INFECTIOUS_DISEASES

Expectoration is more profuse, sometimes blood-streaked. Sometimes bronchitis may be more protracted; this is connected with the duration of the primary disease and with domestic condition s, particularly when the child is deprived of fresh air and sunlight for prolonged periods. Such unfavourable factors may lead to a number of complications auch as, otitis media, pyelitis, secondary anemia. Bronchopneumonia is the most frequent complicatio n in infants.

Prognosis is good for acute bronchitis; in childhood the conversion to chronic forms is rare. Even in protracted cases uncomplicated by pneumonia complete recovery is often obtained by proper care and improved domestic conditions.

Treatment. Bronchitis usually requires only fresh air, good ventilation of premises, a well-balanced diet. Warm baths are indicated, especially for infants. Mustard plasters and mustard packs are recommended. The symptomatic drugs administered are usually expectorants or, on the contrary, anesthetics to keep the cough down.

ACUTE BRONCHITIS

Acute bronchitis is an acute disease of the bronchi, characterized by an inflammation of their mucous membrane, caused by the chemical and biological extension of irritation from the upper air passages, often following a rhinitis or a laryngotracheitis. The larger bronchi are first affected. Affection of the smaller bronchi may be secondary to affection of the larger tubes. Further spread of the infection may cause bronchopneumonia. The condition is also found in association with influenza, measles, scarlet fever, and some of the other acute febrile diseases.

Symptoms: These are retrosternal pain, hoarseness, cough, and often soreness; there may be a slight rise of temperature, though the temperature often remains normal.

Physical Signs: Inspection of the chest is negative; the trachea and pharynx may be infected. Nothing abnormal is elicited by palpation and percussion, but on auscultation the respiratory murmur may be harsh, and numerous large moist or dry rales are found along the large bronchi, which of.ten disappear after cough and expectoration.

CHRONIC BRONCHITIS

This is a chronic inflammatory condition of the medium sized and small bronchi, associated with destructive changes in the bronchial wall and peribronchial space. As a rule, it is a secondary

disease. It is characterized by dyspnea, cough and various types of expectoration.

Most cases of chronic bronchitis occur in those past middle life. In the young it may be caused 'by some irritating condition within the upper air passages, the trachea or the bronchi, and also by the presence of enlarged tonsils, sinus infections, focal infections, enlarged pendulous uvula, adenoids, congenital malfor - mation of the trachea. A foreign body in the bronchi or lungs may at times be the cause of chronic bronchitis.

Symptoms: These are cough which occurs in paroxysms, copious expectoration, absence of fever, and a history of long -standing cough.

Physical signs: A person suffering from chronic bronchitis is usually emphysematous. Inspection, therefore, will reveal an emphysematous chest. Palpation will give evidence of diminished tactile fremitus throughout thechest. Percussion will elicit a hyperresonant note, except when associated congestion of the bases is present, in which case, impaired resonance or relative dullness is obtained over these areas. On auscultation the examiner will hear low-pitched, prolonged inspiration, accompanied by low-pitched, prolonged wheezy expiration. The rales heard will be large and small, moist and dry. A profusion of all kinds of rales is usually audible in this class of cases, though the rales may disappear temporarily after the secretion has been coughed up.

BRONCHIAL ASTHMA

General Considerations

Familial susceptibility, environmental exposure, and such modifying factors as psychogenic stimuli must all be considered in the etiologic evaluation of an allergic patient. Half of these patients give a definite history of family allergy (rhinitis, asthma, eczema, urticaria). Seventy-five per cent of children with 2 allergic parents will be allergic. A familial history gives no information, however, about the specific clinical expression of the allergy.

Most allergic disorders of the respiratory tract are caused by inhalant allergens, principally pollens (especially the ragweed family), animal danders, and housedusts.

Modifying factors (psychic stress infections, endocrine distur - bances) may precipitate symptoms by upsettin g the "balance" between the patient and his allergenic environment. The antigen - antibody reaction then results, and leads to the rapid appearance of reversible tissue changes; increased capillary permeability, in - creased secretion of mucus, spasm of smooth muscle, and increased

numbers of eosinophils in the tissues, secretions and peripheral blood.

The onset of bronchial asthma is usually before 20 years of age.

Clinical Findings

A. Symptoms and signs: Bronchial asthma is characterized by recurrent acute attacks of wheezing, dyspnea, cough, and expec toration of mucoid sputum (especially at the end of an attack).

Coughing	at night, coughing and wheezing on exertion, and a
history of	frequent "colds" may be more prominent in children

than clear-cut paroxysms of wheezing. Nasal symptoms (itching, congestion, and watery discharge) may precede attacks of wheezing.

The acute attack presents a characteristic picture. The patient sits up, "fighting for air", with his chest fixed in the inspiratory position and using his accessory muscles of respiration. Great difficulty is evident with expiration. Wheezing may be audible across the room and usually overshadows other pulmonary signs.

When bronchial asthma becomes prolonged, with acute, severe, intractable symptoms, it is known as status asthmaticus.

B.Laboratory findings: The sputum is characteristically tena cious and mucoid, containing "plugs" and "spirals". Eosinophils are seen microscopically.

C.X-ray findings: Chest films usually show no abnormalities. Emphysema may be acute (reversible) in severe paroxysms or chronic (irreversible) in long-standing cases. Transient, migratory pulmonary infiltrations have been reported. Pneumothorax may complicate severe attacks.

Complications. Chronic bronchial asthma may lead to such complications as chronic pulmonary emphysema and chronic cor pulmonale. Other complications are atelectasis, pulmonary infection and pneumothorax.

Treatment. The treatment during attacks consists mainly of the administration of substances that alleviate or arrest the paroxysm. Such old substances as adrenaline and ephedrine have not lost their efficiency and are still prescribed in severe and prolonged paroxysms.

Besides those in some subacute cases when typical expiratory dyspnea, cyanosis restlessness and tachycardia are observed the preparations of theophedrine, antasthmane, euphylline, novodrine, neoepinephrine* and others are administered. In severe cases hormonotherapy (ACTH, cortisone, prednisolone) is indicated.

neoepinephrine — изадрин

To support the cardiac activity strophanthin or isolanid (a digitalis preparation) as well as oxygen therapy should be prescribed.

To dissolve mucoid expectorations aerosolic inhalations and bronchial lavage should be provided.

Change in environic conditions is very desirable for the asthmatic patients, climatic therapy (altitute and sea sanatoriums, altitude chambers* and salt mines**) being the most beneficial.

However, before any treatment is administered all possible alimentary allergens and those of environments must be elicited and removed.

The attack often subsides without treatment, sudden death during paroxysms is rare. Proper hygienic measures, relief of apprehension by reassurance, fresh air and rest are the most reliable agents for checking asthma. The institution of such a regimen for prolonged periods causes the attacks to subside.

Sometimes relief is obtained by the. surgical removal of enlarged tonsils and adenoids, and also by nose therapy (rhinitis), as these are also frequent factors in the origin of respiratory disorders.

Prognosis. Most patients with bronchial asthma adjust, well to the necessity for continued medical treatment throughout life. Inadequate control or persistent aggravation by unmodifiable environmental conditions favors the development of incapacitating or even life-threatening complications.

ACUTE VIRAL HEPATITIS

This is a common worldwide disease, which occurs sporadically and in epidemics with outbreaks, most commonly in institutions, in rural areas and in military forces during wars. Incidence is the highest in autumn and early winter.

There are two types of hepatitis with distinctive clinical, epidemiological and immunological features. The two types of disease are caused by two different viruses. The disease associated with virus A is the classical type of mfect ious hepatitis, in former years it was also known as epidemic jaundice and acute jaundice. The disease associated with virus В resembles serum hepatitis, posttransfusion hepatitis and postvaccinal hepatitis. Detection of the infection depends on the demonstration of an antigen, hepatitis В

antigen (HBAg or Australia antigen) or its antibody (HBAb) in the

serum	of exposed individuals.
It	is well recognized that viral A hepatitis is a contagious

disease and that the most common mode of transmission is by the intestinal-oral route. Man is a reservoir and source of infection.

Virus В is mainly transmitted parenterally. Transfusion of contaminated blood or blood products is a usual source of infection, although the use of needles by drug abusers is also responsible for the infection. Nonparenteral spread can also occur.

Virus A infection has an incubation period of 2 to б weeks, virus В — about 6 to 25 weeks. All age groups are affected.

The prodromal phase begins suddenly with malaise, nausea, vomiting and fever. Jaundice reaches a peak within 1 to 2 weeks. Then the recovery phase begins. The liver is usually enlarged and tender.

High values of transaminase appear early in the prodromal stage and slowly fall during the recovery phase. Urinary bile appears before jaundice; its early detection provides a valuable clue to the diagnosis. The WBC count is usually low — normal and blood smear often shows a few atypical lymphocytes. In the prodromal phase hepatitis mimics a variety of illnesses and is difficult to diagnose. Where the

diagnosis is uncertain, liver	biopsy usually helps.
A favourable prognosis	in hepatitis В is less certain than in

virus A infection, especially in elderly people where mortality is 10 to 15%.

Personal	hygiene	helps	to prevent	spread of	hepatitis	A with
a particular	emphasis	on	disposal of	feces.	Globulin	provides'

protection against hepatitis A and should be given to close contacts. Hepatitis В is minimized by proper technical procedures to prevent transmission by blood from an infected donor or through the use of properly sterilized syringes and needles. High immune serum globulin against virus В provides partial protection but is

not yet available.

In most cases no special treatment is required. Appetite usually returns to normal after the first few days and the patient need not be confined to bed. Restrictions on diet or activity are unnecessary and have no scientific basis. Vitamin supplements are rarely required. Corticosteroids are contraindicated in ordinary cases. Most patients can safely return to work before jaundice completely resolves and before transaminases are normal.

ALERT OVER SPREAD OF HEPATITIS В

The Government has grossly underestimated the spread of hepatitis В in Britain and should launch a drive to vaccinate those most at risk, one of the country's leading experts said.

Professor Aris Zuckerman said there were probably 20000 cases of the potentially fatal disease, 10 times more than the government figures of annual cases.

But the Government was lagging several years behind most European countries and the United States in defining which sections of the population should receive the vaccine against the acute infection of the liver.

Professor Zuckerman, director of medical microbiology at the London School of Hygiene and Tropical Medicine, said homosexuals, drug addicts and prostitutes were high risk groups who should be offered vaccination.

He told an international conference in London organized by the Hospital Infection Society that progress with the development of hepatitis В vaccines has been encouraging.

One of the latest vaccines was given government approval and is estimated to be about half as expensive as previous versions.

Worldwide hepatitis В kills 9000 children every day and more than 284 million are estimated to be carriers of the infection which is transmitted in the same way as AIDS, through contaminated blood and sexual intercourse.

Because of its costs — a course of immunization costs about $70 — vaccination is restricted in Britain to health care workers who are perceived as most at risk through contact with infected blood.

But the World Health Organization recommends that in addition, drug addicts, homosexuals, prostitutes, members of rescue services

and patients and staff in institutions should	also be protected.
IS "THUCYDIDES SYNDROME"	BACK?

For centuries, historians and scientists have puzzled over the calamitous plague of Athens, which decimated the ancient city-state between 430 and 427 B.C. As vividly described by the historian Thucydides, himself a survivor of the illness, the plague attacked suddenly, causing "violent heats" in the head, inflammation of the eyes and throat, "reddish, livid" skin, extreme diarrhea and high fever. Historians agree that the epidemic, which killed the great statesman Pericles, contributed to the fall of Athens in the Peloponnesian War. But there is no agreement on its cause. Was it smallpox? Scarlet fever? Typhus? Measles?

A more exotic explanation was posed in the "New England Journal of Medicines in 1985 by Dr. Alexander Langmuir, formerly chief epidemiologist at the Centres for Disease Control in Atlanta. Thucydides' description, Langmuir theorized., fit the criteria for influenza complicated by toxic shock syndrome. And although this

peculiar combination of ailments had never been observed by modern physicians, Langmuir predicted that "Thucydides syndrome", as he called it, "may reappear", perhaps as part of some future epidemic of influenza.

The Delphian oracle could not have been more clairvoyant. In a recent issue of the "Journal of the American Medical Association", doctors at the Minnesota Department of Health, and the University of Virginia reported a total of ten cases of suspected Thucydides syndrome — flu complicated by TSS. Nine of the cases .occurred during a major influenza outbreak in Minnesota in the winter of 1985 —1986. One occurred in Roanoke, Va., and an eleventh case, in Oregon, has since been reported to the CDC. Like the Athenian scourge, the two-part illness was tethal: six of the patients died. Langmuir says the apparent fulfillment of his prophecy had him "blown over like a feather".

Though most U.S. cases of toxic shock occur in menstruating women, often in conjunction with the use of tampons, this was not true of the flu victims. Four of the eleven were males, and only two of the females were menstruating at the time they fell ill (both said they were not using tampons). The patients ranged in age from five to 56, but most of the deaths were among children. Says Dr. Kristine MacDonald of the Minnesota Department of Health: "There is some suggestion that younger people are more susceptible to TSS. As people get older, more of them have antibodies to protect them". Indeed most adults are immune to the syndrome.

TSS is caused by a toxin-producing strain of the common bacterium, Staphylococcus aureus, carried benignly in the respiratory and genital tracts of perhaps one out of three people. Under certain conditions — a wound, some infections, the presence of a tampon or contraceptive sponge — the bacteria multiply. If the toxinproducing strain is present, such proliferation can lead to TSS. The symptoms are dramatic and develop quickly: high fever, a sunburn-like rash, severe vomiting and diarrhea, culminating in shock, in which blood pressure plummets and circulation deteriorates. Doctors usually try to head off this life-threatening conditions by administering intravenous -fluids with electrolytes, and sometimes drugs to restore blood pressure.

MacDonald speculates that the influenza virus can injure the throat or lungs in a way that favors the growth of S. aureus. Though the complication appears to be rare, it is urgent that doctors be aware of it, says TSS Expert Bruce Dan, in an editorial that accompanied MacDonald's paper. Early recognition and treatment of the syndrome "is the most important facto r in being able to prevent fatalities", says Dan. "It behooves all physicians to be on

the lookout for any influenza patient whose condition suddenly worsens".

IMMUNIZATION AGAINST CONTAGIOUS DISEASES

Contagious or infectious diseases undermine the child's health considerably, therefore all measures should be taken to protect the child against infections. Infectious diseases are caused by pathogenic bacteria or other microorganisms that multiply in the body and have a harmful effect on it. These organisms (germs and viruses) are capable of producing poisonous substances, or toxins, that poison the body. Having penetrated into the body the causative agents of a disease do not necessarily cause the disease; the body itself must be susceptible to this disease. Having had some infectious disease people do not usually get it again, or if they do they have it in a very mild form.

The state when the body resists or overcomes infection is called immunity. Immunity is a most complex phenomenon in which various protective reactions of the body participate. There exist both specific and non-specific factors' of resistance.

A well-planned schedule, proper diet, regular walks in the fresh air and inurement of the body to various environmental factors help to strengthen the body resistance to disease.

Prophylactic (preventive) inoculations are also very important for the prevention of infectious diseases. In the 18 t h centur y an English physician Edward Jenner discovered that milkers who were affected with cowpox developed blisters on their fingers and subsequently became immune to human pox — smallpox. In 1796 Jenner publicly inoculated an 8-year-old boy with cowpox, us ing the f luid fr om a blis ter on the f inger of a m ilk m ai d . Having been inoculated with cowpox the boy did not contract smallpox because inoculation with cowpox produced immunity to smallpox. Jenner's method Was called vaccination (from vaccinia, the Latin for cowpox).

The introduction into the body of a vaccine became known as preventive inoculation. Inoculation is done either under the skin, on its surface, or through the mouth or nose depending on the specific features of the vaccine. The site of inoculation usually reddens, swells and becomes tender. A slight elevation of temperature is sometimes noted, and some mild general malaise may be felt; however, these symptoms rapidly disappear and the person becomes immune to the disease. Being taken by mouth vaccines usually have no side effects at all.

Preventive inoculations are absolutely harmless and provide complete protection against infectious diseases.

Having been introduced into medical practice the vaccines created immunity against many diseases, including tuberculosis, smallpox, diphtheria, whooping cough, poliomyelitis, typhoid fever, dysentery, cholera, tetanus and typhus.

INFLUENZA VIRUS VACCINE FOR ALL AGES

Industrial production of inactivated split influenza virus vaccine, has been launched at the Mechnikov Research Institute of Vaccines and Sera in Ufa (Bashkiria).

All vaccines protecting the human organism against the invasion of viruses have a serious drawback: it is not safe to innoculate them, for the development of immunity, to people suffering from chronic ailments, and also to children, for this may entail undesirable complications. So it happens that those for whom flu is particularly pernicious remain practically defenceless in the fight with it. It is for them that the new vaccine is, meant. To explain its adva ntage in comparison with the existing preparations, it will be enough to decipher the notions "inactivated" and "split".

The first means that the virus in the vaccine has been killed. But that is not all. The destroyed pathogene has been split, with only those components isolated from it which are responsible for protection against flu. Due to this, the vaccine has become harmless, while the immunity it produces is no less stable than any other. For the first time it has become possible to vaccinate ch ildren beginning approximately from three-year-olds, and people susceptible to chronic diseases of the respiratory organs and the cardiovascular system.

A COMEBACK FOR WHOOPING COUGH

When she was 5 /2 months old, Traci Cohn of Rockville, Md., developed a 104 °F fever and cried inconsolably for three days.

Ever since that illness Traci, now 1 7 , has been mentally retarded. Her family and one of her doctors believe that the fever and subsequent mental damage were the direct result of the pertussis, or whooping cough inoculations that she received in the first months of her life.

Whooping cough, named for the distinctive sound made by its victims as they gasp for air between bouts of violent coughing, was until the 1940s a major killer of children. Caused by a bacterial infection that increases the amount of mucus in the lungs, the disease sometimes results in convulsions and death. Over the past four decades, however, pertussis has been largely subdued in developed nations by mass inoculations with a vaccine made from killed pertussis bacteria. Now doctors annually pump :some 18

million doses of the vaccine into U.S. children — usually in the form of a D.P.T . shot, so called because it also provides protection against diphtheria and tetanus. Some 40 states require children to have D.P.T. inoculations before they are allowed to enter school.

Despite these efforts, the Center for Disease Control in Atlanta reports that the incidence of whooping cough is increasing; the latest figures show that the number of U.S. cases has nearly doubled in the past three years, from 1895 in 1982 to 3275 in 1985. Meanwhile, health officials are concerned that more and more parents, aware. of cases like Traci's, will refuse to allow their youngsters to be inoculated.

Minor reactions to the vaccine, such as redness and swelling, are common. Permanent brain damage, according to one study, occurs only once in about every 300000 inoculations, death even less frequently. Researchers suspect that these severe complica - tions — which can include convulsions, shock, loss of muscle control and fever — are caused by bacterial toxins. Still, most doctors insist that the shots are worth the risks. Martin Smith, president of the American Academy of Pediatrics, calculates that the chances of suffering serious damage from whooping cough are ten times .greater than having damaging side effects from the vaccine. Says Dr. Peter Patriarca of the CDC's immunization division: "There is no question that the vaccine has more side effects than any other vaccine. But it's a matter of risk vs. benefits".

However, many parents of children stricken by the vaccine complain that they were unaware of the risk. "Doctors don't sit down with parents and talk about the vaccine", says Washington Attorney Jeff Schwartz, whose daughter Julie died of apparent vaccine-related seizures at age three. "It's shocking to us that this information is not routinely provided". In other nations, fear of the vaccine's potential dangers has had tragic resul ts. After two children died from side effects in 1974 and 1975, Japan banned use of pertussis vaccine for two months. Many parents were so alarmed that even after it was reinstated, they refused to inoculate their children. Between 1977 and 1979, as a resu lt, 28000 Japanese children contracted whooping cough, and 93 died. (By comparison, between 1972 and 1974 Japan reported only 1024 cases and 6 deaths.) In Britain, more than 100000 cases of pertussis and 36 . deaths occurred between 1977 and 1979, after re ports about side effects were broadcast on television. A similar epidemic struck in Sweden after the government decided to withdraw the vaccine. Says Swedish Pediatrician Patrick Olin, who is testing an alternative to the still banned shot: "The fact that we have no mass vaccination is the clear reason for the rapid increase".