Richard W. Newcomb

Emergency management of asthma in children

We studies the records of 242 consecutive visits paid by 85 children for emergency treatment of asthma, using a standard format that included history, physical signs, peak expiratory flow rates, and responses to treatments. The decision for admission was made in 23% of the episodes. It was based on the degree of airway obstruction, as reflected in physical signs and depression of PEFR, remaining after treatment. The risk of hospital admission was directly related to duration of symptoms prior to the visit, to the extent of signs of airway obstruction on arrival, and to response to the first epinephrine injection. In 39 instances, children were sent home only to return within two days because symptoms recurred. Review of data from their initial visits did not allow us to predict most of these returns. These data may serve as an aid to composing criteria useful for managing episodes of asthma in children. They support the utility of pulmonary function data in discriminating between episodes that can and those that cannot be managed safely as outpatients.

Outcomes of emergency room visits for asthma: I. Patient determinants*

To learn how differences among individual patients influence the outcomes of their emergency room (ER) visits for asthma, we matched the results of 1209 sequential ER visits with the records of the 464 children and young adults who visited during a 37-week interval. Most patients visited the ER only once and were unlikely to be admitted. Those patients admitted once were unlikely to be admitted a second time. Only 119 patients (25.6%) made 54.7% of all ER visits and were responsible for 68.5% of admissions; they also accounted for all but eight of 92 relapses. Patients were accordingly stratified into group F, frequent visitors, and group I, infrequent visitors. A separate high-risk category (group HR) was composed of 50 other patients who received especially conservative treatment in the ER owing to prior episodes of severe asthma. HR patients included both frequent and infrequent visitors and had a very high probability of being admitted on any given visit. The patients of group F, each of whom visited the ER at least four times during the 37 weeks initially studied, were also consistently frequent visitors for comparable periods before and after the initial period. Their rate of ER relapses for exceeded their visiting rate, at least in part because some patients tended to relapse on repeated occasions. Patterns of ER use allow differentiation among groups of patients with distinctly different prognoses. These groups are similar to prognostic categories reported by previous authors. Such differences among individual patients must be taken into account when management systems are evaluated or clinical strategies are organized.

Tracheal Obstruction Secondary to Esophageal Achalasia

A 12-year-old girl presented with cough, emesis, and weight loss of 18-month duration. She was diagnosed as having achalasia of the esophagogastric junction. Flow-volume loops done because of the cough revealed a configuration consistent with variable intrathoracic tracheal obstruction. A barium swallow revealed the cause of obstruction to be massive dilatation of the esophagus. Balloon dilatation of the esophageal sphincter resolved all symptoms and normalized the flow-volume loops. This case illustrates that some pulmonary symptoms in achalasia can be due to direct tracheal obstruction in addition to the usual aspiration of esophageal contents.

Excessive numbers and activity of peripheral blood B cells in infants with Chlamydia trachomatis pneumonia

The peripheral blood lymphocytes of seven infants who had lower respiratory infections caused by Chlamydia trachomatis (chlamydial pneumonia) were studied for abnormalities that may be related to the hyperimmunoglobulinemia characteristic of this infection. Both proportions and numbers of B cells and plasma cells were strikingly elevated in these infants, as indicted by the percentage of peripheral blood mononuclear cells (PBMC) that reacted with fluorochrome-labeled antibodies to human immunoglobulins. Cells expressing IgM and IgD on their surface, and cells possessing IgM and IgG in their cytoplasm were especially increased above levels found in normal adults, infants, and a group of infants with other infections. Cells from infected infants secreted exceptionally large amounts of IgM, IgG, and IgA when cultured in the absence of added mitogens. These data suggest that chlamydial pneumonia induces substantial B-cell activation during a period of development when antibody responses are normally difficult to stimulate.

1860 PULMONARY ASSESSMENT OF CHILDREN AFTER CHLAMYDIAL PNEUM0NIA OF INFANCY

We evaluated the pulmonary status of 18 children 7 to 8 years after their hospitalization for chlamydial pneumonia of infancy. Pulmonary function tests (PFT) and respiratory questionnaire results on this group (CT) were compared to those of a control group (CR) comprised of 19 age, race and sex comparable children from the same community, or to values that other investigators have reported for normal children. Significant limitations of expiratory airflow were found in the CT group mean values compared to CR group (FEV1 p = .01; FEV1FVC p < 0.03; PEF p = .04; and FEF25–75% p = .009). CT group plethysmographic results revealed abnormally elevated volumes of trapped air (> 2 SD from reference means) present in 3 of 18 FRC and 13 of 18 RV/TLC ratios. These obstructive patterns were responsive to inhaled isoproterenol. Similarly, the CT group also had a significantly greater number of children with physiciandiagnosed asthma than the control group (6/18 vs 1/19, p<.03). The obstructive PFT abnormalities could not be accounted for by recognized risk factors such as exposure to smoking at home (11/18 vs 12/19 p = NS) or family history of atopy (6/18 vs 4/19 P = NS). Our results show that chlamydial pneumonia of infancy is associated with PFT and respiratory symptom abnormalities 7 to 8 years after recovery from the acute illness.

Pediatric Sports Medicine for the Practitioner: From Physiologic Principles to Clinical Applications

Physicians who care for children are often called upon to render advice on sports and exercise. Long before the physical fitness fad struck the adult sector, children used sports to have fun, work off steam, test themselves against their peers, and learn about real life. Their physicians, once called on only to tend their wounds, now must be prepared to advise on exercise appropriate to age, size, development, and any concurrent disease, and to control access to many competitive activities. This well-written, carefully documented book provides a great deal of information by which such decisions can be informed. Its extended title accurately describes the focus of the book: exercise physiology in the immature human, with special applications to children with several forms of chronic disorders. Two initial chapters clearly describe the response of children of differing age, sex, and size to exercise. Applications to children with pulmonary, cardiovascular, endocrine, nutritional,

IMMUNITY TO DIPHTHERIA IN AN URBAN POPULATION

Immunity against diphtheria (D) is poorly understood since protection is a complex interaction between host and environment and there are technical problems with existing antitoxin assays. Using a radioimmunoassay, antitoxin was detected in sera from premature infants after 33 weeks of gestation and the maternalcord serum ratio of 18 term infants was 0.8 ±0.3 (1 SD), Following the first DTP (7.5 Lf units D toxoid) significant antitoxin production was not detected. This relatively poor antigenicity was found in the absence as well as presence of maternal antibody. A rise in antibody concentration and affinity was found after the 2nd, 3rd, and 4th injections. More than four injections did not alter concentration and affinity of the antitoxin or the rate of decline in concentration. Correlation with recent epidemiologic studies suggests that a serum contained a protective concentration of antitoxin if it bound more than 150 ng D toxin N/ml of serum. By this criteria only 74% of children who received 3 immunizations and 84% of children who received 4 or more were protected. Among the 188 children studied 34% had appropriate immunizations for age. These observations suggest that the immunologic status of urban children to D is inadequate and an improvement in patient education and immunization practices is needed, (supported by AI-07854)