Evidence Of Consolidation Research Articles

Enterococcus faecalis Causing Empyema in a Patient With Liver Disease

A 57-year-old man with a history of liver disease had shortness of breath, fever, and pleuritic chest pain. Ascites was not present. Computed tomography (CT) of the chest revealed a large unilateral pleural effusion, compressive atelectasis, and no evidence of consolidation. Culture of the pleural fluid grew Enterococcus faecalis. Treatment with ampicillin in conjunction with tube thoracostomy resulted in clinical improvement. This case illustrates the development of spontaneous monomicrobial empyema due to E. faecalis in a patient with liver disease, in the absence of pneumonia and peritonitis.

Enterococcus faecalis Causing Empyema in a Patient With Liver Disease

A 57-year-old man with a history of liver disease had shortness of breath, fever, and pleuritic chest pain. Ascites was not present. Computed tomography (CT) of the chest revealed a large unilateral pleural effusion, compressive atelectasis, and no evidence of consolidation. Culture of the pleural fluid grew Enterococcus faecalis. Treatment with ampicillin in conjunction with tube thoracostomy resulted in clinical improvement. This case illustrates the development of spontaneous monomicrobial empyema due to E. faecalis in a patient with liver disease, in the absence of pneumonia and peritonitis.

Lower respiratory tract infections associated with influenza A and B viruses in an area with a high prevalence of pediatric human immunodeficiency type 1 infection.

Despite the high burden of pediatric HIV-1 infection in developing countries, there are few data on the clinical course of influenza virus-associated lower respiratory tract infection (LRTI) in these children. To define and compare the clinical course of HIV-1-infected and -uninfected African children hospitalized with influenza virus associated severe LRTI. Children with severe LRTI were prospectively recruited between March, 1997, and March, 1999, as part of a broader study evaluating the etiology and outcome of this condition in hospitalized HIV-1-infected and -uninfected children. The results of children in whom influenza A or B virus was identified by immunofluorescent antibody staining after shell vial culture are reported. Viruses isolated were typed by hemagglutination inhibition assays. Twenty-five (21.6%) of the 116 children hospitalized with severe LRTI in whom influenza A or B virus was identified were HIV-1-infected. HIV-1-infected children were older than uninfected children (mean age +/- SD 17.4 +/- 10.8 months vs. 10.2 +/- 8.9 months; P = 0.002). HIV-1-infected children were more likely to have an underlying medical illness (in addition to HIV-1 infection) predisposing them to more severe LRTI (32.0% vs. 13.2%; P = 0.03). HIV-infected children were also more likely to have indirect evidence of bacterial coinfection, including chest radiographic evidence of confluent alveolar consolidation (78.9% vs. 35.1%, P = 0.006), and were less likely be wheezing (8.0% vs. 31.9%, P = 0.01). However, there was no difference in the clinical outcome of HIV-1-infected and -uninfected children. The duration of hospitalization [median (range) 5 (2 to 33) days vs. 4 (0 to 21) days, P = 0.08] and the mortality rates (8.0% vs. 2.2%, P = 0.20) were similar between HWV-1-infected and -uninfected children. HIV-1-infected children hospitalized with severe LRTI associated with influenza virus have an outcome similar to that of HIV-1-uninfected children even in the absence of antiretroviral or anti-influenza virus treatment.

Standard case management of pneumonia in hospitalized children in Uruguay, 1997 to 1998.

To report the results of the use of antimicrobial guidelines for the management of children with community-acquired bacterial pneumonia. Admittance and discharge criteria and algorithms for diagnosis and treatment were established. The decision to treat with antibiotics was based on radiologic findings in pneumonia with pulmonary consolidation and left to the attending physician's criteria in the remaining cases. The use of antibiotics was limited to penicillin and derivatives (ampicillin, amoxicillin) and macrolides. Of the 1163 children treated as bacterial pneumonia, hospitalized in public and private health facilities in Montevideo from September, 1997, through September, 1998, standard case management was applied in 1082 (93%). Age distribution was: <1 month, 1%; between 1 and 11 months, 29%; between 1 and 5 years, 50%; >5 years, 20%. Chest radiography showed evidence of pulmonary consolidation in 843 children (73%). Bacteria were detected in blood culture and/or pleural fluid of 57 children (5%). In 51 the identified microorganism was Streptococcus pneumoniae, susceptible to penicillin in 30, intermediate in 6 and resistant in 5 (maximum MIC, 4 microg/ml); in 10 cases etiologic diagnosis was made by antigen detection. Empyema was present in 62 children (5.3%); 38 (3.27%) required treatment in an intensive care unit; and 5 (0.4%) died. Compliance with standard case management was highly satisfactory. Outcome of children treated with penicillin and derivatives was good, including children with empyema and pneumatocele and two patients with penicillin-resistant S. pneumoniae. At the present time S. pneumoniae resistant to penicillin is not an important problem in children with pneumonia in Uruguay. Surveillance of identified microorganisms and their antimicrobial susceptibility must continue.

Central Lung Tumors with Obstructive Pneumonitis:Ultrasonographic Findings and Usefulness of Ultrasound-guided Biopsy

Purpose: To determine the ultrasonographic findings and assess the usefulness of ultrasound (US)-guided biopsy of central lung tumors in patients with obstructive pneumonitis. Materials and Methods: Fourteen patients with central lung tumors causing obstructive pneumonitis, as seen on chest radiographs and chest CT scans, were examined between January 1997 and January 2000. In no patient conclusive histologic diagnosis obtained by means of bronchoscopic biopsy or sputum cytology. Eleven patients were men and three were women, and their ages ranged from 45 to 83 (mean, 64) years. For all examinations, real-time, linear-array, convex US units with a 3.75- and a 5.0-MHz transducer were used. The images obtained were analyzed for evidence of consolidation or atelectasis in the lung, demonstrable tumors, and tumor size and echogenicity. For US-guided percutaneous transthoracic biopsy, 19.5G automatic biopsy devices, were employed. Results: Lung consolidation due to a wedge-shaped, homogeneous, hypoechoic lesion was revealed by sonographic fluid bronchograms, air bronchograms, air alveolograms, and visualization of intraparenchymal pulmonary vessels, which showed appropriate motion with respiration. The tumor presumed to be causing obstruction was seen as a hypoechoic nodule near the hilum or as a well-defined hyperechoic mass inside the partially consolidated lung. Pleural effusion was observed in one case. The cytologic findings indicated the presence of squamous cell carcinoma (n=4), adenocarcinoma (n=4), small cell carcinoma (n=3), non-small cell carcinoma (n=2) and large cell carcinoma (n=1). The success rate was 100%, and there were no complications. Conclusion: In patients with central lung tumors causing obstructive pneumonitis, chest ultrasonography and US-guided biopsy are useful adjunctive diagnostic modalities and techniques.

Determining the optimal time for consolidation after distraction osteogenesis.

The consolidation period, one of the biological factors participating in the distraction osteogenesis phenomenon, has not been elucidated. Parameters to assess new bone formation and consolidation in craniofacial distraction have been borrowed from the orthopedic experience. Up until now, the decision to discontinue distraction has been based more on personal experience than on objective data. By using Scintigraphy with Tc99 DP a method has been developed to accurately assess the termination of the consolidation phase. Scintigraphic evidence of consolidation was seen between the fourth and the fifth week after terminating distraction in infants (younger than 12 months). Not before the 10th week in children and between the 10th and the 14th week in adolescents and adults. The data roughly correlates with previous reports. It is believed that the consolidation period should be addressed in biologic terms and not in radiologic terms as done up until now. A method is proposed that offers objective qualitative and quantitative data for the noninvasive evaluation of bone consolidation which could have further applications in distraction of the craniofacial skeleton.

Defining the burden of pneumonia in children preventable by vaccination against Haemophilus influenzae type b.

To determine the burden of pneumonia requiring hospitalization in infants and young children preventable by vaccination against Haemophilus influenzae type b (Hib). Vaccination centers in Santiago, Chile, were randomly selected to administer PRP-T, an Hib conjugate vaccine, combined with diphtheria-tetanus toxoids-pertussis (DTP) vaccine or DTP alone. Infants who received > or =2 doses of DTP or DTP and Hib conjugate vaccine combined. Pneumonia episodes leading to hospitalization accompanied by indicators of likely bacterial infection including radiologic evidence of alveolar consolidation or pleural effusion, an elevated erythrocyte sedimentation rate (> or =40 mm/h) or bronchial breath sounds on auscultation. In participants age 4 to 23 months, PRP-T reduced the incidence of pneumonia associated with alveolar consolidation or pleural effusion by 22% (95% confidence interval, -7 to 43) from 5.0 to 3.9 episodes per 1000 children per year. When the pneumonia case definition included any of the following, alveolar consolidation, pleural effusion, erythrocyte sedimentation rate > or =40 mm/h or bronchial breath sounds, PRP-T provided 26% protection (95% confidence interval, 7 to 44) and prevented 2.5 episodes per 1000 children per year. Hib vaccine provides substantial protection against nonbacteremic pneumonia, particularly those cases with alveolar consolidation, pleural effusion or other signs of likely bacterial infection. Hib vaccination prevented approximately 5 times as many nonbacteremic pneumonia cases in infants as meningitis cases, thus indicating that the largest part of the effect of Hib vaccination might be undetectable by routine culture methods.

Managed Care, Consolidation among Health Care Providers, and Health Care: Evidence from Mammography

We discuss the effects of managed care on the structure of the health care delivery system, focusing on managed-care-induced consolidation among health care providers. We empirically investigate the relationship between HMO market share and mammography providers. We find evidence of consolidation: increases in HMO activity are associated with reductions in the number of mammography providers and with increases in the number of services produced by remaining providers. We also find that increases in HMO market share are associated with reductions in costs for mammography and with increases in waiting times for appointments, but not with worse health outcomes.

EPIDEMIOLOGY OF ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS

Shortly after Hinson et al proposed the term allergic bronchopulmonary aspergillosis (ABPA) in 1952, 23 Pepys et al at the Brompton Hospital, London, discovered several immunoserological features that confirmed the designation of allergy. 30,31 The initial proposal was based on only three patients: two women ages 45 and 55 years and a 37-year-old man. Their criteria for the diagnosis of ABPA were as follows: recurrent fever, radiologic evidence of recurrent collapse and consolidation in different areas; sputum containing plugs from which fungi could be cultured (all three had Aspergillus fumigatus ); and a blood eosinophilia of 1000/mm 3 . Interestingly, neither asthma nor bronchiectasis were considered diagnostic criteria, although each patient had evidence of asthma, and two had definite saccular bronchiectasis whose location, central or peripheral, was not emphasized. Hinson et al thought sensitization to the fungus was the pathogenic mechanism because of the eosinophilia, character of the sputum, and absence of significant fungal invasion in histologic examinations of biopsy and necropsy material. They attributed inconclusive results of skin tests to Aspergillus extracts in two of the patients and controls to the quality of the extracts. It remained for the Pepys group to develop fungal extracts that produced immediate and delayed skin tests and serum precipitating antibodies that showed clinical correlation. By 1971, they had published a series of 111 cases diagnosed as ABPA and proposed the immunopathogenic mechanism of a combination of IgE-mediated (Gell and Coombs Type I) and immune complex-mediated (Type III) factors. 30 Bronchiectasis of a central or proximal distribution was considered a complication of recurring local bronchial plugging and resultant immunologic inflammation. For the first 16 years after the initial report, it was believed to be a disease limited to the United Kingdom. Eventually, reports first by Patterson and Golbert 41 and then by Slavin et al 51 conceded it was present in North America but only as a rarity. By 1973, however, ABPA was termed no longer rare in the United States, 24 probably because of the more widespread application of potent Aspergillus extracts in both in vivo and in vitro tests and heightened awareness; the diagnosis was being reported worldwide. 43 The true prevalence of ABPA remains highly speculative: ABPA is not recognized in the international classification of diseases (including the ninth revision of 1996) and the diagnostic criteria lack clinical uniformity and standardized tests. Thus epidemiologic conclusions will be based on circuitous reasoning. In this article, an attempt is made to approach its prevalence by several routes. Statistical and epidemiological aspects of related or associated diseases such as asthma, cystic fibrosis, bronchiectasis, pulmonary eosinophilia, and aspergillosis are invoked. Sensitization rates to Aspergillus antigens are also assessed. Finally, we discuss whether ABPA represents a condition recently born or recently discovered.

The Evolution of Best-in-Class Pharmacy Management Techniques

The health care industry is becoming increasingly integrated and regional in focus as the market responds to consumer and governmental pressure to continually. reduce the cost of care. In an effort to drive administrative economies of scale, payors and providers-and even distributors and manufacturers-of health care services are consolidating to gain efficiencies, reduce costs, and enhance their access to capital (see Figure 1). The consolidation trend among health plans hasn't been limited to publicly traded, for-profit players. The Blue Cross and Blue Shield (BCBS) system also has shown evidence of substantial consolidation, resulting in a decrease in the total number of BCBS plans from 86 plans in 1985 to the 56 plans licensed in 1998. Nearly a third of these recent mergers were transactions that crossed state boundaries. In addition to efforts to gain administrative efficiencies from consolidation, health plans also are attempting to control medical costs by working more closely with network providers. Most health plans have developed innovative programs to

Short- and long-term neurological outcomes following neonatal chest physiotherapy.

To test the hypothesis that chest physiotherapy in extremely premature infants is associated with abnormal neurological outcomes. All babies born during the years 1992-1994 at gestations of 24-29 weeks who survived to 28 days were included in the study cohort (n=213). Chest physiotherapy was provided by trained physiotherapists for babies with secretions causing obstruction to the airway or for babies with evidence of collapse and/or consolidation. The relationship between chest physiotherapy and cystic brain lesions at discharge, or cerebral palsy (CP) and developmental quotient (DQ) at 1 year corrected age, were then explored. Ninety-seven babies (45% of the cohort) received physiotherapy. No baby had a brain lesion similar to that described as encephaloclastic porencephaly. Babies receiving physiotherapy had significantly lower birthweights and gestational ages. Of the 13 babies found to have either periventricular leucomalacia or porencephalic cysts, seven (7%) were in the physiotherapy group, and six (5%) were in the nonphysiotherapy group. Of the babies surviving to 1 year corrected age, 189 (92%) had multidisciplinary follow-up. Eleven (13%) of the babies who received physiotherapy had suspected CP, and 14 (13%) of those not receiving physiotherapy had CP. The DQ of those who received physiotherapy was 96.0+/-16.6, and 101.6+/-16.6 for those who did not. Following adjustment for gestational age and other unequal risk factors using logistic regression, none of the above outcomes was significantly associated with the number of physiotherapy treatments. We could find no evidence that chest physiotherapy, as given in our unit, was associated with abnormal neurological outcomes in extremely preterm infants.

The Incidence of Respiratory Tract Infection in Adults Requiring Hospitalization for Asthma

Acute respiratory tract infections (RTI) are known to worsen asthma particularly in children. There are few studies in adults assessing the incidence of RTI in patients hospitalized with acute asthma.AimTo document the incidence of RTI in adults hospitalized with acute asthma.MethodsA prospective study of patients with acute asthma admitted to the Department of Respiratory Medicine, Western Hospital Footscray, over a 12-month period. A control group was studied from elective surgical inpatients. Patients were investigated with serologic tests for Chlamydia, Mycoplasma, Legionella, and influenza A and R. Nasopharyngeal aspirate (NPA) samples were cultured for influenza, respiratory syncytial virus (RSV), adenovirus, parainfluenza, rhinovirus, and herpes simplex virus. If sputum was available, it was assessed with microscopy and culture. Rlood cultures were taken if patients were febrile and all patients had a chest radiograph. Control subjects completed serologic tests and NPA.ResultsSeventy-nine patients (33 male and 46 female) and 54 control subjects (26 male and 28 female) were studied. Two patients were enrolled twice. Mean (±SD) age of patients was 35 ±15 years (range, 16 to 66 years), and mean age of control subjects was 37±15 years (range, 18 to 69 years). In the patient group, 29 (37%) had evidence of recent RTI of which 23 were viral. Five of the control subjects (9%) had evidence of recent RTI (p<0.001). Twenty-four patients were positive on serologic and/or NPA culture. Five patients had positive serologic test results and/or NPA culture to two or more agents. Two patients tested positive on sputum, radiograph, and temperature criteria. Three patients tested positive on the basis of radiographic evidence of consolidation, blood neutrophilia, and temperature. Influenza A (13) and rhinovirus (9) were the most common infectious agents. Other agents identified were RSV (one), influenza R (two), adenovirus (one), and Mycoplasma (one). Influenza and rhinovirus infections occurred predominantly in late and early winter, respectively. Summer hospitalization did not relate to RTI.ConclusionThirty-seven percent of adult patients with acute asthma admitted to the Department of Respiratory Medicine over a 12-month period had evidence of recent RTI.

Acute hemorrhagic pulmonary infarction and necrotizing pneumonia in horses: 21 cases (1967-1993)

Objective— To characterize history, clinical signs, and pathologic findings in horses with histologically confirmed acute hemorrhagic pulmonary infarction and necrotizing pneumonia. Design— Retrospective study. Animals— 21 horses. Results— 19 of the 21 horses were Thoroughbred racehorses in training. Eighteen horses had had strenuous exercise immediately prior to onset of illness. Fifteen horses had a serosanguineous nasal discharge during hospitalization. Seventeen horses had radiographic evidence of pulmonary consolidation and pleural effusion. Nine of 14 horses had ultrasonographic evidence of large pulmonary parenchymal defects consistent with consolidation. Pleurocentesis yielded a suppurative, serosanguineous effusion in the 14 horses in which it was performed. Bacteria were isolated from all transtracheal aspirates (14) and from 6 of 12 pleural fluid samples. Actinobacillus suis-like organisms and Streptococcus equi subsp zooepidemicus were most commonly isolated. Nineteen horses were hospitalized and treated, Mean duration of treatment was 5 days, and most horses were euthanatized because of secondary complications, continued costs of medical treatment, or poor prognosis for future performance. Pathologic lesions included well-demarcated regions of hemorrhagic pulmonary infarction with necrosis and a serosanguineous pleural effusion. Thrombosis of pulmonary vessels was found in 11 horses. Clinical Implications— An acute or peracute onset of severe respiratory distress, with serosanguineous nasal discharge, ultrasonographic and radiographic evidence of severe pulmonary consolidation, and serosanguineous suppurative pleural effusion, is strongly suggestive of pulmonary infarction in horses. Horses with pulmonary infarction responded poorly to conventional treatment for pleuropneumonia and had a poor prognosis for recovery. (J Am Vet Med Assoc 1997;210:1774–1778)

Gender Differences in the Class of 1989 Study: The School Component of the Minnesota Heart Health Program

Abstract The Class of 1989 Study is part of the Minnesota Heart Health Program (MHHP). Beginning in sixth grade (1983), seven annual waves of measurements were taken from students in one of the MHHP intervention communities and its matched pair (baseline n = 2,376). Self-reported data were collected at each time period describing a variety of health-related behaviors, including smoking, physical activity, and food preferences. With regard to the intervention hypotheses, significant positive differences between genders were observed on the physical activity and food preference variables. Significant gender by treatment interactions were observed on five of six follow-up periods for food preferences. The effects of the intervention on smoking by gender were less apparent. The results from the tracking analysis indicate there is evidence of early consolidation and tracking of physical activity, food preference, and smoking behaviors, but these results did not differ greatly by gender. These data suggest that...

Longitudinal tracking of adolescent smoking, physical activity, and food choice behaviors.

A major assumption underlying youth health promotion has been that physiological risk factors track from childhood into adulthood. However, few studies have systematically examined how behaviors change during adolescence. This paper describes longitudinal tracking of adolescent health behaviors in two Minnesota Heart Health Program communities. Beginning in sixth grade (1983), seven annual waves of behavioral measurements were taken from both communities (baseline n = 2376). Self-reported data included smoking behavior, physical activity, and food preferences. A progressive increase in the change to weekly smoking status was observed across the smoking status categories. As students began to experiment with smoking, they were more likely to either begin to be or remain regular smokers. Tracking of physical activity and food choice variables was also apparent. In nearly all the follow-up periods, the students identified at baseline as measuring high remained high, and those measuring low remained low. These results indicate that there is evidence of early consolidation and tracking of physical activity, food preference, and smoking behavior. The early consolidation of health behaviors implies that interventions should begin prior to sixth grade, before behavioral patterns are resistant to change. The smoking results suggest that students are experiencing difficulty quitting smoking; thus, youth smoking cessation interventions are warranted.

Diagnosis of pulmonary complications associated with lung transplantation in children: value of CT vs histopathologic studies.

The purpose of this study was to compare the CT findings with those of histopathologic studies to determine if CT can be used to differentiate between the pulmonary parenchymal complications that occur in children after lung transplantation. Seventeen children who underwent 14 bilateral and three single lung transplantations were studied. The study population included nine girls and eight boys 2-16 years old (mean, 11 years). CT scans were examined for evidence of interlobular septal thickening, air-space consolidation, ground-glass opacities, nodules, bronchial dilatation, decreased vascularity, and pleural effusions. Thirty-one histopathologic diagnoses from 25 transbronchial biopsies were available for comparison with CT findings. The final histopathologic diagnoses were acute rejection (n = 10), chronic rejection (n = 6), infection (n = 7), nonspecific findings (n = 4), and no abnormalities (n = 4). No significant difference was noted in the CT findings in patients with acute rejection, chronic rejection, and infection. In this limited study of children, CT findings were not helpful in differentiating between the different parenchymal pulmonary complications associated with lung transplantation. On the basis of these preliminary findings, we recommend caution in suggesting specific diagnoses based on CT scans without histologic proof.

Postoperative complications and prognostic indicators in dogs and cats with septic peritonitis: 23 cases (1989–1992)

Summary Medical records of 21 dogs and 2 cats treated for septic peritonitis were reviewed. Animals were between 1 and 12 years old, (mean, 6.5 years) and weighed between 6 and 51.4 kg (mean, 22.7 kg). Overall, 13 animals survived and were discharged from the hospital. Immediately after surgical correction of the underlying cause of peritonitis, most animals were tachycardic (mean heart rate, 148 beats/min; range, 80 to 204 beats/min), and many were hypotensive (mean arterial pressure, 84.4 mm of Hg; range, 44 to 156 mm of Hg). Hypotension was attributed to sepsis and hypovolemia secondary to extensive loss of fluid into the peritoneal cavity. Survivors did not differ from nonsurvivors with regard to mean arterial pressure immediately after surgery, and in most animals, hypotension could be corrected by iv administration of fluids. Three animals died after failing to respond to fluid treatment, despite concurrent administration of inotropic or pressor agents. Mean rate for crystalloid fluid administration was 12.8 ml/kg of body weight/h (range, 5 to 23.5 ml/kg/h) during the first 24 hours after surgery. Six of 23 animals had low urine output for a short time after surgery, but urine output increased when fluids were administered. Hypoalbuminemia developed in all animals (mean serum albumin concentration, 1.17 g/dl; range, 0.6 to 2.3 g/dl), and peripheral edema developed in 13. Neither lowest mean serum albumin concentration nor fluid administration rate was significantly different between animals that developed peripheral edema and those that did not. Fluid administration rates were significantly higher in nonsurvivors (15 ml/kg/h; range, 5.5 to 23.5 ml/kg/h) than in survivors (11 ml/kg/h; range, 5 to 17.5 ml/kg/h). Thirteen animals had evidence of pulmonary alveolar consolidation, and 9 had pleural effusions; however, fluid administration rates were not significantly different between animals that did and those that did not develop clinical respiratory disease. Eleven animals had pancreatitis at the time of surgery, or developed pancreatitis subsequently. Four animals developed disseminated intravascular coagulation, and only 1 survived. Indicators of a poor prognosis included refractory hypotension, cardiovascular collapse, and development of respiratory disease or disseminated intravascular coagulation. Development of pancreatitis, high serum concentrations of hepatic enzymes, high or low wbc count, hypo- or hyperglycemia, signs of abdominal pain, and abdominal effusion were not associated with outcome.

Importance of clinical staging in limited small-cell lung cancer: a valuable system to separate prognostic subgroups. The University of Toronto Lung Oncology Group.

In an attempt to assess the response to treatment and survival of a group of patients treated with standard chemotherapy and radiotherapy, we undertook a retrospective review of small-cell lung cancer (SCLC) patients treated by the University of Toronto Lung Oncology Group. We reviewed the records of 264 patients with limited SCLC who were treated from 1976 to 1985. Based on radiologic review and physical examination, patients were assigned to three prognostic groups: group 1 (very limited SCLC), negative mediastinoscopy and/or no evidence of mediastinal nodes on radiologic review; group 2, x-ray evidence of mediastinal node involvement or a positive mediastinoscopy; group 3, supraclavicular adenopathy or x-ray evidence of pneumonic consolidation, pleural effusion, or atelectasis. All patients received combination chemotherapy, radiotherapy to the primary site, and prophylactic cranial irradiation. Complete response was seen in 52% of patients and partial response in 29%. Response rates did not differ among the three prognostic subgroups. The median survival time for patients in group 1 was 15.7 months, compared with 12 months for group 2 and 11 months for group 3 (P = .0175). Projected 5-year survival for group 1 was 18%, compared with only 6% and 2% for groups 2 and 3, respectively. There was no difference among the prognostic subgroups with respect to either local or distant recurrence rates. Using simple clinical staging techniques, we were able to identify a subgroup of patients with very limited SCLC who had a significantly better prognosis. We recommend that randomized clinical trials stratify patients according to the presence or absence of clinically detectable mediastinal lymphadenopathy.

Blastomycosis in Africa: Clinical Features, Diagnosis, and Treatment

Four cases of blastomycosis seen in two acute care hospitals in Harare, Zimbabwe, are described. All patients had symptoms of at least 2 months' duration before presentation, and all had radiographic evidence of pulmonary consolidation. Three patients had confirmed bone involvement, and two had chronic discharging sinuses. The features of blastomycosis in Africa are reviewed, and problems of diagnosis and treatment are discussed. It is concluded that blastomycosis in Africa may often be misdiagnosed as tuberculosis or pyogenic infection in the absence of adequate facilities for mycologic investigation.

Pathogenesis and Chemotherapy of Experimental Legionella pneumophila Infection in the Chick Embryo

The pathogenicity of Legionella pneumophila, serogroup 1, strain Nottingham N7, was assessed in terms of LD50 data and the ability of the organism to induce pathological lesions in the fertile hen's egg. Histopathological examination of embryo organs after inoculation with 1, 10, 100 and 1000 times the yolk sac LD50 revealed a disseminated infection. Systemic spread of the organism resulted in widespread necrosis and evidence of consolidation together with generation of copious amounts of oedema fluid. These were particularly severe in the liver, heart, spleen and kidney. The infection elicited a massive inflammatory response typified by infiltration with polymorphonuclear leucocytes and lymphocytes. Selected antimicrobial chemotherapeutic agents were investigated in protection studies for their capacity to ameliorate or control disease processes in this test system. Of those examined ciprofloxacin was most effective in reducing the incidence of lesions in these tissues and for prolonging embryo viability. Rifampicin, and to a lesser degree, erythromycin and doxycycline, also showed antimicrobial activity in these in vivo trials. These results indicate that the fertile hen's egg may be a useful alternative to other animal systems for the in vivo testing of clinically putative antimicrobial agents in the treatment of Legionnaires' disease.