Atopy and acquired immune deficiency - issues of control of two extremes of a spectrum of paediatric respiratory disorders with an immunological basis

[摘要] Twenty publications are submitted. All deal with the issues of control of twoends of the spectrum of immune-mediated respiratory disorders in children,namely atopic (asthma and allergic rhinitis) and HIV-related lung disease.This submission summarises the research by the author into this spectrum oflung diseases of children in South Africa, highlighting the diversity of conditionsthat are not only clinically important, but also common. Understanding of allconditions is required to improve the health of children in this region.Management of chronic conditions requires two major end points - adequateand timely diagnosis and - management to control the condition. The author hasa passion for improving the quality of life of children and firmly believes that theresearch findings will, and have, led to transformation in management of boththese common disorders.This document follows the progression of the authors research work andhighlights how interesting and important is the scope of two disorders whichcould be thought to have a central origin, namely in the T-cell. T-cells form thebasis of cellular immunity and an excess of T-helper 2 cell activity promotesatopy, whilst the human immunodeficiency (HI) virus infects T-helper cells andpromotes cellular immune deficiency and its attendant clinical disorders. Theauthor's research work is not based on the immunological basis of theseconditions but does deal with the clinical implications and especially aspectsrelating to control of these two extremes of a clinical spectrum of disorders. Totake the clarity of two diseases at the end of a spectrum to its natural conclusionthese extremes are defined in aetiology or pathophysiological differences(excess versus suppression of the immune system), occurring in the affluentand poor alike versus just the poor, control being required to improve quality oflife versus to save lives and finally that management requires anti-inflammatorytherapy versus antibiotic and anti-infective therapy.For the eight publications based on atopic respiratory disease in children thethemes are firstly that children with asthma and chronic rhinitis are diagnosedlate, that most individuals with these conditions are not well controlled andfinally that the reasons for lack of control are becoming obvious.For the first time, the significant lack of asthma and allergic rhinitis control inSouth Africa is documented. These studies suggest that, like surveys from therest of the world, asthma control is seriously under-estimated and neglected inall asthmatics in South Africa, in both the privileged and the under-privileged.The research also defines reasons for poor asthma and allergic rhinitis controlin this region. As in many studies published from around the world it is nowevident that poor asthma and allergic rhinitis control cannot be blamed on anyone source. A multitude of reasons underlie this phenomenon and each of thesubsequent papers in this section illustrates attempts at defining theseprinciples. The three most important reasons for poor control are probably thatmost asthmatics are managed in the wrong hands (by doctors who don'tunderstand adequate control and who aren't empowered to use the correcttherapy), that control may actually be a pipe dream and practically difficult to door even impossible to achieve and lastly that the allergic basis of asthma is overemphasised and may not in fact determine all asthma.The subsequent papers summarise research work in the field of HV infection inchildren and exposes the opposite end of a spectrum of Paediatric respiratorydisease and highlight research into the conditions common in HIV-infectedchildren. Eleven papers are presented. For the diseases associated with the HIvirus the major complications of inadequate diagnosis and prevention inchildren are acute pneumonia (especially severe pneumonia) andbronchiectasis. Bronchiolitis is not common in HIV infected children, despiteepidemics of this condition in non-infected children. Passive smoking does notaggrevate or worsen disease progression in children. The complications of HIVrelated diseases in children require the same principles of adequate diagnosisand control as would apply to the chronic atopic conditions. Once the author delved into the disorders at the other end of the clinicalspectrum, namely those associated with immune deficiency secondary to HIVinfectionhe faced the question of a possible relationship between theconditions. One submission explores that relationship.This research has a unique perspective, conferred by the fact that these twoconditions do not occur to the same extent anywhere else in the world. Atopicrespiratory conditions and HIV-related lung diseases occur side by side inabundance in this region. This perspective has created a clarity for research toaddress the two most important aims in clinical medicine, namely to diagnosecorrectly and then to manage the condition so that control is achieved. Thesemust be universal principles of the successful practice of medicine.

[发布机构] University of Pretoria