Sun Nov 01, 1998 12:41:06 PM pelo:hello
Sun Nov 01, 1998 12:41:50 PM Julius:hola pelo
Sun Nov 01, 1998 12:42:01 PM Julius:hola willy
Sun Nov 01, 1998 12:42:20 PM Julius:what is up today
Sun Nov 01, 1998 12:42:38 PM willy:Hello everybody
Sun Nov 01, 1998 12:42:54 PM pelo:hola willy
Sun Nov 01, 1998 12:43:15 PM Julius:willy remind us who you are and from where
Sun Nov 01, 1998 12:43:20 PM willy:Hola Pelo , where are you from
Sun Nov 01, 1998 12:43:32 PM Julius:I am Julius Edlavitch MD from Minneapolis
Minnesota
Sun Nov 01, 1998 12:43:42 PM willy:Guillermo Jose Acion, Pediatrician, Buenos Aires,
Argentina
Sun Nov 01, 1998 12:44:09 PM pelo:I am Juan Francisco Cabello, medical student (only
for 5 weeks more) from Chile
Sun Nov 01, 1998 12:44:11 PM Julius:Harty's friend
Sun Nov 01, 1998 12:44:33 PM Julius:I understand Harty was in Chile but he didn't call
PELO :(
Sun Nov 01, 1998 12:44:45 PM pelo:really??????
Sun Nov 01, 1998 12:44:58 PM pelo:when and where? do you know???
Sun Nov 01, 1998 12:45:11 PM willy:Julius, again, I am lost I think I am late or the tour
doesn 't start yet, what time is it there
Sun Nov 01, 1998 12:45:53 PM Julius:it is 1:50 ny time so we have about 10 minutes
before it starts actually 15 minutes
Sun Nov 01, 1998 12:46:31 PM pelo:In Viña del Mar: 15:50
Sun Nov 01, 1998 12:47:00 PM Julius:that is 3:50 PM
Sun Nov 01, 1998 12:47:05 PM pelo:(On?) I don't know the correct phrase
Sun Nov 01, 1998 12:47:17 PM willy:Ok, here it is 3:50 PM
Sun Nov 01, 1998 12:47:31 PM pelo:At?
Sun Nov 01, 1998 12:47:55 PM willy:In Buenos Aires, we are vecinos
Sun Nov 01, 1998 12:48:16 PM pelo:Very beautiful city
Sun Nov 01, 1998 12:48:43 PM Julius:QUE PASA Vecinos
Sun Nov 01, 1998 12:48:47 PM willy:Pelo, I have been in Viña del Mar in 1992,
wonderful city, very nice, the Pacific, people,
Sun Nov 01, 1998 12:49:13 PM Julius:I can not wait to visit all of you there someday
Sun Nov 01, 1998 12:49:19 PM pelo:nd me in B.Aires in 1994
Sun Nov 01, 1998 12:49:38 PM pelo:when you want Julius
Sun Nov 01, 1998 12:49:46 PM Julius:someday
Sun Nov 01, 1998 12:50:24 PM willy:Julius you have my door open when ever you
want, I live in a town 20 Kilometers from the city of Buenos Aires, it is called
QUILMES
Sun Nov 01, 1998 12:50:27 PM Julius:i hope some more people show up today
Sun Nov 01, 1998 12:50:42 PM Julius:When the speaker comes please introduce
yourself
Sun Nov 01, 1998 12:50:53 PM pelo:beautiful picture in AAP meeting
Sun Nov 01, 1998 12:51:07 PM Julius:thanks i wil have a lot more soon
Sun Nov 01, 1998 12:51:39 PM Julius:i sure hope the speaker comes today
Sun Nov 01, 1998 12:51:51 PM pelo:I hope too
Sun Nov 01, 1998 12:51:52 PM willy:Is there any way to record our introductions from
this web tour, like we use to do in Mirc
Sun Nov 01, 1998 12:52:13 PM Julius:you meant to log the session
Sun Nov 01, 1998 12:52:30 PM pelo:I don't know
Sun Nov 01, 1998 12:52:49 PM willy:To avoid writing everytime our personal dates
Sun Nov 01, 1998 12:52:57 PM Julius:i log al the sessions but have not had time to post
them yet
Sun Nov 01, 1998 12:53:10 PM Julius:i see what you mean
Sun Nov 01, 1998 12:53:37 PM Julius:you can write it in advance and copy it to the clip
board and then paste it often
Sun Nov 01, 1998 12:54:22 PM willy:So meanwhile we write our introductions
everytime you tell us to introduce . I understand, the clipboard
Sun Nov 01, 1998 12:56:10 PM Julius:hi gulnir welcome
Sun Nov 01, 1998 12:56:22 PM Julius:have you heard about the research job yet\
Sun Nov 01, 1998 12:57:11 PM Julius:any one still there
Sun Nov 01, 1998 12:57:32 PM Julius:I hope dr Brown figures out how to come here
Sun Nov 01, 1998 12:58:30 PM Julius:hi tome welcome
Sun Nov 01, 1998 12:58:59 PM tball:hi here we are--Tom aBall and Mark Brown
Sun Nov 01, 1998 12:59:07 PM Julius:welcome back willy form buenos ares
Sun Nov 01, 1998 12:59:12 PM mabrown:Hello!  A bit late but here.
Sun Nov 01, 1998 12:59:23 PM Julius:Welcome Tom and Mark
Sun Nov 01, 1998 12:59:52 PM Julius:I am Julius Edlavitch MD from Minneapolis
Minnesota USA
Sun Nov 01, 1998 01:00:19 PM mabrown:I am Mark Brown, one of the Pediatric
Pulonologists at the University of Arizona.
Sun Nov 01, 1998 01:00:29 PM pelo:I am Juan Francisco Cabello, medical student from
Viña del Mar, Chile
Sun Nov 01, 1998 01:00:30 PM Julius:Welcome Mark
Sun Nov 01, 1998 01:00:50 PM Julius:I understand You have a very famous pulmonary
Dept at tucson
Sun Nov 01, 1998 01:00:55 PM Phil:Hi, I'm Phil Monteleone from Springfield, Mass.
Sun Nov 01, 1998 01:01:10 PM willy:Thank you Julius
Sun Nov 01, 1998 01:01:27 PM Julius:welcome phil
Sun Nov 01, 1998 01:01:39 PM Julius:Willy introduce yourself
Sun Nov 01, 1998 01:01:46 PM Phil:Hi Julius
Sun Nov 01, 1998 01:02:12 PM Julius:Vlady has you one the schedule for microcytic
anemias
Sun Nov 01, 1998 01:02:28 PM mabrown:We have been fortunate to have a number of
distinguished faculty in our section.  We also have quite a few international research
fellows, bringing us ideas from around the world.
Sun Nov 01, 1998 01:02:29 PM Phil:I know, now I just have to get the slides together
Sun Nov 01, 1998 01:02:42 PM willy:Guillermo Jose Acion, Pediatrician , Buenos Aires
Sun Nov 01, 1998 01:03:08 PM Julius:I think it is so interesting that u of Arizona in
Tucson has such an international diversity
Sun Nov 01, 1998 01:03:19 PM Julius:Welcome denis form Croatia
Sun Nov 01, 1998 01:03:36 PM Julius:Before we start let me remind anyone who wants
to attend
Sun Nov 01, 1998 01:04:03 PM tball:Julius, I will let you decide when we should get
going.
Sun Nov 01, 1998 01:04:07 PM Julius:on wednesday of this week at 10 am ny time we
will discuss the health concerns facing the children in kosovo
Sun Nov 01, 1998 01:04:18 PM Julius:one more minute
Sun Nov 01, 1998 01:04:29 PM dvulic:Hi Julius. Regards  to all
Sun Nov 01, 1998 01:04:50 PM Julius:Tino Please introduce yourself
Sun Nov 01, 1998 01:04:52 PM tball:I am Tom Ball, a member of the General Pediatric
Dept at the Univ of Arizona, Tucson, USA
Sun Nov 01, 1998 01:05:28 PM Julius:Did everyone see the slide change
Sun Nov 01, 1998 01:05:50 PM Tino:Hi everyone
Sun Nov 01, 1998 01:05:52 PM mabrown:Yes.
Sun Nov 01, 1998 01:05:53 PM Phil:Yup
Sun Nov 01, 1998 01:06:02 PM willy:Yes
Sun Nov 01, 1998 01:06:05 PM Julius:GULNUR PLEASE INTRODUCE YOURSELF
Sun Nov 01, 1998 01:06:31 PM GUL:hello..Dr.Gulnur from Turkey.:)
Sun Nov 01, 1998 01:06:33 PM Julius:ANDREI please introduce yourself
Sun Nov 01, 1998 01:06:59 PM Julius:Ok i think we should begin and i will post the
first slide
Sun Nov 01, 1998 01:07:11 PM Tino:Florentino De La Cruz, pediatrician and
perinatology from Barranquilla, Colombia
Sun Nov 01, 1998 01:07:12 PM Julius:let me know if you see the slide change PLEASE
Sun Nov 01, 1998 01:07:34 PM Tino:Yes, Julius.
Sun Nov 01, 1998 01:07:45 PM Phil:Looks great
Sun Nov 01, 1998 01:07:46 PM tball:yes, Julius
Sun Nov 01, 1998 01:08:01 PM willy:Yes
Sun Nov 01, 1998 01:08:02 PM Julius:looks like bronchiolitis patient to me but could
be chlamydia
Sun Nov 01, 1998 01:08:22 PM mabrown:A typical presentation of an infant with
bronchiolitis .
Sun Nov 01, 1998 01:08:26 PM Andrei:Andrei Zamfirescu, Bucharest, Romania. Hello
to you all!.
Sun Nov 01, 1998 01:08:36 PM miki:hi everybody
Sun Nov 01, 1998 01:08:38 PM tball:Julius--please move to next slide
Sun Nov 01, 1998 01:09:23 PM mabrown:I think it is important to remember that
bronchiolitis is a broad descriptor, referring not just to infectious causes.
Sun Nov 01, 1998 01:09:34 PM miki:miki arbel from phoenix AZ
Sun Nov 01, 1998 01:10:08 PM Julius:tom the user button on the bottom bar you should
click and it will show
Sun Nov 01, 1998 01:10:12 PM paula:hi everyone I am Paula Otero, from Argentina
Sun Nov 01, 1998 01:10:13 PM mabrown:Some risk factors can be avoided, others not.
Breast feeding, even for a brief period of time conveys some protection.
Sun Nov 01, 1998 01:10:38 PM Julius:how does breast feeeding inpart protection
Sun Nov 01, 1998 01:11:00 PM Robert Shayne:bob shayne, Richmond, VA
Sun Nov 01, 1998 01:11:02 PM mabrown:In some cultures the use of wood for cooking
or heating can also substantially increase the risk of more severe disease.
Sun Nov 01, 1998 01:11:15 PM Julius:welcome robert
Sun Nov 01, 1998 01:11:39 PM Julius:in minnesota a  lot of people have indoor wood
heaters to save money
Sun Nov 01, 1998 01:11:54 PM Andrei:Is there a relation between parents asthma and
bronchilitis in the infant? Asrham is a chronic disease, bronchiolitis is an acute one.
Sun Nov 01, 1998 01:12:05 PM tball:Hve people from other countries noticed risk
factors specific to their lifestyle?
Sun Nov 01, 1998 01:12:14 PM mabrown:It is not entirely clear how breast feeding does
this.  There is likely a transfer of immunoglobulin, but there may also be growth factors
or immune modulators transfered to the infant in breast milk which may modulate
susceptibility or immune resonse.
Sun Nov 01, 1998 01:12:51 PM Julius:is this verufied with a study
Sun Nov 01, 1998 01:13:04 PM Julius:how about andrei's question
Sun Nov 01, 1998 01:13:36 PM Julius:are there facors specific to romania or turkey or
chile or argentina
Sun Nov 01, 1998 01:13:47 PM mabrown:Infants from families with asthma do have
higher risk.  This may be an increase in the manifestations of the disease and not so
much an increased susceptibility to infection with RSV, paraflu, etc.
Sun Nov 01, 1998 01:14:15 PM Andrei:The same risk factors here in ROmania
Sun Nov 01, 1998 01:14:25 PM paula:In Argentina most of bronchiolitis are due to RSV
Sun Nov 01, 1998 01:14:48 PM Phil:does the reverse hold true- are infants with
bronchiolitis more likely to develop asthma later?
Sun Nov 01, 1998 01:14:49 PM Andrei:and RSV in etiology
Sun Nov 01, 1998 01:14:53 PM GUL:nothing different in Turkey.infections...
Sun Nov 01, 1998 01:15:00 PM mabrown:Another important concept is that typical
bronchiolitis is a polymicrobial disease as illustrated by the above numbers.  RSV is,
though, the major pathogen.  At least one study has implicated pertussis as well.
Sun Nov 01, 1998 01:15:11 PM pelo:in Chile the same
Sun Nov 01, 1998 01:16:00 PM tball:It is interexting to note that virtually all chldren
show serological evidence fo infection with RSV by 3 years of age--so why do some
have colds and others bad lung disease?
Sun Nov 01, 1998 01:16:29 PM Andrei:I knew that  the risk for asthma in children with
bronchiolitis is the same as in the normal population
Sun Nov 01, 1998 01:17:08 PM Julius:when should one look for somthing other than
bronchiolitis
Sun Nov 01, 1998 01:17:15 PM mabrown:The pathophysiology is related to small
airway obstruction. Previous exposure to airborne irritants, such as cigarette or wood
smoke, can lead to the children starting at a smaller airway luminal size than others,
thus increasing their chances of having more trouble.
Sun Nov 01, 1998 01:17:56 PM Julius:fighting the cigarete smoke battle is not an easy
one for peds docs
Sun Nov 01, 1998 01:18:12 PM mabrown:If there is no evidence of concommitant URI,
a monophonic (rather than polyphonic) wheeze should prompt consideration of a
foreign body.
Sun Nov 01, 1998 01:18:43 PM Andrei:The smooth muscle is  responsible for the
obstructuion in small infants?
Sun Nov 01, 1998 01:18:52 PM Julius:when do you need to suspect pertussis rather than
rsv
Sun Nov 01, 1998 01:18:59 PM mabrown:You're absolutely right, Julius.  We preach to
parents all the time, but rarely make an impact.
Sun Nov 01, 1998 01:19:23 PM Julius:we have periodic pertussis outbreaks in Minesota
Sun Nov 01, 1998 01:20:22 PM mabrown:The primary cause of obstruction is
intraluminal inflammation.  Smooth muscle spasm does contribute, but its alleviation
will not lead to decreased distress in all (or even most) infants.
Sun Nov 01, 1998 01:20:43 PM tball:In our pulmonary dept--Fernando Martinez (from
Chile)and others showed that infants born with small lung volume are at higher risk for
wheezing with infection during the first 3 years of life.  They checked lung volumes in
the newborn period before infection.
Sun Nov 01, 1998 01:20:44 PM Julius:if i see a young infant with uri and no wheezing
to protect myself from parents thinking i missed bronchiolitis  I tell them wheezing may
sart in a few days
Sun Nov 01, 1998 01:21:31 PM mabrown:The studies linking pertussis to bronchiolitis
suggest it is the former premature infant (<34 weeks) who is at greatest risk.  Perhaps
up to a third of infants in this group who are hospitalized have pertussis.
Sun Nov 01, 1998 01:21:54 PM Julius:wow thT IS  a lot
Sun Nov 01, 1998 01:22:16 PM tball:Do people think the incidence of bronchiolitis has
increased over the past decade?
Sun Nov 01, 1998 01:22:23 PM mabrown:It is a lot, but remember these are
hospitalized infants, not just infants who wheeze a little at home.
Sun Nov 01, 1998 01:22:45 PM Julius:good question, i feel it is a disease of the 90's for
my practice
Sun Nov 01, 1998 01:23:00 PM Richard:It seems to me, the incidence has increased
Sun Nov 01, 1998 01:23:07 PM Julius:i don't know why i feel it is more common soon
Sun Nov 01, 1998 01:23:31 PM Julius:are we jsut more aware or has it increased and if
so why
Sun Nov 01, 1998 01:23:36 PM mabrown:The incidence has actually increased though
the increase of asthma would predict an increase in bronchiolitis as well.  It may be that
we are more atuned to recognizing it.
Sun Nov 01, 1998 01:23:41 PM willy:In many counties misery has increased, so with
bronquilitis
Sun Nov 01, 1998 01:23:46 PM Andrei:My professor of pediatrics did not see the
disease in the 50-60ties
Sun Nov 01, 1998 01:24:18 PM paula:I agree with waht willy says
Sun Nov 01, 1998 01:24:25 PM Julius:here misery has not increased but ? increased
bronchioltis
Sun Nov 01, 1998 01:24:35 PM Richard:and with pulse-ox machine in office, it seems
hospitalization rate has increased also
Sun Nov 01, 1998 01:24:43 PM Vladimiro:Me too...but in the past we used to classify
those clinical pictures as asmathiform bronqchitis, now we do more bronchilitis -vs-
asmatic bronchitis
Sun Nov 01, 1998 01:25:09 PM mabrown:Again, with increases in airborne irritants -
smoke, air pollution, etc. - and the increase expression of asthma more infants may be
prone to wheeze with viral respiratory tract infections.
Sun Nov 01, 1998 01:25:16 PM Vladimiro:bronchiolitis
Sun Nov 01, 1998 01:25:58 PM tball:I began to practice in 1986--In the 90's I feel I
have seen more kids who are wheezing and I have to decide if I will watch them at home
or in the hospital.  I don't reember having to make that decision so often in the past.
Sun Nov 01, 1998 01:26:07 PM mabrown:I agree that the routine use of pulse oximetry
has led to an increase in hosptialization of infatns who otherwise would have been
managed at home.  This has also increased hosptial stay for thsoe infants admitted.
Sun Nov 01, 1998 01:26:31 PM Julius:yes this is good point, difficult to decide who to
hospitalize
Sun Nov 01, 1998 01:26:59 PM mabrown:We have recently re-examined our reliance on
oximetry, focusing more on clinical features such as degree of distress, ability to feed,
etc.
Sun Nov 01, 1998 01:27:06 PM Vladimiro:difficult to have an oximeter at office
settings here ($)
Sun Nov 01, 1998 01:27:07 PM tball:Has the use of pulse oximetry caught on in Chile,
Argentina, Turkey...?
Sun Nov 01, 1998 01:27:31 PM Andrei:We have pulse oximetry here
Sun Nov 01, 1998 01:27:54 PM GUL:but not in the offical setting. in turkey.
Sun Nov 01, 1998 01:27:58 PM paula:we have pulse oximetry in some hospitals
Sun Nov 01, 1998 01:28:05 PM willy:Yes we have, but not in all places
Sun Nov 01, 1998 01:28:06 PM mabrown:The admission criteria listed here are
guidelines.  The saturation in particular has to be modified for factors such as altitude.
Sun Nov 01, 1998 01:28:15 PM Vladimiro:we hardly have oximeters at NICU's and
PICU's
Sun Nov 01, 1998 01:28:42 PM pelo:We use pulse oximetry in public hospital
Sun Nov 01, 1998 01:29:05 PM mabrown:one of our fellows from Chile will be
publishing soon an article correlating saturaion with a modified Tal score for wheezing.
This may be helpful in those settings without easy access to oximetry.  It will be in
Pediatric Pulmonology.
Sun Nov 01, 1998 01:29:26 PM Phil:does the pulse ox really "improve" outcome?
Sun Nov 01, 1998 01:29:46 PM Vladimiro:good question
Sun Nov 01, 1998 01:29:59 PM dvulic:We have not pulse oximetry in hospital. In office
having it is science fiction.-Croatia,EU
Sun Nov 01, 1998 01:30:09 PM Vladimiro:maybe insurance payment outcome
Sun Nov 01, 1998 01:30:17 PM mabrown:My bias is that oximetry does not improve
outcome for the majority of infants.  It may be useful in infants with BPD, heart disease
or other underlying illnesses.
Sun Nov 01, 1998 01:30:38 PM tball:I understand that Santiago, Chile has a reputation
of having problems with air pollution--has there been an increase in the nujmbers of
wheezing children seen?
Sun Nov 01, 1998 01:30:58 PM miki:pulse ox make you feel better supporting your
clinical assess.
Sun Nov 01, 1998 01:31:11 PM pelo:is really a problem
Sun Nov 01, 1998 01:31:34 PM tball:next slide
Sun Nov 01, 1998 01:31:40 PM Julius:BEFORE WE START toDISCUSS
TTRREATMENT, PLEASE PLEASE INTRODUCE YOURSELF AND FROM WHERE
Sun Nov 01, 1998 01:31:54 PM miki:here we can charge for pulse ox and recover cost
rapidly
Sun Nov 01, 1998 01:32:03 PM pelo:here in Viña del mar (from Santiago 100 km to
Pacific coast) we have considerably less than santiago
Sun Nov 01, 1998 01:32:03 PM Richard:same here
Sun Nov 01, 1998 01:32:09 PM GUL:do you se  often very ill patients who require
hospitalisation in your clicical practise?
Sun Nov 01, 1998 01:32:24 PM Julius:Julius Edlavitch MD From Minneapolis
Minnesota
Sun Nov 01, 1998 01:32:29 PM Andrei:Andrei Zamfirescu, Bucharest, Romania -
pediatrician
Sun Nov 01, 1998 01:32:34 PM Tino:Florentino De La Cruz, pediatrician and
perinatology, from Barranquilla, Colombia
Sun Nov 01, 1998 01:32:44 PM Guillermo:Guillermo Franco Queretaro Mexico
Sun Nov 01, 1998 01:32:48 PM pelo:sorry, but who is the chilian fellow?' please send
him my greeters

Sun Nov 01, 1998 01:32:53 PM willy:Guillermo Jose Acion, Pediatrician, Buenos Aires,
Argentina
Sun Nov 01, 1998 01:32:57 PM Vladimiro:Vladimiro Alcaraz from Hermosillo, Sonora
Sun Nov 01, 1998 01:32:58 PM Robert Shayne:Bob Shayne, General Peds, Virginia
Sun Nov 01, 1998 01:33:01 PM Julius:we try to keep brobchiolitis out of hospital but many are
still hospitalized
Sun Nov 01, 1998 01:33:13 PM paula:Paula Otero from Buenos Aires, Argentina
Sun Nov 01, 1998 01:33:15 PM Richard:Richard Ash, pediatrician from  Pittsburgh, Pennsylvania
Sun Nov 01, 1998 01:33:20 PM miki:miki arbel phoenix AZ
Sun Nov 01, 1998 01:33:23 PM GUL:Gulnur Com Istanbul-Turkey..gen ped.
Sun Nov 01, 1998 01:33:30 PM Julius:sometimes during epidemics the hospitals have no more
room
Sun Nov 01, 1998 01:33:33 PM pelo:Francisco Cabello, Viña del Mar, Chile
Sun Nov 01, 1998 01:33:43 PM mabrown:Once admitted, treatment really focuses on support -
fluids, oxygen, and for some bronchodilators.
Sun Nov 01, 1998 01:33:44 PM tball:Tom Ball, Peds in Arizona
Sun Nov 01, 1998 01:34:20 PM Julius:does steroids help in treatment
Sun Nov 01, 1998 01:34:22 PM miki:I have been in Santiago last July , nice city but pollution
terrible
Sun Nov 01, 1998 01:34:29 PM Richard:good queston Julius
Sun Nov 01, 1998 01:34:31 PM Andrei:Inhaled steroids are not usefull?
Sun Nov 01, 1998 01:34:49 PM pelo:Santiago is a good example of the polution influence. The
reality is totally different with respect other near places
Sun Nov 01, 1998 01:34:57 PM Julius:what kind of inhaled steroids andrei
Sun Nov 01, 1998 01:35:23 PM Andrei:Beclometasone
Sun Nov 01, 1998 01:35:34 PM Julius:by nebulizer
Sun Nov 01, 1998 01:35:37 PM mabrown:Steroid have anecdotally helped , but larger trials don't
seem to confirm this.  Use of inhaled steroides during and after the eprisode may decrease the
incidence of wheezing several months later, but this needs to be studied more caref
Sun Nov 01, 1998 01:35:39 PM Vladimiro:I dont use inhaled steroids for bronchiolitis..should I??
Sun Nov 01, 1998 01:35:42 PM miki:why people are so scared to give to give 5 days of oral
steroids it is cheap harmless
Sun Nov 01, 1998 01:35:46 PM dvulic:In Croatia definition for bronchiolitis is for wheezing
infant under 3 mo. All above this age received diagnosis asmathic type of bronchitis. The first
group of infants are not increased in number, but second group of infants are increasing
Sun Nov 01, 1998 01:35:52 PM GUL:isnt it contraversial using corticosteroids?
Sun Nov 01, 1998 01:35:56 PM tball:In the 80's I used albuterol syrup...and kids seemed to get
better (those I saw in the office with mild disease).  Now all seem to expect a home nebulizer--
something certainly not available in many parts of hte world.  I'm not sure if we've improved care,
but we've increaed the cost.
Sun Nov 01, 1998 01:36:10 PM miki:and  if in doubt give it
Sun Nov 01, 1998 01:36:31 PM pelo:what sistemic corticoids (comparative)??
Sun Nov 01, 1998 01:36:38 PM Julius:good points everyone
Sun Nov 01, 1998 01:36:45 PM Vladimiro:I do use home "Cold mist" nebulizers
Sun Nov 01, 1998 01:36:46 PM mabrown:Steroids are cheap and simple, but not without side
effects.   primum non nocere.
Sun Nov 01, 1998 01:37:18 PM Vladimiro:first do no harm
Sun Nov 01, 1998 01:37:19 PM miki:no side effect that I know for 5 days tx.
Sun Nov 01, 1998 01:37:24 PM Julius:what is IPRATROPIUM IS THIS SYNERGIS
Sun Nov 01, 1998 01:37:50 PM Vladimiro:in < 6 mo ?
Sun Nov 01, 1998 01:38:06 PM GUL:I want to learn..do u usually use Corticosteroids?
Sun Nov 01, 1998 01:38:10 PM Richard:No, it's atrovent,  synergis is the monoclonal antibody...
Sun Nov 01, 1998 01:38:48 PM Robert Shayne:I find it is difficult not to convince my partners not
to use home nebulizers.  It is done to be nice to the patient, but very $$$
Sun Nov 01, 1998 01:38:49 PM tball:I don't use steriods
Sun Nov 01, 1998 01:39:00 PM miki:why?
Sun Nov 01, 1998 01:39:06 PM Vladimiro:paravizumab
Sun Nov 01, 1998 01:39:15 PM GUL:I try to not to use Cs..
Sun Nov 01, 1998 01:39:20 PM Julius:i see you use reacemic epi rahter than albuteral
Sun Nov 01, 1998 01:39:24 PM mabrown:Regarding albuterol, studies have suggested that a rule
of thirds applies - one third of infants improve, onethird have no benefit, one third get worse.  The
numbers for epinephrine are better - about 50% show some improvement. This is likely due to
decreases in intraluminal swelling.
Sun Nov 01, 1998 01:39:45 PM Vladimiro:only for High risk infants and chronic lung dissease
Sun Nov 01, 1998 01:40:12 PM Julius:how often does one give racemics in infant with
bronchiolitis and what dose
Sun Nov 01, 1998 01:40:31 PM Richard:has anyone started using synergis yet? $900/dose
Sun Nov 01, 1998 01:40:34 PM Vladimiro:has the maturity of the lung something to do with the
response to bronchodilators, like albuterol or salbutamol ?
Sun Nov 01, 1998 01:40:54 PM Robert Shayne:What parameters do you use to demonstrate
improvement?  Maybe this would help with our argument.
Sun Nov 01, 1998 01:41:06 PM GUL:what is synergis?
Sun Nov 01, 1998 01:41:14 PM Julius:let us wait til the end to iscuss synergis issues
Sun Nov 01, 1998 01:41:21 PM Richard:ok
Sun Nov 01, 1998 01:41:29 PM miki:there is a study showing no difference between racemic epi
and epi when use for croup
Sun Nov 01, 1998 01:41:32 PM tball:Hold on with Synergis questions--its coming up in slides
Sun Nov 01, 1998 01:41:33 PM mabrown:The data is pretty good for epinephrine, in my opinion.
I would use this before albuterol.  The doses listed are VERY conservative and can be given every
two hours. They could also be increased so long as no serious adverse effects are seen such as
sustained tachycardia, tremor, etc.
Sun Nov 01, 1998 01:41:46 PM Vladimiro:paravizumab the RSV vaccine Sinergys
Sun Nov 01, 1998 01:41:53 PM Julius:I would like to know more about using racemic epi
Sun Nov 01, 1998 01:42:14 PM mabrown:What can I answer about epi?
Sun Nov 01, 1998 01:42:20 PM dvulic:Yes, if albuterol helps I will expect asthma in next years.
Sun Nov 01, 1998 01:42:23 PM Julius:can you give us a reference to read about rx with racemic
epis and i will post this in next weeks mailing
Sun Nov 01, 1998 01:42:32 PM Vladimiro:Is it the same dosage used for laringotracheitis??
Sun Nov 01, 1998 01:42:36 PM tball:Her at Univ Of AZ we are using rac. epi on in-patients only.
Sun Nov 01, 1998 01:43:02 PM mabrown:Certainly!  There have even been some head-to-head
comparisons of epi and albuterol.
Sun Nov 01, 1998 01:43:12 PM Julius:how about in er for croupers you don't send them home
from er sometimes
Sun Nov 01, 1998 01:43:34 PM Vladimiro:I used to give it diluted with Saline solution in
nebulizer
Sun Nov 01, 1998 01:43:37 PM miki:depends
Sun Nov 01, 1998 01:43:46 PM mabrown:Depends.  If they are opbserved for 4 or more hours
after they can be sent home, especially if they rec'd steroids.
Sun Nov 01, 1998 01:45:08 PM tball:How do you handle these patients in countries without some
of these options?  Do you tend to treat with antibiotics?
Sun Nov 01, 1998 01:45:18 PM Richard:the "discharge criteria" surprise me...just 88% SpO2?
Sun Nov 01, 1998 01:45:26 PM mabrown:one point - pavilizumab is not a vaccine.  It is a
monoclonal antibody preparation used for passive immunity.
Sun Nov 01, 1998 01:45:39 PM Robert Shayne:Are there any interventions for the office patient
either in office or home so child doesn't wind up hospitalized like the other kid at sitters.
Sun Nov 01, 1998 01:45:54 PM pelo:no, we never treat wth antibiotics if we don't have evidences
Sun Nov 01, 1998 01:46:08 PM pelo:our managment is very similar
Sun Nov 01, 1998 01:46:26 PM GUL:I must confess that at the end  ,I have to use antibiotics..may
be the rate  of seconder inf is high in turkey.
Sun Nov 01, 1998 01:46:39 PM mabrown:You are the first person to question the 88% criteria.  It
is normal, at least at higher altitudes for infants to have transient drops in saturation to high 80's
during sleep.  We ignore these so long as the child is otherwise getting better.
Sun Nov 01, 1998 01:46:44 PM miki:unfortunately there is no breakthruogh for bronchiolitis
except maybe Synergys, what about daycare control and seperate waiting rooms inthe office for
sick and well(we have it)
Sun Nov 01, 1998 01:47:34 PM miki:any studies?
Sun Nov 01, 1998 01:47:38 PM Andrei:We give antibiotics in very severe cases in very small
infants
Sun Nov 01, 1998 01:47:44 PM Vladimiro:Not me..usually those patients look well, other than the
respiratory distress
Sun Nov 01, 1998 01:48:01 PM Julius:let us finish by discussing su=ynergis since this is so hot
and expensive and we are getting a lot of pressure
Sun Nov 01, 1998 01:48:09 PM willy:Our treatments are very similar, except that we don't use epi
as a first line drug
Sun Nov 01, 1998 01:48:11 PM mabrown:regfarding office measures - good general care, perhaps
the use of albuterol syrup or aerosols (if the family already has the equipment).  The key,
obviously would be prevention in the first place with measures such as good handwashing,
avoidance of sick individuals, breast feeding, etc.
Sun Nov 01, 1998 01:48:15 PM dvulic:As in Turkey , our peds often use antibiotics in therapy
Sun Nov 01, 1998 01:48:24 PM Andrei:In older children with mild disease no ab
Sun Nov 01, 1998 01:48:39 PM Guillermo:Greetings to all, bye.
Sun Nov 01, 1998 01:48:54 PM pelo:yes, with fever under 3 month we use the scheme of "febril
syndrome under 3 month"
Sun Nov 01, 1998 01:49:03 PM Richard:Julius, if you get references on racemic epi...send them;
I'd like to learn more about that too, since we use albuterol usually
Sun Nov 01, 1998 01:49:11 PM pelo:but is other chapter
Sun Nov 01, 1998 01:49:16 PM Julius:SHALOM DR ROBERT NEEDLEMAN FROM CASE
WESTERN UNIVERSITY WHO WILL DISCUSS ILLITERACY NEXT WEEK
Sun Nov 01, 1998 01:49:32 PM mabrown:Synagis - a very difficult topic.  Its efficacy is
somewhat limited, and its expense high. We are taking a very restrained approach to its use, even
more restrained than the AAP guidelines.
Sun Nov 01, 1998 01:49:54 PM Julius:I will post the reference about racemic and bronchiolitis in
the next major mailing
Sun Nov 01, 1998 01:50:08 PM Julius:boy is the sales force pressuring us
Sun Nov 01, 1998 01:50:25 PM miki:what about racemic vs. simple epi?
Sun Nov 01, 1998 01:50:32 PM mabrown:Basically we plan to treat any infant leass than 6 months
old at the start of the season who was born at less than 32 weeks gestation.  Infants with BPD who
are less than 2 years and treated for BPD in the last 6 months also get it.
Sun Nov 01, 1998 01:50:38 PM willy:Thanks Julius
Sun Nov 01, 1998 01:50:50 PM mabrown:There is indeed a ferocious sales effort for this product.
Sun Nov 01, 1998 01:51:19 PM Vladimiro:pasive immunity with synergis, what about respigam?
Sun Nov 01, 1998 01:51:20 PM miki:???
Sun Nov 01, 1998 01:51:35 PM Julius:because of pressure from managed care and sales force the
pressure stinks
Sun Nov 01, 1998 01:51:37 PM mabrown:We may also give it to infants with acyanotic heart
disease less thahn 6 months old, infants with CHF requiring treatment less than 6 months old.
Sun Nov 01, 1998 01:51:48 PM Julius:did you say less than 32 weeks
Sun Nov 01, 1998 01:52:06 PM miki:bye thank you
Sun Nov 01, 1998 01:52:08 PM Robert Shayne:It has had few blockades in Va.  Insurance cos.  are
coming around easily.
Sun Nov 01, 1998 01:52:08 PM tball:yes he did--32 weeks.
Sun Nov 01, 1998 01:52:08 PM Julius:i thought between 32 and 35 weeks is a periosd when it
mauy help too
Sun Nov 01, 1998 01:52:15 PM Julius:bye miki
Sun Nov 01, 1998 01:52:18 PM Vladimiro:premature babies g a
Sun Nov 01, 1998 01:52:24 PM dvulic:CHF?
Sun Nov 01, 1998 01:52:44 PM mabrown:Respigam may still be useful, for instance, in children
receiving IVIG as part of treatment of immunodeficiency.  In this group substuituting Respigam
for regular IVIG may be useful.
Sun Nov 01, 1998 01:52:46 PM tball:congenital heart disease
Sun Nov 01, 1998 01:53:40 PM GUL:congestive heart failure I think
Sun Nov 01, 1998 01:53:43 PM Vladimiro:doesn't IVIG has more side effects?
Sun Nov 01, 1998 01:53:47 PM Julius:welcome natasha from detroit
Sun Nov 01, 1998 01:54:28 PM mabrown:I recently recommeded Respigam for a 4200 gm infant
with meconiium aspiration.  This product conveys pasive protection against a number of
respiratory viruses, not just RSV.  It does have more side effects, especially related to the volume
infused.  It is also a blood product with all the attendant risks.
Sun Nov 01, 1998 01:54:29 PM Tino:Hi  Nat.
Sun Nov 01, 1998 01:54:38 PM nat:Hi all
Sun Nov 01, 1998 01:54:46 PM nat:I had some trouble getting in
Sun Nov 01, 1998 01:54:59 PM willy:Sorry, Respigam?
Sun Nov 01, 1998 01:55:12 PM Vladimiro:hola nat :-)
Sun Nov 01, 1998 01:55:28 PM mabrown:Respigam is a high-titer anti-RSV immunoglobulin
product harvested from adult donors.
Sun Nov 01, 1998 01:56:03 PM willy:Is it cheapest, than the other Ig, Synergis
Sun Nov 01, 1998 01:56:15 PM tball:another slide? Julius
Sun Nov 01, 1998 01:56:20 PM Julius:PLEASE DON"T FORGET NEXT WEDNESDAY IN THE
CHAT ROOM NOT IN WEBTOUR WE WILL DISCUSS HEALTH ISSUES RELATED TO
KOSOVO
Sun Nov 01, 1998 01:56:27 PM Julius:the slides are all done
Sun Nov 01, 1998 01:56:53 PM mabrown:The company predicts that becuase of administration
costs, Respigam will still be 17-25% more costly to give than Synagis.
Sun Nov 01, 1998 01:57:42 PM willy:Ok Synagis, thank you
Sun Nov 01, 1998 01:57:44 PM Julius:also next week Dr needleman form case western discusses
illiteracy and it should be very interesting
Sun Nov 01, 1998 01:58:24 PM GUL:illiteracy in the USA? :)
Sun Nov 01, 1998 01:58:34 PM Julius:Excellent discussion today
Sun Nov 01, 1998 01:58:44 PM pelo:yes
Sun Nov 01, 1998 01:58:47 PM Julius:Thank you Dr Brown
Sun Nov 01, 1998 01:58:52 PM Andrei:Thank you Mark for the chat. Still there are arguments
about the treatment and outcome of bronchiolitis. Maybe some day we will know better.
Sun Nov 01, 1998 01:58:54 PM willy:Yes
Sun Nov 01, 1998 01:59:00 PM Richard:Thank you
Sun Nov 01, 1998 01:59:03 PM tball:interesting, thanks
Sun Nov 01, 1998 01:59:21 PM mabrown:My pleasure.  I wil get those references to Julius.
Sun Nov 01, 1998 01:59:40 PM willy:I agree with Andrei, Thank you mabrown
Sun Nov 01, 1998 01:59:46 PM Julius:great and i will post them in the next letter
Sun Nov 01, 1998 01:59:53 PM tball:Good luck to all fending off the sales force, we had to do it
with Ribovirin!!
Sun Nov 01, 1998 01:59:59 PM Tino:Thank you Dr  Brown. Interesting chat
Sun Nov 01, 1998 02:00:13 PM Julius:dr needleman please tell us about the literacy discussion
next week
Sun Nov 01, 1998 02:00:33 PM mabrown:We haven't heard the last from or about bronchiolitis!
Sun Nov 01, 1998 02:01:01 PM Julius:ANY LAST QUESTIONS FOR DR BROWN
Sun Nov 01, 1998 02:01:03 PM Tino:I have to go. Bye everybody. Thank you
Sun Nov 01, 1998 02:01:08 PM dvulic:thank you dr Brown. It is nice to hear something about non
registrated drugs here
Sun Nov 01, 1998 02:01:16 PM willy:Mabrown, do you use Rivavirin,frequently
Sun Nov 01, 1998 02:01:56 PM pelo:thank you Dr Brown, thank you for include me in the
discussion
Sun Nov 01, 1998 02:02:02 PM mabrown:We use ribavirin only on immunocompromised children
(bone marrow transplants mostly) and very rarely in infants with heart disease and severe
bronchiolitis.
Sun Nov 01, 1998 02:02:28 PM GUL:Ribavirin. RVS Ig and RSV vaccine..new  for me..
Sun Nov 01, 1998 02:02:30 PM Julius:Gulnar the literacy discussion i feel wil apply to all of
pediatrics across borders and etc
Sun Nov 01, 1998 02:02:34 PM willy:Thank you Dr Brown , excellent chat
Sun Nov 01, 1998 02:02:37 PM Mark Cheren:Gul, the topic next week is about reducing illiteracy
and its consequences as pediatricians... what can be done
Sun Nov 01, 1998 02:03:12 PM Julius:taste of next week
Sun Nov 01, 1998 02:03:38 PM Julius:this is super, I hope someday we can give some type of
education credit for this
Sun Nov 01, 1998 02:03:48 PM Julius:Dr needleman do you see the slides
Sun Nov 01, 1998 02:03:58 PM Julius:would you like a rehearsal this week
Sun Nov 01, 1998 02:04:53 PM Julius:I am going to play golf , Indian summer day in minnesota
Sun Nov 01, 1998 02:05:08 PM GUL:thanks..greeting to you all from turkey..
Sun Nov 01, 1998 02:05:47 PM willy:Thanks to all, greetings from Buenos Aires, Adios, till next
week
Sun Nov 01, 1998 02:06:01 PM Julius:gul have you heard about the research
Sun Nov 01, 1998 02:06:01 PM pelo:bye Julius AMIGAZO
Sun Nov 01, 1998 02:06:19 PM Andrei:Thank you Julius, bye all
Sun Nov 01, 1998 02:06:25 PM GUL:oh..yes..:(((((((((I was late to apply!!!!!!
Sun Nov 01, 1998 02:06:54 PM pelo:bye friends
Sun Nov 01, 1998 02:06:56 PM Julius:adios and good by eall time for golf
Sun Nov 01, 1998 02:07:14 PM GUL:bye pelo:)
Sun Nov 01, 1998 02:07:14 PM dvulic:Julius I will try to attend a meeting at 04.11.
Sun Nov 01, 1998 02:07:32 PM pelo:chao gul
Sun Nov 01, 1998 02:07:38 PM nat:bye all
Sun Nov 01, 1998 02:07:39 PM Julius:yes come on 04-11 for discussion everyone a
Sun Nov 01, 1998 02:07:49 PM GUL:chao..
Sun Nov 01, 1998 02:07:50 PM willy:Chau Pelo
Sun Nov 01, 1998 02:08:00 PM nat:ciao
Sun Nov 01, 1998 02:08:51 PM Julius:I am closing the web tour now, if you want you amy go chat
room
Sun Nov 01, 1998 02:09:11 PM Richard:bye everyone
Sun Nov 01, 1998 02:09:29 PM dvulic:bye  all, see you for 3 days about children from Kosovo