Peroxidase-mediated virucidal systems.

Peroxidase (myeloperoxidase or lactoperoxidase), hydrogen peroxide, and a halide such as iodide, bromide, or chloride form a potent virucidal system that is effective against polio and vaccinia viruis, particularly at a low pH. The peroxidase-halide-hydrogen peroxide system may contribute to the host defense against certain viral infections.

Gastrointestinal cytomegalovirus infection in heart and heart-lung transplant recipients.

Cytomegalovirus (CMV) causes major morbidity in organ transplant recipients. Gastrointestinal disease was the most prominent manifestation of CMV infection in a population of heart and heart-lung transplant patients, with an incidence of 9.9%, compared with pneumonitis (4.0%) and retinitis (0%), and occurred most frequently in CMV-seronegative recipients of organs from CMV-seropositive donors. Clinical manifestations included gastritis (nine patients), gastric ulceration (four patients), duodenitis (three patients), esophagitis (one patient), pyloric perforation (one patient), and colonic hemorrhage (one patient). Patients with gastrointestinal CMV infection were treated with intravenous ganciclovir sodium therapy, 5 mg/kg twice daily, for 2 to 8 weeks, with positive clinical, endoscopic, histologic, and virologic responses. Relapses occurred in four of nine patients who were followed up for a median period of 18 months. Retreatment resulted in healing of endoscopic lesions and in viral clearing. We conclude that early endoscopic evaluation for CMV is indicated in heart and heart-lung transplant patients with gastrointestinal symptoms. This study further suggests that intravenous ganciclovir therapy is effective for the treatment of gastrointestinal CMV in these patients.

Unusual acute neurologic presentations with Epstein-Barr virus infection.

We describe two patients with serologic evidence of active Epstein-Barr virus infection who presented with unusual neurologic manifestations and minimal systemic findings of infectious mononucleosis. One girl developed an acute hemiplegic migraine syndrome followed by acute psychosis, and the other patient had severe, generalized chorea. The wide spectrum of presenting central nervous system findings associated with Epstein-Barr virus infections underscores the need to suspect this agent in a variety of acute neurologic syndromes.

Herpes simplex type 2 virus encephalitis presenting as psychosis.

The current literature recognizes two antigenic types of herpes simplex virus, type 1 and 2. Type 1 is the most common cause of sporadic necrotizing encephalitis in the United States, with a mortality rate of 30 to 70 percent, and leaves various neurologic sequelae in the survivors. Herpes simplex virus type 2 had been recognized as an etiologic agent in fatal infections in neonates and a mild meningitis in adults, but its role in encephalitis in adults is less well known. We report a case of herpes simplex virus type 2 encephalitis with an analysis of four additional cases previously documented in the literature. Herpes simplex virus type 2 may cause more infections than is presently recognized, and we suggest that some cases of acute psychosis may, like in our case, represent herpes simplex virus type 2 encephalitis.

Acute myositis associated with influenza B infection.

An epidemic of acute myositis affecting children occurred in association with influenza B infections. The myositis followed the initial influenza-like episode, and almost exclusively involved the gastrocnemius and soleus muscles. Patients improved without specific treatment and made a complete recovery in four to five days. Laboratory studies characteristically showed elevated CPK, SGOT values, and a low peripheral white blood cell count. Influenza B virus was isolated from 11 of the 17 patients studied. This influenza-associated acute myositis of childhood is a recognized syndrome that should not be confused with dermatomyositis.

Reye's syndrome and salicylate use.

During an outbreak of influenza A, seven patients with Reye's syndrome and 16 ill classmate control subjects were evaluated for characteristics of the patients' prodromal illness and the control subjects illness and for medication usage. Patients during the prodrome and control subjects had similar rates of sore throat, coryza, cough, headache, and gastrointestinal complaints except for documented fever which occurred significantly more often in patients than in control subjects (P = .05). While medications which did not contain salicylate were taken as frequently by patients as control subjects, patients took more salicylate-containing medications than did control children (P < .01). All seven patients took salicylate whereas only eight of 16 control subjects did so (P < .05). Patients took larger doses of salicylate than did the entire control group (P < .01). When the eight control subjects who took salicylate were compared with the patients, the patients still tended to take larger doses (P = .08). Patients with fever took salicylate more frequently than control subjects with fever (P < .01). In addition, salicylate consumption was correlated with severity of Reye's syndrome (P < .05). It is postulated that salicylate, operating in a dose-dependent manner, possibly potentiated by fever, represents a primary causative agent of Reye's syndrome.

Microbiology of endotracheal aspirates in intubated pediatric intensive care unit patients: correlations with radiographic findings.

We studied the utility of Gram-stained smears and semiquantitative cultures of endotracheal aspirates (ETAs) in diagnosing pneumonia in intubated patients in a pediatric intensive care unit. The chest radiographs of 35 intubated patients were independently reviewed by a pediatric radiologist and classified into probable, possible and unlikely pneumonias. Concomitant bacteriologic and radiographic information was available in 15 episodes of probable and 13 of possible pneumonia. These findings were compared with the ETAs obtained during the study from patients with no radiographic evidence of pneumonia (N = 21). There was a good correlation between ETA findings and radiographic evidence of pneumonia when ETAs were obtained within 60 minutes of initial intubation. Only a growth of greater than or equal to 3+ of a pathogen was associated with probable pneumonia when ETAs were obtained more than 60 minutes from initial intubation. There was a poor correlation between the microbiologic findings from ETAs and the results of blood cultures and postmortem examinations. Moreover 5 of 10 pairs of ETAs obtained within 18 hours of each other demonstrated discordant results. The ETAs from patients with indwelling endotracheal tubes correlated poorly with radiographic findings and are of questionable value in diagnosing the presence of pneumonia or its etiology in this group. They must be cautiously interpreted in critically ill patients.

Respiratory syncytial virus-associated lower respiratory illnesses: possible influence of other agents. The Group Health Medical Associates.

Acute lower respiratory illnesses were prospectively investigated in a cohort of 1246 healthy infants who were enrolled at birth in the Tucson Children's Respiratory Study and followed through the first 3 years of life. Respiratory syncytial virus (RSV) infection was documented by culture, antigen detection or both in 276 episodes. In 21 (7.6%) of these 276, other viruses were simultaneously detected. Further serologic studies of 50 episodes in which RSV had been found increased the apparent viral codetection rate to 24%. When culture results for Chlamydia trachomatis and Mycoplasma pneumoniae were also considered, the rate of codetection was found to be 10.9% (30 of 276); this increased to 28% for the subgroup of episodes (14 of 50) that was further studied serologically. Illnesses associated with more than one agent were not significantly different from those involving RSV alone, with respect to month of onset, age at illness, illness type or duration of illness. We conclude that when RSV has been detected in previously healthy infants, routine searches for the concomitant presence of other viruses are usually not warranted.

Acute lower respiratory illnesses during the first three years of life: potential roles for various etiologic agents. The Group Health Medical Associates.

Lower respiratory tract illnesses (LRIs) occurring during the first 3 years of life among children enrolled in the Tucson Children's Respiratory Study have been studied for evidence of viral, mycoplasmal and Chlamydia trachomatis infections. This report examines those from whom adequate acute and convalescent sera were available at the time of the LRI. Two groups were compared: those in whom culture and/or antigen detection yielded an etiologic agent (N = 110); and those who did not (culture negative, N = 124). Seroconversions (> or = 4-fold titer rise) to respiratory syncytial virus; influenza virus types A and B; parainfluenza virus types 1, 2 and 3; or adenovirus were found in only 0 to 5% of the culture negative group. No significant differences between groups with regard to frequencies of seroconversion to influenza type C, parainfluenza virus type 4, human coronaviruses 229E and OC43 or cytomegalovirus were detected, which suggests that these agents may not be frequent primary causes of LRIs among otherwise healthy children. Significant differences in seroconversions to Epstein-Barr virus were detected, suggesting that Epstein-Barr virus may contribute to LRI morbidity; however, its exact role remains to be defined.

Use of immunoperoxidase on brain tissue for the rapid diagnosis of herpes encephalitis.

An indirect immunoperoxidase method to detect herpes simplex viral antigen in brain cell suspensions from patients suspected to have herpes encephalitis is described. The method is rapid, reliable and specific, and successfully identified the herpes virus infected cells in four of five culture-proven cases. There was one false-negative reaction, but no false-positive. The immunoperoxidase technic offers a number of advantages over immunofluorescence for routine diagnosis.

Changes in lung mechanics and reactivity with age after viral bronchiolitis in beagle puppies.

We measured changes with growth in lung function and airway reactivity after acute canine parainfluenza virus type 2 (CPI2, n = 5), canine adenovirus type 2 (CAV2, n = 7), and sequential CAV2-CPI2 (n = 6) infections or no infection (controls, n = 6) in beagle puppies (age approximately 79 days). In the CPI2 and CAV2 groups, a lower respiratory illness developed by day 3 postinfection with clinical recovery by day 14. In the CAV2-CPI2 group, puppies were inoculated initially with CAV2 and 12 days later with CPI2. In this group, illness persisted until day 14 after infection with CPI2. Lung resistance (RL), dynamic (Cdyn) and static (Cst) lung compliance, functional residual capacity (FRC), and responsiveness to aerosolized histamine were measured before infection and at periodic intervals until 239 +/- 43 days of age. Lung function data were analyzed using a longitudinal random effects model. In all groups, FRC, Cst, and Cdyn increased with age. In all infected groups, the regression slopes for Cdyn were steeper than in controls. RL decreased linearly with age without group slope differences. Histamine reactivity increased with age, but there were no differences in slope among groups. Lung pathological studies showed areas of obliterative bronchiolitis and chronic small airways inflammation particularly in the CAV2 and CAV2-CPI2 groups. Thus, viral bronchiolitis produces chronic small airways inflammation in beagle puppies and alters the changes in lung function occurring with growth. Histamine reactivity increases with age and is not modified by viral infection.

Application of pooled monoclonal antibodies for 1-hr detection of respiratory syncytial virus antigen in clinical specimens.

A fluorescein isothiocyanate-conjugated pool of monoclonal antibodies (MoAb) to respiratory syncytial virus (RSV) was prospectively evaluated for its utility as a direct, 1-hr test for the diagnosis of RSV infection. Direct nasopharyngeal swab smears collected from 109 infants and children with acute respiratory illnesses were studied and compared with results obtained by indirect immunofluorescence using bovine polyclonal anti-RSV antibody on eluted cells derived from pooled nasopharyngeal and throat swab specimens (a 2.5-3 hr procedure), and culture. The MoAb-direct smear method was at least 86%-89% sensitive and 95%-100% specific compared with either of the other procedures. Additional prospective evaluations, as well as retrospective studies on a selected bank of slides stored from the preceding year, established that this MoAb could also be used with confidence in testing where direct smears are not employed.

An eight-year study of the viral agents of acute gastroenteritis in humans: ultrastructural observations and seasonal distribution with a major emphasis on coronavirus-like particles.

During an 8-yr period, 862 stool specimens from patients with gastroenteritis were examined by electron microscopy after negative staining with 2% phosphotungstic acid (pH 6.5). Forty-one percent of the specimens submitted over an 8-yr period were determined to be positive for virus or viruslike particles belonging to one or more of seven morphologically distinct viral groups. Coronavirus-like particles (CVLPs) were present in 69.8% of the positive stool specimens. Membranous profiles containing "complement-type" holes (10 nm in diameter) were identified in some preparations containing CVLPs. The second most prevalent viral agent found in stool specimens was the rotavirus (17% of all positive stools). The incidence of other viruses identified in the survey were as follows: adenovirus 4.5%, picorna/parvovirus agents 2.9%, Norwalk-like agent 2.9%, astrovirus 1.9%, and calicivirus 0.5%. Unclassified small round viruses (approximately 25-30 nm in diameter) represented 0.5%. It was also determined that there was a seasonal distribution in excretion of all viruses except for CVLPs. A greater number of viruses were identified in the cooler, drier months of the year.

Mycoplasma and ureaplasma in bronchoalveolar lavage fluids from immunocompromised hosts.

The significance of Mycoplasma spp. and Ureaplasma urealyticum infection in immunocompromised patients has not been clearly established. We identified mycoplasma or ureaplasma in bronchoalveolar lavage fluid from 12 of 61 (20%) immunocompromised patients with pulmonary infiltrates. A complete microbiological investigation was made on the bronchoalveolar lavage fluids, and Mycoplasma pneumoniae was the sole agent detected in three instances, suggesting that it may have been the cause of the infiltrates in these immunocompromised patients. Other Mycoplasma spp. and ureaplasma were detected in nine patients, but in eight of these patients other pulmonary pathogens were also recovered.

"Stand-up" urologic endoscopy.

OBJECTIVES: To report the advantages of performing diagnostic and therapeutic urologic endoscopic procedures with the urologic surgeon in the standing-up position. METHODS: Our 25-year institutional experience with more than 10,000 cases of transurethral ablation of the prostate and other urologic endoscopic procedures, performed by the urologist in the standing-up position, was examined. A questionnaire of all 55 of our former urology residents was carried out to determine current practice trends. RESULTS: We have noted no drawbacks from performing transurethral surgery in the standing-up position. Ninety-two percent of the respondents believe that the standing-up position was more comfortable for endoscopic surgery than the sitting-down position. CONCLUSIONS: the standing-up technique of transurethral surgery minimizes positional stresses on the urologist's cervical and thoracic spine while optimizing endoscopic visualization and maneuverability. We recommend it in preference to the conventional sitting-down technique.

Changes in lung mechanics and histamine responsiveness after sequential canine adenovirus 2 and canine parainfluenza 2 virus infection in beagle puppies.

We determined the effects of an immediately antecedent viral lower respiratory tract infection (LRI) on the severity of clinical illness, changes in lung function and airway histamine responsiveness produced by a subsequent LRI in 9-12 week old beagle puppies inoculated with canine adenovirus 2, followed in 2 weeks by inoculation with canine parainfluenza 2 virus (CAV2-CP12, n = 7). We compared their acute responses to puppies infected with CP12 alone (n = 5), CAV2 alone (n = 7), and no infection (control, n = 6). Puppies inoculated with either virus alone developed a LRI 3 to 6 days after inoculation which resolved by 12-14 days after inoculation. However, the illness was more severe in the CAV2 group. In the CAV2-CP12 group, CP12 infection following CAV2 infection resulted in a clinical illness nearly comparable to that observed with CAV2 alone. Whereas in control and CP12 puppies, lung resistance (RL) decreased and dynamic lung compliance (Cdyn) increased during the study due to normal growth, RL increased and Cdyn remained unchanged in the CAV2 group. In contrast, RL did not change and Cdyn increased in the CAV2-CP12 group. Airway histamine responsiveness in the CAV2-CP12 group increased during infection with CP12 and was similar to that observed with CAV2 alone. In contrast, infection with CP12 alone produced a small, but non-significant increase in histamine responsiveness. The duration of the increase in histamine responsiveness was not prolonged in the CAV2-CP12 group in comparison to CP12 or CAV2 alone. However, the length of clinical illness was extended in the CAV2-CP12 group in comparison to the other infected groups. These data suggest that an immediately antecedent viral LRI can potentiate the clinical and physiologic effects of a subsequent viral LRI.

Bronchoalveolar lavage fluid cytology reflects airway inflammation in beagle puppies with acute bronchiolitis.

Beagle puppies infected with both canine parainfluenza virus type 2 (CPI2) and Bordetella bronchiseptica (Bb) develop more severe acute bronchiolitis and airways hyperresponsiveness than do those infected with CPI2 or Bb alone. The aim of our study was to characterize the inflammatory response associated with airway hyperresponsiveness, and to determine whether the inflammatory cell response of bronchoalveolar lavage fluid (BALF) reflected changes in the bronchioles in this model. We investigated 25 beagle puppies (ages 76 +/- 5 days, mean +/- SEM) in four groups: controls (n = 6), or puppies inoculated with both CPI2 and Bb (CPI2-Bb) (n = 11), with only CPI2 (n = 4), or only Bb (n = 4). The puppies were killed 3-4 days after inoculation, the lungs excised, the intermediate lobe lavaged, and BALF and the bronchiolar wall tissue examined for neutrophils and other inflammatory cells. Control puppies had no evidence of inflammation. However, the CPI2-Bb puppies had developed cough and rhinitis, positive cultures for CPI2 and Bb, and a neutrophilic cellular response in both the bronchioles and the BALF. Puppies inoculated with only CPI2 or Bb had milder illnesses and no significant bronchiolar and BALF neutrophilic response. For all groups, the severity of bronchiolar wall inflammation correlated with the total number of BALF inflammatory cells, and bronchiolar wall neutrophil counts correlated with the percentage of neutrophils in the BALF. The illness and the airway hyperresponsiveness observed in the CPI2-Bb group were associated with airway neutrophilia. Our studies support the hypothesis that neutrophils are associated with airway dysfunction in this model, and the use of BALF to study the process.

Risk for measles related to immunization status in two Tucson high schools.

An outbreak of measles occurred in Tucson, AZ, in 1985; 112 of the 225 cases were among students at two large high schools. A review of the immunization records of all students at both schools was undertaken in order to assess the risk of a person contracting measles in relation to that person's immunization status. Two factors, the lack of an immunization record and immunization prior to 12 months of age, showed a positive association with contracting measles. The association was statistically significant at one high school but not the other. At the first high school, students who were immunized at 12 to 14 months of age had a greater risk of infection than those immunized at 15 months or older. However, age at immunization of 12 to 14 months was not associated with a significantly higher risk when persons with multiple doses of vaccine were excluded from the analysis. Students of both schools showed a lower attack rate for those who had received multiple doses of vaccine, but the difference was not statistically significant.

Dialogue. Industry consolidation: what's at stake for consumers and purchasers?

The behavioral healthcare field has undergone massive consolidation, especially in the last year. Health plans, hospital systems, and community-based organizations have all been affected. Economists argue that consolidation is a logical consequence of the current, competitive healthcare market. But consumers and purchasers wonder if the mergers and acquisitions will benefit them. Efficient markets are supposed to stimulate competition in ways that reward purchasers and consumers of services. When prices go down and quality improves as a result of competitive market forces, then the market has functioned properly and has served its purpose. Behavioral healthcare, however, is an essential human service, not a commodity. And the consumers and purchasers of healthcare are typically not the same person or entity, which also makes the healthcare market different from the markets for cars, computers, food, or any other type of consumer product. More than 100 million Americans now receive managed behavioral health benefits from only three companies. With such intense power concentrated in the hands of such a small number of providers, the time has come to evaluate the impact of the consolidation trend. In the following dialogue article, leaders, representing different interest groups review the benefits and risks of massive industry consolidation, and propose solutions to the critical challenges that it raises.