Nasal cytokine responses to natural colds in asthmatic children.

BACKGROUND: The mechanisms by which viruses induce asthma exacerbations are not well understood. OBJECTIVE: We characterized fluctuations in nasal aspirate cytokines during naturally occurring respiratory viral infections in children with asthma. METHODS: Sixteen children underwent home collections of nasal aspirates when they were without cold symptoms and again during self-reported respiratory illnesses. The presence of viral infection was ascertained by multiplex PCR. Cytokines were measured using multiplex immune assay. mRNA expression for selected markers of viral infection was measured using RT-PCR. A cumulative respiratory symptom score was calculated for each day of measurement. Generalized estimated equations were used to evaluate associations between viral infection and marker elevation, and between marker elevation and symptom score. RESULTS: The 16 patients completed a total of 37 weeks of assessment (15 'well' weeks; 22 self-assessed 'sick' weeks). Viral infections were detected in 3 of the 'well' weeks and 17 of the 'sick' weeks (10 rhinovirus, three coronavirus, two influenza A, two influenza B, two respiratory syncytial virus, one parainfluenza). Compared to virus-negative well weeks, nasal aspirate IFN-γ, CXCL8/IL-8, CXCL10/IP-10, CCL5/RANTES, CCL11/eotaxin-1, CCL2/MCP-1, CCL4/MIP-1ß, CCL7/MCP-3, and CCL20/MIP3α protein levels increased during virus-positive sick weeks. Only a subset of cytokines (IFN-γ, CXCL8, CCL2, CCL4, CCL5, and CCL20) correlated with self-reported respiratory tract symptoms. While many aspirates were dilute and showed no mRNA signal, viral infection significantly increased the number of samples that were positive for IFN-λ1, IFN-λ2/3, TLR3, RIG-I, and IRF7 mRNA. CONCLUSIONS AND CLINICAL RELEVANCE: We conclude that in children with asthma, naturally occurring viral infections apparently induce a robust innate immune response including expression of specific chemokines, IFNs, and IFN-responsive genes.

Unilateral diaphragmatic paralysis secondary to carbon monoxide poisoning.

Complications of carbon monoxide poisoning include peripheral neuropathy, which is usually confined to the lower extremities. We report a case of carbon monoxide-associated neuropathy resulting in unilateral diaphragmatic paralysis. Possible mechanisms of injury are described.

Quality assurance in the department of pediatrics. An application of quality management.

A continuous quality improvement program can provide the means through which medical organizations can guide their activities. This article illustrates how a pediatrics department in an urban medical center incorporated continuous quality improvement into the management of health services. Key elements of the Quality Assurance program included the organization and facilities in the department of pediatrics, important processes related to patient care, and outcome measures. If a structure is established that allows participation in decision-making and mutual adjustment, trained professionals can perform up to their standards and those standards of their peers. Involvement of physicians in the design of quality management programs and other administrative strategies offer an opportunity to develop a working formula for ongoing success.

Problem-based ACLS instruction: a model approach for undergraduate emergency medical education.

The optimal format for teaching advanced cardiac life support (ACLS) to medical students and other groups with little emergency medicine experience has not been studied extensively. We report an ACLS provider course that was taught to sophomore medical students using a self-directed, problem-based learning model. The traditional two-day provider course format was replaced by a series of clinical problems that emphasized various aspects of the ACLS curriculum. Students then met weekly with an ACLS instructor who served as a tutor to discuss the problem. A specific set of learning objectives for the entire ACLS curriculum was developed into a study unit index and given to students at the beginning of the course. Enhanced practice time was offered to students in the form of traditional teaching stations and skills laboratories. Students were tested using standard ACLS criteria. The students in the problem-based course achieved a higher pass rate on the written test and skills stations than senior medical students did in a standard two-day course during the same time period. The problem-based format with enhanced practice time would appear to be an effective alternative for groups that need to acquire the basic skills needed in a resuscitation attempt but have little previous experience in this area.

Immunogenicity of low-dose intradermal recombinant DNA hepatitis B vaccine.

Low-dose intradermal vaccination with plasma-derived hepatitis B vaccine has been shown to give high rates of seroconversion at greatly reduced vaccine cost. We report a study comparing two groups given lower doses (1.0 or 1.5 microgram) of recombinant-derived vaccine intradermally with a control group given the standard intramuscular dose. Of the 132 randomized medical students and hospital employees, 95 completed the study. Rates of seroconversion and peak antibody titers were comparable, though antibody rose more slowly and fell somewhat faster in the intradermal groups. Increasing the intradermal dose did not improve response. Most intradermal vaccinees (80%) developed small (average 2 to 3 mm) areas of local induration, which faded slowly. Low-dose intradermal vaccination with recombinant hepatitis B vaccine results in high rates of seroconversion (greater than 90% in each protocol) at a cost that will allow individual practitioners and program with limited budgets to offer vaccination.