations of PC lack specificity. BAL is the most useful procedure for the diagnosis of PC. The natural history of untreated primary PC in HIV-infected patients is DCD. Itraconazolc is highly effective in the acute treatment and in the primary prevention of DCD in patients with primary PC. Documented diagnosis of HIV-t-associated primary PC should become an absolute indication for acute as well as maintenance treatment with an effective anti-cryptococcal drug.
368 VALUE PUTED TIENTS
OF CHEST X-RAY AND COMTOMOGRAPHY IN HIV-PA-
Kauczor, H. U.,’ Schwickert, H. C.,’ Hartel, S..’ Gerken, G.,’ Fischer, B.;’ Schweden, F. ,’ Thelen, M. ’ ’ Klinik fiir Radiologie, “I. Medizinische Klinik, -‘II. Medizinische Klinik -’ Pneumologie, Universitiitskliniken, D-55/01 Mainz
Purpose: To evaluate the role of chest x-ray and computed tomography (CT), including high resolution computed tomography (HRCT), in asymptomatic and symptomatic HIV-patients.
The statistical analysis was performed by regression function and correlation coefficient. We observed no correlation between the considered immunological parameters and the functions of AIDS alveolar macrophages. We suppose that the decrease of bacterial killing and phagocytosis in alveolar macrophages is due not only to a reduction of lymphocyte number but to a direct damage of AIDS virus too.
Patients and Methods: 64 HIV-positive patients were classified as follows: 15 were asymptomatic (group I), 30 had non-specific symptoms (group II) and 19 suffered from severe respiratory distress (group III). All had blood and microbiologic tests, chest x-ray and CT within two weeks. Results:
infiltrations
In group I chest x-ray revealed pulmonary in 13 %, CT in 40 % of patients. In group II
Tubercle and Lung Disease: Supplement
In this series, 63 % of the patients had positive cultures in at least one of the maxillary sinuses. The most common bacteria isolated were Haemophilus influenzae (51%) and Streptococcus pneumoniae (30%). Anaerobic bacteria were isolated in 20 % of the maxillary sinus secretions and fungi in 10%. Sore throat, nasal and post-nasal purulent secretions were statiscally more frequent in Group A. Complete opacification of the maxillary sinuses was the radiologic finding observed in most patients in this subset, with sensitivity of 79 % and specificity of 86%.
362 A MODEL FOR RESPIRATORY SYNCYTIAL VIRUS (RSV) INFECTION BASED ON EXPERIMENTAL AEROSOL INEECTION WITH BOVINE RSV IN CALVES Otto, P.,’ Elschner, M.,’ Reinhold, P.,’ Streckert, H.-J.,2 Werchau, H.,2 Philippou, S.3 t Institute for Veterinary Medicine of Federal Health Office, 07722 Jena, Germany; 2 Department of Virology, Ruhr-University Bochum, 44780 Bochum, Germany; 3 Department of Pathology, Ruhr-University Bochum, 44780 Bochum, Germany.
Since respiratory infections with RS virus occur naturally in humans, as well as in bovines, an infection model has been established in calves in order to clarify the mechanisms of pathogenesis and pathophysiological changes of this disease. Five conventionally kept and colostrum-fed calves aged 17-24 days were infected with the Bovine RSV strain 375 (ATCC No.: VR-1339) on either 2 or 4 consecutive days. The virus (4,5 ml, lo4 to lo5 TICDsc) was administered as an aerosol (180 to 220 htres daily) produced by means of a jet nebulizer. Each calf had to breathe the virus-containing aerosol using a tightly fitting face mask. A mouthpiece with respiration valves was used in order to filtrate the expiratory flow for virus retention. Few days after the first inhalation of RSV, a mild clinical disease could be observed in all calves characterized by cough, tears, and nasal discharge. A decrease in tidal volume and an increase in respiratory rate, as well as in expiratory flow were the main changes in lung function testing. The calves were necropsied at day 7 after the first infection. Gross findings consisted of irregularly distributed atelectasis developed both in central and peripheral regions mainly in the basal parts of the upper, middle and lower lung lobes. Viral antigen was present in the cytoplasm of epithelial cells of the collapsed bronchioli and in the vicinity of the intraluminal cellular debris. The reaction to the antibody 18FI2 (directed towards the F protein) was more intensive than the reaction to the antibody 3C4 (directed towards the P protein). The bronchial epithelium, in which there was no inflammatory reaction, showed a negative reaction. Viral antigen was also detected in the tracheal epithelium with both anti‘bodies. The infection strain of RSV has been reisolated from bronchoalveolar lavage fluid of all infected calves on bovine turbinate cells. The typical cytopathic effect due to Bovine RSV was obtained 3 to 4 days after inoculation of the cells. In conclusion, this animal model of RSV-infection was found to be suitable for further immunological and pathophysiological investigations with respect to viral respiratory infections in humans.
363 SHORT-TERM
PROSPECTIVE
STUDY
IN
CHILDREN HOSPITALIZED WITH ACUTE BRONCHIOLITIS Holgado, D., Misol, A., Halty, M., Sarachaga, M., Hortul, M., Russi, .I., Lozano, W.; Hospital Pereira Rossell, Montevideo, Uruguay
The authors report the clinical and biological findings of 36 children hospitalized with a first episode of acute bronchiolitis. A prospective study was possible in 23 of them with a follow up of 1 year. The children will be controlled yearly up to 6 years. The RSV was found in the nasopharingeal secretions in 91.3 % The total serum IgE was elevated in 44.5 % and normal in 41.7 % . There was a family history of asthma in 72.2 % Parental smoking was present in 80 % The prospective study shows that 56.5% has recurrent wheezing. The severity of the bronchiolitis does not correlate with the subsequent symptoms. There is a higher incidence of asthma in first degree relatives of those infants who developed recurrent wheezing (92.3%). There is no difference neither in the IgE values nor in the parental smoking between the group who wheezes (I) and the symptom free group (II). The compliance was below normal values in 58.1% of the group I and 57.7% of the group II. The total respiratory resistance was elevated in 42.3% of the group I and 25.8 % of the group II. After the 6th month this value was normal in the group II; being still abnormal in the 62.5% of the group I. The follow up of a control group of infants matched for sex and month of birth showed: recurrent wheezing in 26%. These children had a family history of asthma in 83.3 % The incidence of parental smoking was: 83.3% for the patients with wheezing and 64.7% in those without wheezings.
364 ASSESSMENT OF QUALITY CARE FOR THE RESPIRATORY DISEASE IN CHILDREN Duchiade, M. P., Costa, M. T.; National School of Public Health, Rua Leopold0 Bulhdes, 1480 - sala 820, CEP 21041-210, Rio de Janeiro, Brazil
Acute Respiratory Infection (ARI) is one of the chief causes of mortality in developing countries. Around twenty per cent of the estimated 2500 deaths among children under five years of age occurring each year in city of Rio de Janeiro are attribuited to ARI. The National AR1 Prog. in Brazil has been implemented since 1984. The severity and case fatality of AR1 is greater amoung young children. Acute respiratory infection, particularly during early infancy, presents a special challenge with respect to both assessment and management. A large majority of investigations have reported how good care dramatically reduced the case fatality rate from ARI. This study was conducted to asses the reliability and validity of a medical review instrument used to determine whether inpatient care was appropriate. Consensus criteria for the manegement of children admitted to a pediatric hospital with AR1 was established from questionnaires sent to pediatricians of the Infection Respiratory Diseases Commitee. A public hospital was selected for this study and the reliability of the instrument was
Tubercle and Lung Disease: Supplement determined by having it applied by two differents reviewers to each hospital record. The case record of 78 children under five years (the total number of AR1 admissions in three months in 1993) were reviewed. The judgment of a practicing pediatrian was taken as the standard for assessing validity. This study has indicated that the method used is simple and easy to use for different reviewers. Reliability and validity were found to be appropriate in mild severity cases, but this medical review instrument was considered incomplete in more severely ill admitted infants. 365 FLEXIBLE FIBEROPTIC BRONCHOSCOPY (FEB) IN INTENSIVE CARE UNITS (ICU) Kiss, K., Papai, Zs., Kis, S., Moldvay, J., Szima, B., Strausz, J.; Koranyi National Institute of Pulmonology, H-1529 Budapest, Hungary
During the last two years we have performed 115 FFB-s examining 95 patients in 9 different ICU-s and 7 critically ill patients in other departments in Budapest. Concerning the basic diseases 43 have undergone an operation because of intrathoracic malignancies, 11 were polytrauma-patients, 48 suffered from other pulmonary disorders. FFB-s were carried out mainly for atelectasis (29 % ), extended pulmonary infiltration (16 %), and retained secretions (12%). In 5 1 cases the FFB proved to be of diagnostic, in 20 cases of therapeutic value, and both in 44 cases. The FFB yielded clinical improvement in 32% of cases, and in 36% it contributed to the adequate treatment. 366 THE PHAGOCYI’OSIS AND BACTERIAL KILLING IN AIDS ALVEOLAR MACROPHAGES IS NOT RELATED TO REDUCTION OF THE LYMPHOCYTE SUBPOPULATIONS IN THE LUNG Velluti, G., Garuti, G. C., Gilioli, F., Luppi, F., De Donno, G., Bonucchi, M. E., Rossi, G., Covi, M.; Dept. of Phthisiology and Pulmonary Diseases. University of Modena - Via de1 Pozzo, 41110 Modena, Italy
Our previous study showed a reduction of phagocytosis and bacterial killing in AIDS alveolar macrophages. We tried to compare these functions with the alveolar immunological state by bronchoalveolar lavage. In the bronchoalveolar lavage of AIDS patients we assessed the T and B lymphocyte percentage, the T helper and suppressor lymphocyte percentage, the H/S ratio and the percentage of activated T lymphocytes. The table 1 shows the mean and standard deviation of these parameters:
367 PULMONARY CRYPTOCOCCOSIS ASSOCIATED WITH HUMAN IMMUNODEFICIENCY VIRUS TYPE FECTION IN RWANDA
99
1 IN-
Taelman. H.,’ Batungwanayo, J.,’ Bogaerts, J.,’ Allen, S.,’ Lucas, S.,2 Kagame, A.,’ Clerinx, J.,’ Van de Perre, P.’ et al. ’ Centre Hospitalier de Kigali, BP 780 Kigali. Rwanda; ’ University College London School of Medicine, UK; 3 National AIDS Control Programme, Kigali, Rwanda
Objectives and Methods: We retrospectively the demographics, the clinical and radiographic manifestations, the yield of various diagnostic procedures, the clinical course and therapeutic response in Rwandese patients with HIVl-associated pulmonary cryptococcosis (PC) diagnosed over a 3 year-period. Results: There were 37 HIV-l-infected
Rwandese patients (21 M, 16 F; mean age: 35; range 26-55) with PC. 29 (78%) patients had primary PC and 8 (22%) had concomitant cryptococcal meningitis. Cough (94 %), weight loss (65%), fever (51%), dyspnea (46%), thoracic pain (30%), headache (13%), hemoptysis (8%) were the predominant manifestations. A diffuse interstitial infiltrate on chest film was found in 76% of the patients, an alveolar pattern in 19%, mediastinal and/or hilar adenopathies in 11% , nodules and pleural effusion each in 5 %. With a yield of 82 %, bronchoalveolar lavage was found the most useful and sensitive diagnostic procedure. Screening of cryptococcal antigen in the serum failed to detect cases of primary PC. Twelve patients with primary PC treated with itraconazole as acute and maintenance therapy were all protected against disseminated cyryptococcal disease (DCD) while 7/10 (70%) of those who did not receive a specific anticryptococcal drug developed DCD. Conclusions:
Clinical and radiographic manifestations of PC lack specificity. BAL is the most useful procedure for the diagnosis of PC. The natural history of untreated primary PC in HIV-infected patients is DCD. Itraconazolc is highly effective in the acute treatment and in the primary prevention of DCD in patients with primary PC. Documented diagnosis of HIV-t-associated primary PC should become an absolute indication for acute as well as maintenance treatment with an effective anti-cryptococcal drug.
368 VALUE PUTED TIENTS
OF CHEST X-RAY AND COMTOMOGRAPHY IN HIV-PA-
Kauczor, H. U.,’ Schwickert, H. C.,’ Hartel, S..’ Gerken, G.,’ Fischer, B.;’ Schweden, F. ,’ Thelen, M. ’ ’ Klinik fiir Radiologie, “I. Medizinische Klinik, -‘II. Medizinische Klinik -’ Pneumologie, Universitiitskliniken, D-55/01 Mainz
Purpose: To evaluate the role of chest x-ray and computed tomography (CT), including high resolution computed tomography (HRCT), in asymptomatic and symptomatic HIV-patients.
The statistical analysis was performed by regression function and correlation coefficient. We observed no correlation between the considered immunological parameters and the functions of AIDS alveolar macrophages. We suppose that the decrease of bacterial killing and phagocytosis in alveolar macrophages is due not only to a reduction of lymphocyte number but to a direct damage of AIDS virus too.
Patients and Methods: 64 HIV-positive patients were classified as follows: 15 were asymptomatic (group I), 30 had non-specific symptoms (group II) and 19 suffered from severe respiratory distress (group III). All had blood and microbiologic tests, chest x-ray and CT within two weeks. Results:
infiltrations
In group I chest x-ray revealed pulmonary in 13 %, CT in 40 % of patients. In group II