11 the severity of the clinical symptoms could not be adequately explained by valvular regurgitation, of which there was little evidence on examination of the heart. Blood cultures usually remained sterile, presumably because of inappropriate antibiotic treatment or the limited infectiveness of the organisms present, or both.A striking feature in three patients (cases 1, 2, and 4) was the acute, severe, and rapidly resolving but recurrent episodes of pulmonary oedema. Possibly these were caused by sudden blocking of the orifice by -vegetation-this was indeed shown echocardiographically in one patient (case 4). Other patients (cases 3 and 5 and those reported by Reeve et all and Matula et al2) had more progressive pulmonary oedema, suggesting increasing mitral stenosis. In our experience both types of pulmonary oedema are uncommon in patients with isolated mitral valve regurgitation during bacterial endocarditis.Those of our patients who did not have mitral valve replacement (cases 2, 4, and 5) and the patient of Reeve and his colleagues' had a sudden cardiac arrest. Mitral valve vegetations cause obstruction just as catastrophic as an atrial tumour or a ball thrombus, and hence once the doctor suspects mitral valve obstruction he should confirm the diagnosis promptly and ensure that the patient is rapidly operated on.Accurate diagnosis is vital. Right heart catheterisation showed a raised pulmonary wedge pressure without a striking V wave, but was nevertheless of little value in assessing the severity of the haemodynamic disturbance: pressures may be very high because of rheumatic valve disease (case 4) Journal, 1978, 1, 11-14 Summary and conclusions Thirty-five children known to have had respiratory syncytial virus bronchiolitis in infancy were examined at the age of 8 and their respiratory function tested. The results were compared with those in 35 controls matched for age, sex, and social class. Although 18 of the children who had had bronchiolitis in infancy had experienced subsequent episodes of wheezing, these were neither severe nor frequent in most cases and had apparently ceased by the age of 8. Nevertheless, the mean exercise bronchial lability of the children who had had bronchiolitis was significantly higher than that of the control children and the mean peak expiratory flow rate at rest significantly lower.

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. Diagnosis and clinical significance of parainfluenza virus infections in children. The diagnosis and clinical features of parainfluenza virus infections are described in 151 children admitted to hospital over a 2-year period. Immunofluorescence was the most sensitive method of laboratory diagnosis, while virus isolation in tissue culture was more often achieved from nasopharyngeal secretions than from cough/nasal swabs. Parainfluenza viruses were responsible for approximately 9% of 1603 acute respiratory admissions. Croup was the commonest of the wide range of respiratory illnesses associated with these infections; in a series of 132 children with croup, a parainfluenza virus was identified in 42 %. 24 of the 151 children presented with febrile convulsions, and in a series of 209 children admitted with febrile convulsions, parainfluenza viruses were responsible for 11 %. 3 of the children died in hospital with their parainfluenza virus infections, and in addition there was one instance of a close association between parainfluenza virus type 3 infection and the sudden unexpected death of an infant at home. Parainfluenza virus types 4a and 4b, which have so far rarely been identified, were isolated from 16 children.The age distribution and seasonal patterns of the infections are described. Attention is drawn to the risks of cross-infection by parainfluenza viruses in children's wards, and the finding that virus is commonly excreted for at least a week after the onset of the illness.

SummaryDuring a period covering four winter epidemics 987 respiratory syncytial (RS) virus infections were identified in the children's wards that served a total population of about 875 000 in north-east England. The incidence of admission to hospital with RS virus infection tended to be twice as high among children in Tyneside as that among children from the rest of the catchment area. The risk of hospital admission with RS virus infection in the first year of life for city children was about 1 in 50. The risk tended to be increased when there was a high proportion of children in the population, overcrowded housing, and unemployment. There was no clear relation between climatic changes and the onset or progress of epidemics. Thirteen deaths associated with RS virus infection were identified, four of them sudden and unexpected at home, and nine of them in children with congenital or acquired abnormalities. Twelve children were admitted twice with distinct RS virus infections; the relative severity of their two illnesses depended on age. Hospital cross-infection accounted for 60 of the 987 illnesses.Large families and overcrowding among poorer families seem to lead to a higher incidence of RS virus infection, and measures to reduce overcrowding and improve housing should help to reduce the spread of infection. Breast-feeding also protects infants from infection, but further information is needed to pinpoint the infants at greater risk and how they may best be protected.

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