Prevented harm and cost avoidance with pharmacist intervention while utilizing a discharge medication reconciliation tool

PURPOSE

The aim of this study was to determine prevented harm and cost avoidance following pharmacist intervention utilizing a discharge medication reconciliation tool.

METHODS

A retrospective chart review was conducted to identify patients with pharmacist-initiated, provider-accepted discharge medication reconciliation interventions completed at a community teaching hospital in January 2021. Investigators assigned the discrepancies targeted for intervention a National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) category, probability of harm, and calculated cost avoidance. The primary endpoint was the total cost avoidance associated with discharge medication reconciliation.

RESULTS

Pharmacists intervened 190 times in January 2021, avoiding an estimated $46,958 to $231,032 in cost. High-risk medications were associated with $33,920 to $147,203 in cost avoidance. The 3 high-risk therapeutic classes associated with the highest cost avoidance were insulin ($16,738-$70,793), antithrombotics ($13,884-$60,016), and opioids ($2,638-$11,834).

CONCLUSION

Targeted pharmacist discharge medication reconciliation and related interventions avoid significant cost and patient harm.

Equine model for soft-tissue regeneration

Soft-tissue regeneration methods currently yield suboptimal clinical outcomes due to loss of tissue volume and a lack of functional tissue regeneration. Grafted tissues and natural biomaterials often degrade or resorb too quickly, while most synthetic materials do not degrade. In previous research we demonstrated that soft-tissue regeneration can be supported using silk porous biomaterials for at least 18 months in vivo in a rodent model. In the present study, we scaled the system to a survival study using a large animal model and demonstrated the feasibility of these biomaterials for soft-tissue regeneration in adult horses. Both slow and rapidly degrading silk matrices were evaluated in subcutaneous pocket and intramuscular defect depots. We showed that we can effectively employ an equine model over 6 months to simultaneously evaluate many different implants, reducing the number of animals needed. Furthermore, we were able to tailor matrix degradation by varying the initial format of the implanted silk. Finally, we demonstrate ultrasound imaging of implants to be an effective means for tracking tissue regeneration and implant degradation.

Age effects on blood gas, spirometry, airway reactivity, and bronchoalveolar lavage fluid cytology in clinically healthy horses

Background

Despite the increasing number of geriatric horses attended by veterinarians, there is a lack of understanding of aging‐related changes on the respiratory system of horses.

Objective

To identify aging‐related changes on the respiratory function and bronchoalveolar lavage fluid (BALF) cytology of horses.

Animals

Fifteen healthy young adult (2–11 years) and 16 healthy aged (≥20 years) horses.

Methods

The respiratory system was examined by measurement of arterial blood gases (ABG), use of respiratory inductive plethysmography (RIP) for assessment of breathing pattern and ventilatory parameters, histamine bronchoprovocation, and BALF cytology.

Results

No significant differences were detected with regard to values obtained by ABG or bronchoprovocation of young adult and aged healthy horses. In aged horses, there were significant differences in mean ± SD of the following parameters when compared to young horses: prolonged expiratory time (Te) measured by RIP (3.9 ± 1.5 s versus 3.0 ± 0.6 s), decreased percentage of alveolar macrophages (40.6 ± 11.3% versus 53.5 ± 9.6%), and increased percentage of lymphocytes (53.4 ± 9.5% versus 43.9 ± 11.0%). No correlations between airway reactivity and ventilatory parameters, ABG, or BALF cytology were found in this asymptomatic population.

Conclusions

These results suggest that aging does not cause changes in the results obtained by ABG, most RIP‐derived variables, and bronchoprovocation in the horse. A decreased percentage of macrophage and an increased percentage of lymphocytes in the BALF cytology may be expected in the asymptomatic geriatric horse and may be a result of aging.

Alveolar epithelial stem and progenitor cells: emerging evidence for their role in lung regeneration

Lung injuries that impact the alveolus, such as emphysema, pulmonary fibrosis, and acute lung injury, are costly and prevalent problems. Moreover, the extent of alveolar injury and impairment of gas exchange is strongly associated with prognosis and survival. Thus, mechanisms of repair and regeneration of the lung alveolar compartment have received mounting attention as newer approaches to the study of stem and progenitor cells in this region unfold. The role of type II alveolar epithelial as the sole source of type I (AECI) and II (AECII) alveolar epithelial cells following lung injury has been recently challenged; recently, investigators have described stemprogenitor cells that function like precursors to AECII either in vitro or in vivo, both in mice and humans. Techniques to explore selfrenewal and multipotency have been rigorously applied to these putative stem-progenitor cell populations and the data thus far is compelling. This review provides background to the study of alveolar regeneration with the aim to provide context to the recent discoveries of putative stem-progenitor cells that may contribute to this process.

Pregnancy-associated progenitor cells: an under-recognized potential source of stem cells in maternal lung

Novel therapies are needed for the treatment of acute and chronic lung diseases, many of which are incurable. The use of exogenous stem cells has shown promise in both animal models and clinical trials. However, to date, the stem cell literature has under-recognized naturally acquired pregnancy-associated progenitor cells (PAPCs). These cells are found at sites of injury or disease in female tissues. They persist for decades after parturition in maternal blood and organs, with the largest number being found in the maternal lungs. Their presence there may be one explanation for the sex differences observed in the prevalence and prognosis of some lung diseases. Although the clinical significance of these cells is as yet unknown, the literature suggests that some of the PAPCs are stem cells or have stem cell-like properties. PAPCs harvested from the blood or organs of parous women could potentially be used as an alternate source of cells with regenerative properties for the woman herself or her children. Because PAPCs preferentially traffic to the maternal lung they may play a significant role in recovery or protection from lung disease. In this review article, we discuss ongoing research investigating the administration of both adult and placenta-derived stem cells to treat lung disease, and how PAPCs may also play an important future therapeutic role.

Measurement of the bottom quark contribution to nonphotonic electron production in p + p collisions at √s=200 GeV

The contribution of B meson decays to nonphotonic electrons, which are mainly produced by the semileptonic decays of heavy-flavor mesons, in p + p collisions at √s=200  GeV has been measured using azimuthal correlations between nonphotonic electrons and hadrons. The extracted B decay contribution is approximately 50% at a transverse momentum of pT≥5  GeV/c. These measurements constrain the nuclear modification factor for electrons from B and D meson decays. The result indicates that B meson production in heavy ion collisions is also suppressed at high pT.

Higher moments of net proton multiplicity distributions at RHIC

We report the first measurements of the kurtosis (κ), skewness (S), and variance (σ2) of net-proton multiplicity (Np-Np) distributions at midrapidity for Au+Au collisions at square root of s(NN)=19.6, 62.4, and 200 GeV corresponding to baryon chemical potentials (μB) between 200 and 20 MeV. Our measurements of the products κσ2 and Sσ, which can be related to theoretical calculations sensitive to baryon number susceptibilities and long-range correlations, are constant as functions of collision centrality. We compare these products with results from lattice QCD and various models without a critical point and study the square root of s(NN) dependence of κσ2. From the measurements at the three beam energies, we find no evidence for a critical point in the QCD phase diagram for μB below 200 MeV.

Three-particle coincidence of the long range pseudorapidity correlation in high energy nucleus-nucleus collisions

We report the first three-particle coincidence measurement in pseudorapidity (Δη) between a high transverse momentum (p⊥) trigger particle and two lower p⊥ associated particles within azimuth |Δϕ|<0.7 in square root of s(NN)=200 GeV d+Au and Au+Au collisions. Charge ordering properties are exploited to separate the jetlike component and the ridge (long range Δη correlation). The results indicate that the correlation of ridge particles are uniform not only with respect to the trigger particle but also between themselves event by event in our measured Δη. In addition, the production of the ridge appears to be uncorrelated to the presence of the narrow jetlike component.

Azimuthal charged-particle correlations and possible local strong parity violation

Parity-odd domains, corresponding to nontrivial topological solutions of the QCD vacuum, might be created during relativistic heavy-ion collisions. These domains are predicted to lead to charge separation of quarks along the system's orbital momentum axis. We investigate a three-particle azimuthal correlator which is a P even observable, but directly sensitive to the charge separation effect. We report measurements of charged hadrons near center-of-mass rapidity with this observable in Au + Au and Cu + Cu collisions at square root of s(NN) = 200 GeV using the STAR detector. A signal consistent with several expectations from the theory is detected. We discuss possible contributions from other effects that are not related to parity violation.

Matrix modulation of compensatory lung regrowth and progenitor cell proliferation in mice

Mechanical stress is an important modulator of lung morphogenesis, postnatal lung development, and compensatory lung regrowth. The effect of mechanical stress on stem or progenitor cells is unclear. We examined whether proliferative responses of epithelial progenitor cells, including dually immunoreactive (CCSP and proSP-C) progenitor cells (CCSP+/SP-C+) and type II alveolar epithelial cells (ATII), are affected by physical factors found in the lung of emphysematics, including loss of elastic recoil, reduced elastin content, and alveolar destruction. Mice underwent single lung pneumonectomy (PNY) to modulate transpulmonary pressure (mechanical stress) and to stimulate lung regeneration. Control mice underwent sham thoracotomy. Plombage of different levels was employed to partially or completely abolish this mechanical stress. Responses to graded changes in transpulmonary pressure were assessed in elastin-insufficient mice (elastin +/-, ELN+/-) and elastase-treated mice with elastase-induced emphysema. Physiological regrowth, morphometry (linear mean intercept; Lmi), and the proliferative responses of CCSP+/SP-C+, Clara cells, and ATII were evaluated. Plombage following PNY significantly reduced transpulmonary pressure, regrowth, and CCSP+/SP-C+, Clara cell, and ATII proliferation following PNY. In the ELN+/- group, CCSP+/SP-C+ and ATII proliferation responses were completely abolished, although compensatory lung regrowth was not significantly altered. In contrast, in elastase-injured mice, compensatory lung regrowth was significantly reduced, and ATII but not CCSP+/SP-C+ proliferation responses were impaired. Elastase injury also reduced the baseline abundance of CCSP+/SP-C+, and CCSP+/SP-C+ were found to be displaced from the bronchioalveolar duct junction. These data suggest that qualities of the extracellular matrix including elastin content, mechanical stress, and alveolar integrity strongly influence the regenerative capacity of the lung, and the patterns of cell proliferation in the lungs of adult mice.

Growth of long range forward-backward multiplicity correlations with centrality in Au + Au collisions at square root of sNN = 200 GeV

Forward-backward multiplicity correlation strengths have been measured with the STAR detector for Au + Au and p + p collisions at square root of s(NN) = 200 GeV. Strong short- and long-range correlations (LRC) are seen in central Au + Au collisions. The magnitude of these correlations decrease with decreasing centrality until only short-range correlations are observed in peripheral Au + Au collisions. Both the dual parton model (DPM) and the color glass condensate (CGC) predict the existence of the long-range correlations. In the DPM, the fluctuation in the number of elementary (parton) inelastic collisions produces the LRC. In the CGC, longitudinal color flux tubes generate the LRC. The data are in qualitative agreement with the predictions of the DPM and indicate the presence of multiple parton interactions.

K/pi Fluctuations at relativistic energies

We report K/pi fluctuations from Au + Au collisions at sqrt[s(NN)]= 19.6, 62.4, 130, and 200 GeV using the STAR detector at the Relativistic Heavy Ion Collider. K/pi fluctuations in central collisions show little dependence on incident energy and are on the same order as those from NA49 at the Super Proton Synchrotron in central Pb + Pb collisions at sqrt[s(NN)]=12.3 and 17.3 GeV. We report results for the collision centrality dependence of K/pi fluctuations and results for charge-separated fluctuations. We observe that the K/pi fluctuations scale with the charged particle multiplicity density.

Observation of two-source interference in the photoproduction reaction AuAu --> AuAurho0

In ultraperipheral relativistic heavy-ion collisions, a photon from the electromagnetic field of one nucleus can fluctuate to a quark-antiquark pair and scatter from the other nucleus, emerging as a rho{0}. The rho{0} production occurs in two well-separated (median impact parameters of 20 and 40 F for the cases considered here) nuclei, so the system forms a two-source interferometer. At low transverse momenta, the two amplitudes interfere destructively, suppressing rho{0} production. Since the rho{0} decays before the production amplitudes from the two sources can overlap, the two-pion system can only be described with an entangled nonlocal wave function, and is thus an example of the Einstein-Podolsky-Rosen paradox. We observe this suppression in 200 GeV per nucleon-pair gold-gold collisions. The interference is 87%+/-5%(stat.)+/-8%(syst.) of the expected level. This translates into a limit on decoherence due to wave function collapse or other factors of 23% at the 90% confidence level.

Indications of conical emission of charged hadrons at the BNL relativistic heavy ion collider

Three-particle azimuthal correlation measurements with a high transverse momentum trigger particle are reported for pp, d+Au, and Au+Au collisions at sqrt[s_{NN}]=200 GeV by the STAR experiment. Dijet structures are observed in pp, d+Au and peripheral Au+Au collisions. An additional structure is observed in central Au+Au data, signaling conical emission of correlated charged hadrons. The conical emission angle is found to be theta=1.37+/-0.02(stat)-0.07+0.06(syst), independent of p_{ perpendicular}.

System-size independence of directed flow measured at the BNL relativistic heavy-ion collider

We measure directed flow (v_{1}) for charged particles in Au+Au and Cu+Cu collisions at sqrt[s_{NN}]=200 and 62.4 GeV, as a function of pseudorapidity (eta), transverse momentum (p_{t}), and collision centrality, based on data from the STAR experiment. We find that the directed flow depends on the incident energy but, contrary to all available model implementations, not on the size of the colliding system at a given centrality. We extend the validity of the limiting fragmentation concept to v_{1} in different collision systems, and investigate possible explanations for the observed sign change in v_{1}(p_{t}).

Forward neutral-pion transverse single-spin asymmetries in p + p collisions at sqrt[s] = 200 GeV

We report precision measurements of the Feynman x (xF) dependence, and first measurements of the transverse momentum (pT) dependence, of transverse single-spin asymmetries for the production of pi0 mesons from polarized proton collisions at sqrt[s] = 200 GeV. The xF dependence of the results is in fair agreement with perturbative QCD model calculations that identify orbital motion of quarks and gluons within the proton as the origin of the spin effects. Results for the pT dependence at fixed xF are not consistent with these same perturbative QCD-based calculations.

Association between cough and cytology of bronchoalveolar lavage fluid and pulmonary function in horses diagnosed with inflammatory airway disease

BACKGROUND

The objective of this study was to examine the relationship between chronic cough, pulmonary mechanical function, bronchial hyper-responsiveness, and peripheral airway inflammation in adult performance horses with nonseptic inflammatory airway disease (IAD).

HYPOTHESIS

We hypothesized that horses with a presenting complaint of cough have a higher percentage of inflammatory cells on bronchoalveolar lavage (BAL), greater airway obstruction, and airway hyper-responsiveness (AHR) than do horses without cough. ANIMALS/SAMPLE POPULATION: Adult performance horses (n = 137) referred for evaluation of signs of IAD including cough or exercise intolerance (university hospital patients) and BAL samples (n = 142) taken in first opinion practice.

METHODS

A descriptive, retrospective cohort analysis was performed to evaluate the association between chronic cough and pulmonary mechanical function, AHR, BAL cytology, patient signalment, and comorbid features (multivariable logistic regression).

RESULTS

Cough was significantly more prevalent in horses >7 years, and best characterized by a high BAL neutrophil count (>5%) and nasal discharge. Lung function mechanics, abnormal thoracic auscultation, and exercise intolerance did not retain statistical significance in the logistical regression analysis of cough. Although AHR was not related to neutrophilic airway inflammation (BAL neutrophils >5%), it was significantly associated with BAL mast cells >2%.

CONCLUSIONS AND CLINICAL IMPORTANCE

Our data support that neutrophilic airway inflammation may potentiate cough without further changing respiratory mechanical function in IAD. In contrast, mast cell release increased AHR without affecting the incidence of cough. Cough may be used as an indicator of neutrophilic airway inflammation in the presence of low-grade nonseptic respiratory disease.

Longitudinal double-spin asymmetry for inclusive jet production in p[over -->] + p[over -->] collisions at sqrt[s]=200 GeV

We report a new STAR measurement of the longitudinal double-spin asymmetry A(LL) for inclusive jet production at midrapidity in polarized p + p collisions at a center-of-mass energy of sqrt[s]=200 GeV. The data, which cover jet transverse momenta 5<p(T)<30 GeV/c, are substantially more precise than previous measurements. They provide significant new constraints on the gluon spin contribution to the nucleon spin through the comparison to predictions derived from one global fit to polarized deep-inelastic scattering measurements.

Cellular kinetics and modeling of bronchioalveolar stem cell response during lung regeneration

Organ regeneration in mammals is hypothesized to require a functional pool of stem or progenitor cells, but the role of these cells in lung regeneration is unknown. Whereas postnatal regeneration of alveolar tissue has been attributed to type II alveolar epithelial cells (AECII), we reasoned that bronchioalveolar stem cells (BASCs) have the potential to contribute substantially to this process. To test this hypothesis, unilateral pneumonectomy (PNX) was performed on adult female C57/BL6 mice to stimulate compensatory lung regrowth. The density of BASCs and AECII, and morphometric and physiological measurements, were recorded on days 1, 3, 7, 14, 28, and 45 after surgery. Vital capacity was restored by day 7 after PNX. BASC numbers increased by day 3, peaked to 220% of controls (P<0.05) by day 14, and then returned to baseline after active lung regrowth was complete, whereas AECII cell densities increased to 124% of baseline (N/S). Proliferation studies revealed significant BrdU uptake in BASCs and AECII within the first 7 days after PNX. Quantitative analysis using a systems biology model was used to evaluate the potential contribution of BASCs and AECII. The model demonstrated that BASC proliferation and differentiation contributes between 0 and 25% of compensatory alveolar epithelial (type I and II cell) regrowth, demonstrating that regeneration requires a substantial contribution from AECII. The observed cell kinetic profiles can be reconciled using a dual-compartment (BASC and AECII) proliferation model assuming a linear hierarchy of BASCs, AECII, and AECI cells to achieve lung regrowth.

Impact of positive end-expiratory pressure during heterogeneous lung injury: insights from computed tomographic image functional modeling

Image Functional Modeling (IFM) synthesizes three dimensional airway networks with imaging and mechanics data to relate structure to function. The goal of this study was to advance IFM to establish a method of exploring how heterogeneous alveolar flooding and collapse during lung injury would impact regional respiratory mechanics and flow distributions within the lung at distinct positive end-expiratory pressure (PEEP) levels. We estimated regional respiratory system elastance from computed tomography (CT) scans taken in 5 saline-lavaged sheep at PEEP levels from 7.5 to 20 cmH(2)O. These data were anatomically mapped into a computational sheep lung model, which was used to predict the corresponding impact of PEEP on dynamic flow distribution. Under pre-injury conditions and during lung injury, respiratory system elastance was determined to be spatially heterogeneous and the values were distributed with a hyperbolic distribution in the range of measured values. Increases in PEEP appear to modulate the heterogeneity of the flow distribution throughout the injured lung. Moderate increases in PEEP decreased the heterogeneity of elastance and predicted flow distribution, although heterogeneity began to increase for PEEP levels above 12.5-15 cmH(2)O. By combining regional respiratory system elastance estimated from CT with our computational lung model, we can potentially predict the dynamic distribution of the tidal volume during mechanical ventilation and thus identify specific areas of the lung at risk of being overdistended.

Measurement of transverse single-spin asymmetries for Dijet production in proton-proton collisions at sqrt[s]=200 GeV

We report the first measurement of the opening angle distribution between pairs of jets produced in high-energy collisions of transversely polarized protons. The measurement probes (Sivers) correlations between the transverse spin orientation of a proton and the transverse momentum directions of its partons. With both beams polarized, the wide pseudorapidity (-1< or = eta < or = +2) coverage for jets permits separation of Sivers functions for the valence and sea regions. The resulting asymmetries are all consistent with zero and considerably smaller than Sivers effects observed in semi-inclusive deep inelastic scattering. We discuss theoretical attempts to reconcile the new results with the sizable transverse spin effects seen in semi-inclusive deep inelastic scattering and forward hadron production in pp collisions.

Partonic Flow and phi-Meson production in Au+Au collisions at sqrt radical sNN = 200 GeV

We present first measurements of the phi-meson elliptic flow (v2(pT)) and high-statistics pT distributions for different centralities from radical sNN=200 GeV Au+Au collisions at RHIC. In minimum bias collisions the v2 of the phi meson is consistent with the trend observed for mesons. The ratio of the yields of the Omega to those of the phi as a function of transverse momentum is consistent with a model based on the recombination of thermal s quarks up to pT approximately 4 GeV/c, but disagrees at higher momenta. The nuclear modification factor (R CP) of phi follows the trend observed in the K S 0 mesons rather than in Lambda baryons, supporting baryon-meson scaling. These data are consistent with phi mesons in central Au+Au collisions being created via coalescence of thermalized s quarks and the formation of a hot and dense matter with partonic collectivity at RHIC.

Transverse momentum and centrality dependence of high-pT nonphotonic electron suppression in Au+Au collisions at sqrt[s NN]=200 GeV

The STAR collaboration at the BNL Relativistic Heavy-Ion Collider (RHIC) reports measurements of the inclusive yield of nonphotonic electrons, which arise dominantly from semileptonic decays of heavy flavor mesons, over a broad range of transverse momenta (1.2<p(T)<10 GeV/c) in p+p, d+Au, and Au+Au collisions at sqrt[s_{NN}]=200 GeV. The nonphotonic electron yield exhibits an unexpectedly large suppression in central Au+Au collisions at high p(T), suggesting substantial heavy-quark energy loss at RHIC. The centrality and p(T) dependences of the suppression provide constraints on theoretical models of suppression.

Longitudinal double-spin asymmetry and cross section for inclusive jet production in polarized proton collisions at square root of s = 200 GeV

We report a measurement of the longitudinal double-spin asymmetry A(LL) and the differential cross section for inclusive midrapidity jet production in polarized proton collisions at square root of s = 200 GeV. The cross section data cover transverse momenta 5 < pT < 50 GeV/c and agree with next-to-leading order perturbative QCD evaluations. The A(LL) data cover 5 < pT < 17 GeV/c and disfavor at 98% C.L. maximal positive gluon polarization in the polarized nucleon.

Identified baryon and meson distributions at large transverse momenta from Au + Au collisions at square root sNN=200 GeV

Transverse momentum spectra of pi+/-, p, and p up to 12 GeV/c at midrapidity in centrality selected Au + Au collisions at square root sNN=200 GeV are presented. In central Au + Au collisions, both pi +/- and p(p) show significant suppression with respect to binary scaling at pT approximately >4 GeV/c. Protons and antiprotons are less suppressed than pi+/-, in the range 1.5 approximately < pT approximately < 6 GeV/c. The pi-/pi+ and p/p ratios show at most a weak pT dependence and no significant centrality dependence. The p/pi ratios in central Au + Au collisions approach the values in p + p and d + Au collisions at pT approximately >5 GeV/c. The results at high pT indicate that the partonic sources of pi+/-, p, and p have similar energy loss when traversing the nuclear medium.

Strange baryon resonance production in sqrt s NN=200 GeV p+p and Au+Au collisions

We report the measurements of Sigma(1385) and Lambda(1520) production in p+p and Au+Au collisions at sqrt[s{NN}]=200 GeV from the STAR Collaboration. The yields and the p(T) spectra are presented and discussed in terms of chemical and thermal freeze-out conditions and compared to model predictions. Thermal and microscopic models do not adequately describe the yields of all the resonances produced in central Au+Au collisions. Our results indicate that there may be a time span between chemical and thermal freeze-out during which elastic hadronic interactions occur.

Behavioural lateralisation in the Australian magpie (Gymnorhina tibicen)

In many vertebrates, the brain is lateralised such that each hemisphere is specialised to serve specific functions. This may translate into lateralisation in behaviour through preferential use of receptors or appendages associated with a particular hemisphere (e.g., handedness) or in differential responses to stimuli perceived on the animal's left or right side. In this study, we investigated behavioural laterality in the Australian magpie, Gymnorhina tibicen. We found that, while the birds did not have a population bias for one antipredator behaviour (visual inspection of an approaching human), there were biases for another (alarm calling); those birds that used their left eye more relative to their right eye gave alarm calls more frequently. We also observed that juvenile birds begged for food on the right side of parents significantly more frequently than on the left side. These trends are consistent with trends in behavioural laterality that have been recorded in captive and lab-reared species. Ours is one of the few studies to observe patterns of laterality in a wild species.

Canine awake head-out plethysmography (HOP): Characterization of external resistive loading and spontaneous laryngeal paralysis

We applied a novel head-out plethysmographic (HOP) method to study awake canine responses to external resistive loading and natural laryngeal paralysis. Measurements of inspiratory and expiratory specific airway resistance (sRaw(insp), sRaw(exp)) were obtained before and after uni- and bidirectional loading (R(add) = 5 cmH(2)O/L/s) in large-breed dogs (n = 9). Mean sRaw(insp) after inspiratory, and sRaw(exp) after expiratory loading were 31.4 and 33.3 cmH(2)Os, respectively. Bidirectional loads induced a significantly greater rise in both sRaw(insp) and sRaw(exp) (55.1 and 61.3 cmH(2)Os) compared to unidirectional loading (P < 0.001). Yet, type of loading did not affect flow-volume indices. The mean R(aw) of dogs was 4.81 cmH(2)O/L/s. Expiratory loading resulted in a significant 8.8% increase in functional-residual-capacity (FRC), compared to FRC(baseline) (76.7 ml/kg). Dogs (n = 5) with laryngeal paralysis demonstrated a significant increase in sR(aw) and R(aw) compared to controls without changes in FRC. In conclusion, HOP precisely characterized sR(aw) in response to external resistive loading. Hence, we could accurately quantify airway obstruction in awake dogs with laryngeal paralysis.

Radiographic scoring lacks predictive value in inflammatory airway disease

REASONS FOR PERFORMING STUDY

Diagnosis of inflammatory airway disease (IAD) currently rests upon the results of bronchoalveolar lavage (BAL) cytology, lung function testing and histamine bronchoprovocation (HBP), none of which provides direct information about structural change in the lung.

HYPOTHESIS

That thoracic radiography might better portray structural change in the lungs and therefore offer a good clinical assessment of IAD.

METHODS

A radiographic scoring system was developed to assess the extent of bronchial and interstitial pattern on thoracic radiographs in the dorsocaudal, dorsocranial and caudoventral regions in 16 control horses and 33 horses with IAD. Mean scores were compared to ascertain whether thoracic radiographs could distinguish between the 2 groups. In order to determine whether independent observers reliably scored radiographs similarly, an inter-rater reliability score was employed for each radiographic observation. Correlations between radiographic scores, BAL cytology, lung function testing using the forced oscillatory technique and HBP were examined.

RESULTS

Inter-rater reliability was only moderate. Radiographic scoring demonstrated no differences between the 2 groups. There were no correlations among BAL cytology, lung function testing, HBP and radiographic scores.

CONCLUSIONS AND POTENTIAL RELEVANCE

Thoracic radiographs are a low-yield diagnostic modality in horses with a clinical history compatible with IAD. In the absence of clinical evidence of more extensive, infectious disease, thoracic radiographs neither refine nor improve diagnosis of IAD, but increase diagnostic costs.

Respiratory applications for the future: one perspective

Respiratory diagnostic instruments previously available only to referral centers should be converted into miniature, portable, wireless medical devices for use in practice. Internet and wireless connections of these instruments should expedite the process of seeking second opinions and in general information sharing. We are moving into a world of greater objectivity that should free us from speculation in some areas, yet open new avenues for research and innovation in others.

Effects of aerosolized albuterol on physiologic responses to exercise in standardbreds

OBJECTIVE

To examine the effects of an aerosolized beta2-adrenoreceptor agonist, albuterol, on performance during a standardized incremental exercise test in clinically normal horses.

ANIMALS

8 Standardbred pacing mares.

PROCEDURE

Clinically normal horses, as judged by use of physical examination, hematologic findings, serum biochemical analysis, and airway endoscopy, were randomly assigned to 2 groups and were given 900 microg of albuterol via a metered-dose inhaler 30 minutes before beginning a standardized incremental exercise test in a crossover design with a 7-day minimum washout. Further examination included measurement of baseline lung mechanics, response to histamine bronchoprovocation, and bronchoalveolar lavage.

RESULTS

No significant differences (albuterol vs placebo) were seen for any incremental exercise test variables (ie, maximum oxygen consumption, maximum carbon dioxide consumption, respiratory quotient, treadmill speed at heart rate of 200 beats/min, or number of steps completed during an incremental exercise protocol). Mast cell percentage was significantly (r = -0.84) associated with the concentration of aerosolized histamine that evoked a 100% increase in total respiratory system resistance. No other direct correlations between bronchoalveolar lavage fluid cell types and any indices of exercise capacity or airway reactivity were found.

CONCLUSIONS AND CLINICAL RELEVANCE

Although no horse had exercise intolerance, 4 horses had airway hyperreactivity with bronchoalveolar lavage fluid mastocytosis; these horses may have been subclinically affected with inflammatory airway disease. In our study, albuterol did not enhance performance in 8 clinically normal racing-fit Standardbreds.

Vestibular signs associated with suspected lightning strike in two horses

Two previously healthy 14-year-old horses developed right-sided unilateral vestibular signs after they had possibly been struck by lightning. Repeated radiographic and endoscopic evaluations did not reveal any significant changes. A brainstem auditory evoked response test indicated a subtle left to right interaural latency difference of waves I, III and V in the more severely affected pony, but its central conduction time remained normal.

Development of a standardized nomenclature for bronchoscopy of the respiratory system of harbor porpoises (Phocoena phocoena)

Respiratory disease is common in captive and wild cetaceans. Bronchoscopy may permit early diagnosis of respiratory disease in dolphins and porpoises. Refinement of cetacean bronchoscopy requires development of a nomenclature system to facilitate description of the anatomic site at which lesions occur. A standard bronchoscopic nomenclature also permits serial evaluations of lesions and enhances communication between veterinarians. In this project, we adapted the bronchoscopic nomenclature devised by Amis and McKiernan for the dog and horse to the harbor porpoise (Phocoena phocoena). Silastic and air-dried models of the bronchial tree of the harbor porpoise were made to illustrate the anatomy and devise the nomenclature. Bronchial anatomy was consistent among the four porpoise lungs studied. The Amis and McKiernan nomenclature was readily adaptable to the harbor porpoise lung with minor modifications and may be useful for cetacean bronchoscopy.

Thoracoabdominal asynchrony failed to grade airway obstructions in foals

Respiratory inductive plethysmography (RIP) can be used to obtain a valid measure of tidal volume in humans. This device also compares the contributions to ventilation of the thorax and abdomen. Although thoracoabdominal asynchrony is a prominent clinical feature for patients with airway obstruction, the accuracy of the RIP device to assess the severity of obstruction is unclear. This study analyzes how well RIP variables reflect the degree of a fixed external inspiratory plus expiratory resistive load in foals. Foals were employed because the species and age group are commonly afflicted with respiratory disease. Eight conscious, sedated (xylazine 1.25 mg/kg body wt) foals were subjected to randomly ordered resistive loads at the airway opening and, on a separate day, to histamine aerosol challenge. During resistive loading, phase angle changed significantly, as did phase relation (P < or = 0.05). However, no significant correlation was found between the degree of change in resistive load and the degree to which phase angle or relation was altered (r(s) = 0.41 and 0.25, respectively). In addition, neither phase angle nor relation changed significantly with histamine challenge. We conclude that, although RIP variables changed markedly with fixed upper airway resistive loading, the degree to which they changed was erratic and therefore not useful for grading these obstructions. Furthermore, RIP variables were insensitive measures of histamine-induced bronchoconstriction.

Airway reactivity measured by barometric whole-body plethysmography in healthy cats

OBJECTIVE

To assess the validity of barometric whole-body plethysmography (BWBP) as a means of monitoring airway responses to induced bronchoconstriction in healthy cats.

ANIMALS

8 healthy cats without history of bronchopulmonary disease or exposure to indoor tobacco smoke.

PROCEDURE

Cats were placed into a barometric plethysmograph with an internal volume of 38 L, and air flow was recorded at baseline and after carbachol (concentrations 0.005, 0.01, 0.02, 0.05, 0.1, and 0.2%) was introduced into the chamber. A dose-response curve was generated for several flow-derived measurements, and airway reactivity was determined by interpolation of the dose-response curve for enhanced pause.

RESULTS

Peak inspiratory and expiratory flows increased significantly, but respiratory rate, inspiratory and expiratory times, relaxation time, and tidal volume did not differ significantly from baseline values. Flow-derived measurements (pause, enhanced pause, and end-expiratory pause) increased significantly at carbachol concentrations > 0.02%. Baseline measurements did not correlate with indices of airway reactivity.

CONCLUSIONS AND CLINICAL RELEVANCE

Airway reactivity can be measured by use of BWBP, which is noninvasive. Airway reactivity was highly variable among cats and was not a function of baseline airway caliber, suggesting that other intrinsic mechanisms may be important.

Pulmonary function testing in small animals

Pulmonary function testing (PFT) may be used to help provide objective information concerning the respiratory system in dogs and cats. Available techniques for PFT include spirometry, tidal breathing flow-volume loop analysis, barometric whole-body plethysmography, dynamic and static compliance, and lung and upper airway resistance. The information gained from PFT may help both in patient management and also in gaining understanding of the pathophysiology of the pulmonary system.

Airway responses to histamine aerosol in clinically normal foods

OBJECTIVE

To describe the spectrum of nonspecific airway reactivity in a group of clinically normal foals.

ANIMALS

12 clinically normal mixed-breed foals, 48 to 92 days old, without history of clinical lung disease.

PROCEDURE

Nonspecific airway reactivity was determined by measuring the extent of changes in dynamic compliance during nebulization of incrementally increasing concentrations of histamine aerosol. Degree of airway reactivity was expressed as the dose of histamine that evoked a decrease in dynamic compliance (Cdyn) to 65% of the after saline nebulization value (PC65Cdyn) or increase in pulmonary resistance (R(L)) to 135% of baseline (PC135R(L)).

RESULTS

In all foals, it was possible to induce a decrease in Cdyn in dose-dependent manner to < or = 65% of baseline. Response of foals in terms of R(L) was more erratic, and, in 1 foal, R(L) decreased after histamine exposure. Mean+/-SD PC65Cdyn was 5.43+/-1.74 (range, 0.77 to 19.56) mg/ml, and mean PC135R(L) was 3.34+/-1.52 (range, -0.749 to 17.35) mg/ml. Body weight was not correlated to baseline Cdyn, R(L), PC65Cdyn, or PC135R(L).

CONCLUSIONS AND CLINICAL RELEVANCE

Clinically normal foals had a wide range of airway reactivity, which may contribute to variation in clinical responses of foals to otherwise similar stimuli, such as infection, inflammation, and challenge exposure with environmental irritants.

Efficacy of tacrolimus in the treatment of refractory rejection in heart and lung transplant recipients

BACKGROUND

Refractory acute cellular rejection may occur despite triple-drug immunosuppression (cyclosporine A, steroids, azathioprine/mycophenolate mofetil). The purpose of this study was to determine the efficacy of tacrolimus rescue therapy in patients maintained on cyclosporine-based immunosuppression (CBI).

METHODS

Between December 1993 and October 1996, 208 patients underwent thoracic organ transplantation at the Hospital of the University of Wisconsin at Madison. One hundred forty-nine patients underwent heart replacement; 59 underwent lung transplantation. One hundred thirty-nine of the heart transplant cohort received CBI preceded by induction therapy with OKT3. Forty-six of the lung transplant cohort received CBI without induction cytolytic therapy. Refractory rejection was defined as failure to respond to high-dose steroids (500 mg to 1 g IV methylprednisolone for 3 days) and/or monoclonal antibody therapy (OKT3, 5 to 10 mg IV/day for 7 to 14 days). In patients with refractory rejection, cyclosporine was replaced with tacrolimus.

RESULTS

Overall, 16% (30/185) of patients receiving CBI experienced refractory rejection. Thirty-one episodes of grade IIIa or greater rejection occurred in 11% (15/139) of heart transplant recipients. Twenty episodes of grade II to IV rejection occurred in 33% (15/46) of lung transplant recipients. After tacrolimus rescue therapy, 93% (14/15) of patients in the heart transplant group converted to grade II or less rejection. Refractory rejection was reversed in 73% (11/15) of the lung transplant group. Reversal was documented at biopsy in all (8/8) lung recipients in whom it had been histologically identified. FEV1 values of 3 additional patients stabilized.

CONCLUSIONS

The incidence of refractory rejection in thoracic organ transplant recipients on CBI is significant. Reversal of refractory rejection follows rescue immunotherapy with tacrolimus.

Comparison of forced oscillation with the conventional method for histamine bronchoprovocation testing in horses

OBJECTIVE

To compare response of horses to histamine bronchoprovocation (HBP), using total respiratory resistance (Rrs) measured by forced oscillatory mechanics (FOM) with dynamic compliance (Cdyn) and pulmonary resistance (RL) measured by the esophageal balloon method.

ANIMALS

10 horses with various degrees of airway reactivity.

PROCEDURE

The 2 methods for measuring airway responses to HBP were performed on separate days. Endpoints compared were increase of 150 or 200% of baseline Rrs (PC150Rrs, PC200Rrs) and to 150% of baseline RL (PC150RL) or decrease to 65% of baseline Cdyn (PC65Cdyn). Frequency dependence of respiratory mechanics, using FOM, was evaluated, using the slope of Rrs over 1 to 3 Hz and the ratios of Rrs at 1 Hz to Rrs at 2 and 3 Hz (Rrs1Hz/Rrs2Hz, Rrs1Hz/Rrs3Hz) and of Rrs at 2 Hz to Rrs at 3 Hz (Rrs2Hz/Rrs3Hz). Effect of histamine on frequency dependence was assessed.

RESULTS

Correlation with PC65Cdyn was high for PC150Rrs (rs = 0.93) and PC200Rrs (rs = 0.96). Correlation between PC65Cdyn and PC150RL was weakly positive (rs = 0.61). The slope of Rrs over 1 to 3 Hz changed significantly between baseline (-0.07+/-0.09 cm H2O/L/s/Hz) and final histamine dose (-0.28+/-0.10 cm H2O/L/s/Hz). The Rrs1Hz/Rrs3Hz and Rrs2Hz/Rrs3Hz differed significantly (P < 0.05 between baseline [1.27+/-0.36 and 0.96+/-0.11, respectively] and final histamine dose [1.62+/-0.37 and 1.09+/-0.14, respectively]).

CONCLUSIONS

Correlation between histamine-induced changes in respiratory mechanics, as measured by FOM and the pneumotachograph-esophageal balloon method, was good. The FOM results indicated frequency dependence of respiratory mechanics during HBP.

CLINICAL RELEVANCE

A noninvasive method of measuring airway reactivity will facilitate routine evaluation of horses with suspected small airway disease and may be suitable for field studies.

Adrenal insufficiency in a neonatal foal

A 3-day-old female Pinto was admitted with profuse watery diarrhea and severe hypovolemic shock. After 1 week of intensive care, the foal developed seizures associated with profound serum electrolyte abnormalities suggestive of hypoadrenocorticism. Treatment with prednisone and isotonic saline (0.9% NaCl) solution led to prompt clinical response. Premature withdrawal of prednisone resulted in relapse of clinical signs. A diagnosis of adrenal insufficiency was made on the basis of clinical signs, electrolyte abnormalities, low baseline cortisol concentration, and lack of response to administration of exogenous adrenocorticotropin. Two months later, adrenocortical function was normal and the foal was doing well clinically. Clinical signs of acute adrenal insufficiency in neonatal foals can be confused with other conditions, such as septicemia, enteritis, and ruptured urinary bladder. A persistently low serum sodium-to-potassium ratio associated with CNS malfunction should warrant investigation of adrenal gland function. Acute hypoadrenocorticism in foals may be reversible.

Association between bronchoalveolar lavage cytologic features and airway reactivity in horses with a history of exercise intolerance

OBJECTIVE

To correlate indices of airway reactivity to bronchoalveolar lavage (BAL) fluid cytologic features in horses with a recent decline in exercise tolerance.

ANIMALS

20 actively working horses from 2 to 24 years old.

PROCEDURE

Bronchoalveolar lavage fluid samples were obtained and analyzed. Forced oscillatory mechanics (1-7 Hz) technique was used for measurements of total respiratory system resistance (RRS), compliance (CRS), and resonant frequency (fres). Changes in RRS (1 Hz) during histamine challenge were used to generate histamine dose-response curves, from which the provocative concentrations that evoked a 75 or 100% increase in baseline RRS (PCRRS75 and PCRRS 100, respectively) were determined. Age, sex, baseline lung mechanics, and BAL cytologic findings were correlated with PCRRS75 and PCRRS100.

RESULTS

No horse of the study had clinical signs or history of obstructive pulmonary disease or increased percentage (> 7%) of neutrophils in bronchoalveolar lavage fluid samples. Mean (+/- SEM) RRS, CRS, and fres were 0.67 +/- 0.06 cm of H2O/L/s, 0.52 +/- 0.04 L/cm H2O, and 2.46 +/- 0.02 Hz, respectively. There was no correlation between age or sex, and RRS, CRS, fres, PCRRS75, or PCRRS100. There was a significant correlation (rs = -0.78, P < 0.001) between percentage of BAL fluid mast cells and PCRRS75 or PCRRS100, but correlation with other cell types and indices of airway reactivity were not observed.

CONCLUSION

The strong association between mast cell percentage in BAL fluid and airway reactivity in this group suggests that mast cell products may contribute to bronchospasm, airway wall thickening, and/or loss of elastic recoil, which underlie airway hyperreactivity. Alternatively, mast cells may contribute to nonspecific airway reactivity in horses through unknown mechanisms.

Inhaled medications and bronchodilator usage in the horse

The advantages of aerosol medications include the direct, topical application to the target organ (airways); rapid effect; and low systemic availability. There are now more efficient methods for aerosol delivery that facilitate the use of increasingly sophisticated aerosol drugs. This article reviews the principles of aerosol deposition and the pharmacology of current medications.

Comparison of alveolar ventilation, oxygenation, pressure support, and respiratory system resistance in response to noninvasive versus conventional mechanical ventilation in foals

OBJECTIVE

To compare the efficacy of positive pressure ventilation applied through a mask versus an endotracheal tube, using anesthetized/paralyzed foals as a model for foals with hypoventilation.

ANIMALS

Six 1-month-old foals.

PROCEDURE

A crossover design was used to compare the physiologic response of foals to 2 ventilatory techniques, noninvasive mask mechanical ventilation (NIMV) versus endotracheal mechanical ventilation (ETMV), during a single period of anesthesia and paralysis. Arterial pH, PaO2, PaCO2, oxygen saturation, end-tidal CO2 tension, airway pressures, total respiratory system resistance, resistance across the upper airways (proximal to the midtracheal region), and positive end-expiratory pressures (PEEP) were measured. Only tidal volume (VT; 10, 12.5, and 15 ml/kg of body weight) or PEEP (7 cm of H2O) varied.

RESULTS

Compared with ETMV, use of NIMV at equivalent VT resulted in PaCO2 and pH values that were significantly higher, but PaO2 was only slightly lower. Between the 2 methods, peak airway pressure was similar, but peak expiratory flow was significantly lower and total respiratory resistance higher at each VT for NIMV. Delivery of PEEP (7 cm of H2O) was slightly better for ETMV (7.1 +/- 1.3 cm of H2O) than for NIMV (5.6 +/- 0.6 cm of H2O).

CONCLUSION

These data suggest that use of NIMV induces similar physiologic effects as ETMV, but the nasal cavities and mask contribute greater dead space, manifesting in hypercapnia. Increasing the VT used on a per kilogram of body weight basis, or the use of pressure-cycled ventilation might reduce hypercapnia during NIMV.

CLINICAL RELEVANCE

Use of NIMV might be applicable in selected foals, such as those with hypoventilation and minimal changes in lung compliance, during weaning from endotracheal mechanical ventilation, or for short-term ventilation in weak foals.

Techniques for sampling the respiratory tract of horses

Field diagnostic tests for respiratory diseases are constantly evolving. With each new application, equine patients with sinusitis, acute and chronic bacterial and fungal pneumonia SAID, chronic obstructive pulmonary disease, pleuropneumonia or poor performance are managed with greater proficiency. All of these problems can be investigated adequately in the field. This article is a guide to sampling techniques relevant to the ambulatory clinician.

Physician delivery of smoking-cessation advice based on the stages-of-change model

The purpose of this study is to assess whether a stage-based program of brief physician-delivered smoking-cessation advice changes smoking stages of readiness to quit smoking. First-year residents were trained to assess the stage of their continuity care patients who smoke, using Prochaska and DiClemente's methods, and to deliver brief messages and handouts based on the stages of precontemplation, contemplation, and action. Concurrent with the training, we administered a survey to 252 smokers, before their physician encounter. Eighty-nine smokers saw trained residents (intervention group), and 163 saw untrained residents (usual care group). A follow-up survey was administered six months later. Seventy-four percent of the subjects completed the follow-up survey. After we controlled for baseline stage, the percentage of precontemplators was lower in the intervention group (25%) than in the usual care group (36%) (P < .05, log-linear model). In the intervention group, 50% of the subjects had positive stage shifts versus 40% in the usual care group (P = .2). Subjects in the intervention group moved ahead a mean of 0.63 stage per subject, whereas subjects in the usual care group moved ahead 0.34 stage per subject (P < .05). The self-reported cessation rate was 15.5% and did not differ between the two groups. We conclude that our stage-specific brief advice program enhances short-term movement through the stages-of-change of smoking cessation. Measurement of this movement may be an important intermediary in evaluating small clinical trials of brief advice. Our findings indicate potential benefits of a staged approach for both clinicians and their patients.

Sensitivity and specificity of bronchoalveolar lavage and protected catheter brush methods for isolating bacteria from foals with experimentally induced pneumonia caused by Klebsiella pneumoniae

One indication for referral of horses to veterinary hospitals is for diagnosis of the microbiologic cause of pneumonia, particularly when the initial treatment fails. Although endoscopic methods have long been available for microbiologic sample collection, accuracy of these methods under these conditions have not been studied in detail. We compared the bacteria isolated from samples obtained by bronchoalveolar lavage (BAL) with those obtained by protected catheter brush (PCB) from foals with unilateral pneumonia induced by inoculation with Klebsiella pneumoniae. As part of previously described clinical trials, foals were administered antimicrobial therapy IM (n = 15) or vehicle IM (n = 7), and collection of distal airway secretion samples was conducted during the treatment period. Sensitivity and specificity of the sample collection methods were assessed by comparison of the isolates from BAL or PCB samples with isolates from tissue of the inoculated lung lobe, which was the most severely affected lung region. Sensitivity and specificity of BAL for recovery of K pneumoniae (challenge strain) and Streptococcus zooepidemicus (common secondary pathogen) was 90 and 69%, respectively, compared with 76 and 85%, respectively, for the PCB method. Sensitivity was significantly (P = 0.03) higher for BAL (100%) than for PCB (69%) for recovery of K pneumoniae (P = 0.03) from lungs. However, difference in the sensitivity of these methods for recovery of S zooepidemicus was not significant. In conclusion, BAL was a more reliable method for recovery of bacteria from the lungs in chronically infected foals that received antimicrobial treatment.

Microbiologic changes during antimicrobial treatment and rate of relapse of distal respiratory tract infections in foals

Despite the high incidence of distal respiratory tract infection of undetermined cause on farms, to our knowledge, the microbiologic effects of conventional antimicrobial treatment for this condition have not been studied. We evaluated the possible pathogenic role of bacterial isolates from the distal airways of foals with clinical respiratory tract disease, by correlating changes in their numbers (increase or decrease) with clinical, endoscopic, and pulmonary cytologic signs of disease resolution during treatment with antimicrobial drugs. We also determined qualitative changes in in vitro antimicrobial susceptibility of bacterial isolates after 7 days of treatment and relapse rate of foals. Significant (P < 0.05) decrease in the numbers of an isolate in the airways was considered strong evidence of a pathogenic role in this disease syndrome. Foals with endoscopically confirmed distal respiratory tract infection (DRTI; n = 65) were selected at random for treatment (n = 56) or nontreatment (n = 9), and bronchial lavage specimens were cultured and evaluated cytologically before and after 7 days of treatment with trimethoprim-sulfamethoxazole (TMS) and a beta-lactam drug (penicillin, ampicillin, or sulbactam-ampicillin), the standard treatment in all foals. The effect of treatment was to abruptly reduce the clinical (nasal discharge, cough, adventitious lung sounds) and cytologic signs of airway infection. Severity of disease in nontreated foals, however, did not change or did worsen over time. Reduction in the frequency and numbers of Streptococcus zooepidemicus isolated during treatment supported a causal role for this organism in the clinical syndrome observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical and endoscopic study to estimate the incidence of distal respiratory tract infection in thoroughbred foals on Ontario breeding farms

Respiratory tract infections are prevalent in foals, yet the frequency with which the distal airways are affected in clinical episodes of respiratory tract disease has not been evaluated to our knowledge. The objective of the study was to determine the incidence of distal respiratory tract infection (DRTI) in foals on a sample of Thoroughbred breeding farms (n = 10) in Ontario. In a pilot study, clinical criteria commonly used to select foals for antimicrobial treatment (detection of abnormal lung sounds, plus nasal discharge, cough, fever, tachypnea, and/or lethargy) were found to segregate foals with and without endoscopically confirmed DRTI. Mucopurulent exudate and bronchial erythema were observed more frequently (P < 0.005), bronchial lavage total cell count and neutrophil concentration were significantly (P < 0.005) higher, and intracellular cocci were recovered significantly (P < 0.01) more often from bronchial lavage samples of affected foals (n = 8) than of controls (n = 8). These clinical criteria were used to identify cases in a cohort of Thoroughbred foals (n = 219) from May 1 to October 30, 1991. Case morbidity adjusted for clustering was 82 +/- 5% (95% confidence limits, 72 to 92%). Most (74%) episodes of clinical DRTI were detected in July and August, and equal numbers were detected before (53%) and after (47%) weaning of foals. Of 178 cases, 66 (48%) were selected at random for endoscopy and bronchial lavage. Grade-II pharyngeal lymphoid hyperplasia was observed commonly (60% of foals); auditory tube diverticulum (guttural pouch) discharge was observed in 18 of 86 (21%) foals, and guttural pouch infection was confirmed in 6 of 7 foals examined endoscopically.(ABSTRACT TRUNCATED AT 250 WORDS)