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Public discourse concerning current vaccination recommendations has dramatically increased. The current battle is not new, having had a lengthy foreshadowing during the 19th and early 20th centuries. Over a 30-year period, a concerted effort to limit the use of smallpox vaccine grew at the very time typhoid vaccines were being developed and advocated for widespread prevention. As a long time advocate for widespread smallpox vaccination and a supporter of the newly tested typhoid vaccine, Sir William Osler entered the public debate at the beginning of World War I. Osler was asked to address the officers and men in the British army on the need for typhoid vaccination. His speech entitled "Bacilli and Bullets" outlined the medical reasons for getting inoculated against typhoid. Osler's strong support for typhoid vaccination of the British troops was met by opposition in Parliament but not by most of the troops. Osler's arguments in support of vaccination failed to respond to the concept of "conscientious objection," which was central to the antivaccinationists' argument. Similar arguments are being propounded by current antivaccination groups. [ABSTRACT FROM AUTHOR]

Two patients with herpes zoster ophthalmicus and contralateral hemiparesis are described, and their findings compared with 49 patients previously reported. These patients presented with delayed contralateral hemiparesis approximately seven weeks after the onset of herpes zoster ophthalmicus. Most patients had evidence of infarction of the ipsilateral middle cerebral artery by angiography or by CT scan. Cerebrospinal fluid pleocytosis and elevated protein commonly were found. Twenty per cent of the reported patients died, but they were older than the patients who survived and predisposed to have diffuse CNS lesions. The pathogenesis of this syndrome is thought to be due to direct viral invasion of the blood vessel wall with resulting angiitis. Further studies need to be performed to clarify the role of specific antiviral therapy or anti-inflammatory agents in treating this complication of herpes zoster. [ABSTRACT FROM AUTHOR]

Laryngeal sequelae following prolonged endotracheal intubation are being observed with increasing frequency as this technique of airway management is being employed for extended periods of time. Many etiologic factors have been implicated in the development of these problems with the exact reasons being as yet unknown. After reviewing the records of 372 consecutive patients intubated over an 18-month period, we have observed an increased frequency of these complications in the diabetic female patient and suggest that early tracheostomy should be considered in these individuals when the use of prolonged intubation is anticipated. The possible pathophysiology of this problem in the diabetic, as well as the non-diabetic intubated patient, and its possible prevention will be discussed. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the safety and immunogenicity of a human immunodeficiency virus type 1 (HIV-1) recombinant envelope glycoprotein (rgp 160) candidate vaccine in humans.Subjects: Healthy adults (72) who were seronegative for HIV-1 were randomly assigned to one of four groups.Interventions: The subjects were randomly assigned to receive 40 or 80 micrograms of rgp 160, 10 micrograms of hepatitis B vaccine, or placebo in three doses (on days 0, 30, and 180), with an elective, nonblinded administration of a fourth dose on day 540.Measurements and Main Results: Neither clinical nor laboratory toxicity was encountered during a follow-up period exceeding 21 months. No effect of immunization was noted on lymphocyte counts, mitogenic responses, or delayed-type hypersensitivity. Serum antibody responses to HIV envelope proteins detected by Western blot were seen in 30 of 33 subjects (91%; 95% CI, 71% to 97%) receiving either 40- or 80-micrograms doses of rgp160 and were most commonly of weakly reactive intensity. Responses were first noted by Western blot after the second dose. They markedly increased in frequency after the third dose and declined over the next 12 to 18 months. The administration of a fourth dose resulted in homologous neutralizing activity in sera from 5 to 24 subjects (21%; CI, 7% to 37%) as well as in complement-mediated antibody-dependent enhancement in sera from 6 of 24 subjects (25%; CI, 10% to 42%). Antibody responses were detected by enzyme-linked immunosorbent assay (ELISA) less frequently than by Western blot, and these responses persisted for a shorter time.Conclusions: The administration of rgp160 was well tolerated and safe, resulted in a high rate of antibody response by Western blot after the administration of the third and fourth doses, and generated serum neutralizing activity and complement-mediated antibody-dependent enhancement in some subjects after the fourth dose. [ABSTRACT FROM AUTHOR]

The prophylactic effect of recombinant leukocyte A interferon (rIFN-αA) (dosage, 10 × 106 units per day for four days) against illness and infection in 26 volunteers challenged with rhinovirus type 13 was measured in a double-blind, placebo-controlled study. Significant reductions in illness frequency (7.1% vs 66.7%, P < 0.003), mean symptom scores, nasal secretion weights, and frequency of virus isolation were observed. However, there was no significant difference in infection rates between rIFN-αA- and placebo-treated volunteers. Late posttreatment virus shedding, which was unassociated with late illness, was observed in the rIFN-αA-treated group. In two double-blind, placebo-controlled tolerance studies of rIFN-αA, five (26%) of the 19 volunteers treated with rIFN-αA reported bleeding mixed with mucous nasal discharge and had documented superficial erosions of the nasal mucosa. Future studies will be necessary to evaluate lower doses and/or alternative treatment schedules for improved tolerance and continued efficacy. [ABSTRACT FROM PUBLISHER]

To evaluate the late effects of chronic pulmonary regurgitation against the putative benefits from the current surgical trend of primary repair of tetralogy of Fallot with a transannular patch in infancy, 10 patients > 10 years after early primary repair and 7 matched normal controls underwent exercise stress test and cine magnetic resonance imaging assessment of ventricular functions. Right ventricular impaired diastolic function and decreased exercise capacity, both significantly associated with pulmonary regurgitation in patients, indicated that early primary repair of tetralogy may not prevent late ventricular dysfunction and diminished exercise performance if chronic regurgitation results from right ventricular outflow tract reconstruction. [ABSTRACT FROM AUTHOR]

Aim: To describe a new finding in patients with pectus excavatum - left lower lobe anterior basal segment hyperinflation [LABSH]. A secondary objective is to determine the frequency of the new finding and association with pectus excavatum severity., Material and Methods: The study population included 52 children who underwent preoperative computed tomography (CT) for the evaluation of pectus excavatum. A control group of 50 children was obtained after evaluating 137 CT examinations performed for other reasons. Patient age in both groups ranged from 12 to 20 years. The Haller index was calculated for all patients. LABSH was evaluated by visual inspection of lung windows. The difference in mean radiodensity measurements in regions of interest in the left and right anterior basal segments [ΔHU] was calculated. Spirometry was performed in 44 of the patients and the results were compared to Haller index severity and the presence of LABSH. Echocardiography reports were available for 50 children in the pectus excavatum group., Results: LABSH was identified by visual inspection in 15 patients [29%] and was significantly associated with a Haller index >4.0 (p=0.001). ΔHU for the patients with LABSH was 90.2 HU (standard deviation [SD]=37.7) and for the non-hyperinflated group -5.51 (SD=44.63), which was significant (p<0.0001). There was a significant association of LABSH with the pectus excavatum group as compared to the control group. The difference in mean Haller index for children with normal spirometry (4.4, SD=2.7) was not significantly different (p=0.9899) than for children with obstructive disease (4.5, SD=1). There was mild cardiac compression on two echocardiograms., Conclusion: LABSH is a new sign associated with pectus excavatum. The sign suggests segmental bronchial compression caused by chest deformity results in segmental air trapping., (Copyright © 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

We describe a case of acute dyspnea in a patient with Marfan syndrome secondary to bowel herniation into the thoracic cavity.

Background: The rapidly increasing costs of healthcare pose a major challenge to many governments, particularly in developed countries. Health policy makers in some Western European countries have adopted the policy of a strong primary healthcare system, partly due to their recognition of the value of primary care medicine as a means to restrain costs while maintaining the quality and equity of healthcare services. In these countries there is a growing comprehension that the role of the family physician should be central, with responsibility for assessing the overall health needs of the individual, for coordination of medical care and, as the primary caregiver, for most of the individual's medical problems in the framework of the family and the community., Objectives: To describe primary care physicians in Israel from their own perception, health policy makers' opinion on the role PCPs should play, and patients' view on their role as gatekeepers., Methods: The study was based on three research tools: a) a questionnaire mailed to a representative sample of all PCPs employed by the four sick funds in Israel in 1997, b) in-depth semi-structured interviews with key professionals and policy makers in the healthcare system, and c) a national telephone survey of a random representative sample of patients conducted in 1997., Results: PCPs were asked to rank the importance of 12 primary functions. A total of 95% considered coordination of all patient care to be a very important function, but only 43% thought that weighing economic considerations in patient management is important, and 30.6% thought that 24 hour responsibility for patients is important. Also, 60% of PCPs have undergone specialty training and 94% thought that this training is essential. With regard to the policy makers, most preferred highly trained PCPs (board-certified family physicians, pediatricians and internists) and believed they should play a central role in the healthcare system, acting as coordinators, highly accessible and able to weigh cost considerations. Yet, half opposed a full gatekeeper model. They also felt that the general population has lost faith in PCPs, and that most have a low status and do not have adequate training. Regarding the patients' viewpoint, 40% preferred that the PCP function as their "personal physician" coordinating all aspects of their care and fully in charge of their referrals; 30% preferred self-referral to sub-specialists, and 19% preferred their PCP to coordinate their care but wanted to be able to refer themselves to specialists., Conclusions: In order to maintain high quality primary care, it is important that all PCPs have board certification. In addition, PCP training systems should emphasize preventive medicine, health promotion, health economy, and cost-effectiveness issues. Efforts should be made to render PCPs a central role in the healthcare system by gradually implementing the elements of the gatekeeper model through incentives rather than regulations.

The frequency of colonization and intracellular localization of nontypeable Haemophilus influenzae (NTHi) in the lower respiratory tract was determined in healthy adults and in clinically stable and acutely ill chronic bronchitis (CB) patients. NTHi was recovered from bronchial wash or bronchial brush specimens in 6 of 23 (26%) stable CB patients and in 1 of 15 (7%) CB patients with a respiratory exacerbation. No NTHi (0 of 26) was recovered from lower tract specimens of healthy adults undergoing anesthesia for elective surgery. Molecular typing of NTHi strains revealed that five of nine patients with stable CB had different strains in upper respiratory tract and bronchial wash/brush specimens collected simultaneously. Four stable patients with CB had different strains recovered on repeat bronchoscopy. These results demonstrate the frequent colonization of the lower airways of stable CB patients with multiple strains of NTHi. Bronchial biopsies also were examined for intracellular NTHi by in situ hybridization and immunofluorescence microscopy. Intracellular NTHi were found in 0 of 7 healthy adults, 8 of 24 patients with clinically stable CB, and 13 of 15 acutely ill CB patients. This observation suggests a role for intracellular infection by NTHi in the pathogenesis of exacerbations of CB.

Purpose: To determine if rectal sedation with thiopental sodium produced for intravenous administration provides safe and effective sedation for children undergoing diagnostic imaging., Materials and Methods: Five hundred twenty-five consecutive children (mean age, 2.7 years +/- 2.2 [SD]) underwent magnetic resonance imaging (n = 425), computed tomography (n = 89), and nuclear medicine (n = 11) examinations after rectal administration of thiopental sodium injection solution. The solution was prepared from thiopental sodium powder mixed with sterile water to create a concentration of 100 mg/mL. The dose ranged from 25 to 40 mg per kilogram of body weight, with a total dose limit of 1.5 g. The percentages of successful sedations and adverse reactions were evaluated on the basis of data collected at the time of the sedation., Results: Sedation was successful in 504 (96%) children. Ten (2%) children experienced desaturation, but only three of the 10 experienced sedation failure. All cases of desaturation were treated successfully with head repositioning, administration of supplemental oxygen, or both. No children experienced vomiting, acute rectal irritation, paradoxical hyperactivity, or prolonged sedation., Conclusion: Thiopental sodium sedation for pediatric imaging, with use of a rectal solution prepared from thiopental sodium preparation for intravenous injection, is safe and effective.

Background: Secondary signs of urinary obstruction associated with ureteral calculi are useful adjuncts to diagnosis in adults with renal colic evaluated by unenhanced helical CT., Objective: Our purpose was to evaluate the frequency of secondary signs of obstruction in children with renal colic undergoing unenhanced helical CT., Materials and Methods: Ureteral calculi were identified in 20 of 61 children with acute flank pain examined by unenhanced helical CT. Each imaging study was evaluated for the presence of secondary signs of urinary obstruction. The frequencies of individual signs were compared with each other by means of the McNemar test., Results: Six children had no secondary sign identified. In the remaining 14 children, proximal ureteral dilatation was seen in 10, renal enlargement in 10, hydronephrosis in 9, tissue rim sign in 6, decreased kidney attenuation in 5, and perinephric stranding in 1. Comparison of the frequencies strongly suggested that perinephric stranding occurs less frequently than proximal ureteral dilatation (P = 0.004), hydronephrosis (P = 0.008), or renal enlargement (P = 0.012)., Conclusion: Perinephric stranding, a common secondary sign in adults with ureteral calculi, occurs less frequently in children than other reported secondary signs.

Background: Tetralogy of Fallot repairs invariably result in pulmonary regurgitation with the long term sequelae of ventricular dilatation and dysfunction., Objective: The purpose of this study is to correlate pulmonary flow parameters with right ventricular size and function., Materials and Methods: Pulmonary artery velocity was mapped by magnetic resonance flow analysis in seven children with pulmonary regurgitation following tetralogy of Fallot repair. Right and left ventricular volumes were determined by Simpson's rule from double oblique cine gradient echo images of the heart. The ejection fraction was calculated for each ventricle. Right ventricular enlargement was normalized for patient size by calculating the ratios of right ventricle end diastolic and end systolic volumes to the left ventricle end diastolic and end systolic volumes respectively (EDV RV:LV and ESV RV:LV). The maximum pulmonary artery antegrade and retrograde velocities and the ratio of the time for antegrade to regurgitant flow were compared to ventricular function and volume measurements by regression analysis., Results: A significant linear relationship between the maximum regurgitant pulmonary artery velocity and EDV RV:LV was identified (r2 = 0.82)., Conclusion: An elevated maximum pulmonary regurgitant velocity correlated well with the degree of right ventricular enlargement in patients following tetralogy of Fallot repair. If the results are verified by a larger study, the maximum pulmonary regurgitant velocity may be substituted for the more cumbersome direct measurement of right ventricular size.

A longitudinal cohort study of older adults with chronic obstructive pulmonary disease (COPD) who were stratified by FEV(1) at enrollment was done to define the etiology, frequency, severity, and medical-care impact of respiratory tract viral infections (RTVIs). Controls consisted of a group of subjects of comparable age with the patients. RTVIs were documented in 44% of observed acute respiratory illnesses in control subjects and in 27% of COPD subjects, who were followed for mean periods of 35 and 26 mo, respectively. In this heavily influenza-vaccinated cohort ( approximately 90% vaccinated each year), picornaviruses, parainfluenza viruses, and coronaviruses were most commonly identified. Mean time to return to clinical baseline was approximately 2 wk in each group. Control and COPD subjects with mild airways obstruction (baseline FEV(1) >/= 50% predicted) had few emergency-center visits or hospitalizations. Approximately half of COPD subjects with moderate/severe COPD (baseline FEV(1) < 50% predicted) had at least one emergency-center visit and/or hospitalization for acute respiratory illness. RTVIs were documented in 23% of hospitalizations and in 45% of patients admitted between December and March. RTVIs have a major impact on utilization of health care resources for COPD patients with moderate/severe airways obstruction.

The viruses associated most frequently with the "common cold" are rhinoviruses and coronaviruses. The first prospective cohort study to determine the prevalence of rhinovirus and coronavirus infections in patients of all ages hospitalized for acute respiratory illnesses is described. Hospital admissions for acute respiratory illnesses were identified, and cell culture for rhinovirus and serologic assays on paired sera for coronaviruses 229E and OC43 were performed. A total of 61 infections with rhinoviruses and coronaviruses were identified from 1198 respiratory illnesses (5.1%); in addition, 9 additional infections associated with >/=1 other respiratory viruses were identified. Of those infected with only rhinovirus or coronavirus, underlying cardiopulmonary diseases were present in 35% of the patients aged <5 years, in 93% aged between 5 and 35 years, and in 73% aged >35 years. The predominant clinical syndromes varied by age: pneumonia and bronchiolitis in children aged <5 years; exacerbations of asthma in older children and young adults; and pneumonia and exacerbations of chronic obstructive pulmonary disease and congestive heart failure in older adults. Therefore, rhinovirus and coronavirus infections in hospitalized patients were associated with lower respiratory tract illnesses in all age groups.

The immunologic and virologic efficacy and safety of interferon a (IFN-alpha) administered in combination with zidovudine (ZDV) and zalcitabine (ddC) was evaluated in HIV-infected subjects with CD4+ cell counts between 300 and 500 cells/ml and no more than 14 weeks of prior antiretroviral therapy. A total of 256 subjects enrolled in an open-label, randomized controlled trial. Subjects were randomized equally into treatment groups. All subjects received ZDV and ddC, while half also receive IFN-alpha (3 MU subcutaneously every 24 hr). At 48 weeks the median average area under the curve minus baseline (AAUCMB) for plasma HIV-1 RNA for the two-drug group was -0.68 versus -0.75 log10 copies/ml for the IFN-alpha group (p = 0.046). Mean HIV-1 RNA changes from baseline to 48 weeks for these groups were -0.65 and -1.12 log10 copies/ml, respectively (p = 0.010). The median AAUCMB for CD4+ cell count for the two-drug group was 28 versus -1 cells/mm3 for the IFN-alpha group (p = 0.011). Neutropenia, anemia, and drug intolerance were more common in the IFN-alpha group. This study demonstrates that IFN-alpha inhibits HIV-1 replication but attenuates the CD4+ cell response to dual therapy with ZDV and ddC.

Context: While hospitalization rates have declined overall, hospitalizations for acute lower respiratory tract infections have increased steadily since 1980. Development of new approaches for prevention of acute respiratory tract conditions requires studies of the etiologies of infections and quantification of the risk of hospitalization for vulnerable patients., Objective: To determine the frequency of specific virus infections associated with acute respiratory tract conditions leading to hospitalization of chronically ill patients., Design: Analysis of viral etiology of patients hospitalized with acute respiratory tract conditions between July 1991 and June 1995., Setting: Four large clinics and related hospitals serving diverse populations representative of Harris County, Texas., Patients: A total of 1029 patients who were hospitalized for pneumonia, tracheobronchitis, bronchiolitis, croup, exacerbations of asthma or chronic obstructive pulmonary disease, and/or congestive heart failure., Main Outcome Measure: Virus infection, defined by culture, antigen detection, and significant rise in serum antibodies, by underlying condition; hospitalization rates by low- vs middle-income status., Results: Ninety-three percent of patients older than 5 years had a chronic underlying condition; a chronic pulmonary condition was most common. Patients with chronic pulmonary disease from low-income populations were hospitalized at a rate of 398.6 per 10000, almost 8 times higher than the rate for patients from middle-income groups (52.2 per 10000; P<.001). Of the 403 patients (44.4% of adults and 32.3% of children) who submitted convalescent serum specimens for antibody testing, respiratory tract virus infections were detected in 181 (44.9%). Influenza, parainfluenza, and respiratory syncytial virus (RSV) infections accounted for 75% of all virus infections., Conclusions: Our study suggests that respiratory virus infections commonly trigger serious acute respiratory conditions that result in hospitalization of patients with chronic underlying conditions, highlighting the need for development of effective vaccines for these viruses, especially for parainfluenza and RSV.

Serious waterborne and wilderness infections are common and usually treatable if diagnosed early. The differential diagnosis for these infections requires a careful and thorough history and physical examination. Common clinical presentations include acute febrile illnesses, altered mental status, diarrhea, or pneumonia. Pathogens causing serious infections include bacteria, fungi, viruses, and protozoa. Epidemiologic help can be obtained from local or state health departments as well as the Centers for Disease Control.