Ventricular activation time as a marker for diastolic dysfunction in early hypertension.

BACKGROUND: A standard 12-lead electrocardiogram (ECG) is performed in all hypertensive patients, primarily to detect left ventricular hypertrophy. Echocardiographic assessment of hypertensive subjects reveals that abnormalities in diastolic function occur more commonly and earlier than increased left ventricular mass. However, ECG changes associated with diastolic dysfunction (DD) remain poorly defined; we assessed the ventricular activation time (VAT) (i.e., the time for the ventricle to depolarize) as a potential marker for DD in early hypertension. METHODS: Ninety subjects (aged 46 +/- 1.3 years; 43 men) with newly diagnosed, untreated hypertension underwent ECG and comprehensive two-dimensional echocardiography. Left ventricular DD was echocardiographically assessed using Canadian Consensus Guidelines. We compared VAT, which corresponds to the QR interval in the 12-lead ECG, with echocardiographic parameters of DD. RESULTS: VAT was prolonged in subjects with DD (46.3 +/- 0.4 vs. 39.6 +/- 0.3 ms, P < 0.01). There was a significant correlation between VAT and tissue Doppler imaging (TDI) (early diastolic velocity) e' (r = -0.53, P < 0.0001), (ratio of early and late diastolic velocities) e'/a' (r = -0.53, P < 0.0001), transmitral Doppler (TMD) (early peak filling rate, and early deceleration peak) E/A (r = -0.32, P = 0.001), and (ratio of early diastolic mitral inflow and early diastolic velocities) E/e' (r = 0.44, P < 0.0001). CONCLUSION: Prolongation of the VAT is associated with DD in patients with newly diagnosed untreated hypertension.

Talc pleurodesis: a new technique.

Pleurodesis is a commonly used option in the management of malignant pleural effusion. Although several chemical agents are used talc has only recently been advocated as the sclerosing agent of choice. Talc can be administered via open thoracotomy or tube thoracostomy, but thoracoscopy offers an excellent alternative to these approaches. We describe a new technique of thoracoscopically applied talc pleurodesis that is easy, inexpensive, and reliable.

Aboriginals with multiple sclerosis: HLA types and predominance of neuromyelitis optica.

BACKGROUND: MS is common in people of northern European ethnicity who live in northern geographic areas; however, MS is rarely identified among aboriginal peoples living in the same areas. OBJECTIVES: To determine the prevalence, clinical features, HLA type, and viral infections associated with MS among aboriginals in Manitoba, Canada. METHODS: A retrospective study was performed in which the clinical features of all aboriginal patients with MS together with HLA type and human herpesvirus-6, HIV-1, human T-cell lymphotropic virus-1, and endogenous retrovirus associated with MS (MSRV) infections were analyzed and compared with results from nonaboriginal patients with MS. RESULTS: Seven aboriginals with MS were identified with a period prevalence among aboriginals of 40:100,000. Clinical features included relapsing-remitting (n = 6) or primary progressive (n = 1) phenotypes with aggressive disease courses and frequent involvement of optic nerves and spinal cord (n = 5) compared with nonaboriginal patients. Autopsy of one patient showed necrosis and eosinophil infiltrates in a cervical spinal cord lesion and a demyelinated optic nerve. Analysis of HLA alleles at the DRB1 and DQB1 loci indicated that the HLA types detected were common in aboriginals, but there were no HLA alleles previously associated with the development of MS. Analysis of the copy number of MSRV did not show differences among aboriginals and nonaboriginals with or without MS. CONCLUSIONS: Aboriginals of Algonkian background are at increased risk for an aggressive type of MS, resembling neuromyelitis optica, which is resistant to conventional MS treatments and occurs independently of HLA alleles previously associated with MS.

Intracystic Breast Carcinoma with Giant Axillary Metastasis: A Case Report.

Cystic breast disease is the most frequent cause of benign breast masses. While breast cysts are common, intracystic lesions, especially intracystic carcinomas, are rare. Furthermore, while breast carcinoma is the most common cancer in women, intracystic breast cancers are rare. Most intracystic breast carcinomas have been described as either papillary or medullary subtypes with infiltrating ductal carcinomas being much less common. The literature has shown their incidence to range from 0.3% to 7% of all breast carcinomas. We describe an interesting case of a premenopausal woman with a large cystic breast carcinoma and review the literature.

All-terrain vehicle injuries in children: industry-regulated failure.

Although the sale of all-terrain vehicles (ATVs) to children under 16 years of age was prohibited in 1988, they continue to represent half of the ATV-associated injuries. We conducted a retrospective review of ATV injuries admitted to our institution from 1988 to 1998. We identified 76 patients over the last 10 years, with 50 patients admitted in the last 4 years. Children <16 years of age account for 50 per cent of all ATV-injured patients. Only eight per cent of these children wore helmets. We conclude that despite industry regulation, nearly half of ATV injuries continue to involve children under 16 years of age. The consent decree restricting access of children <16 years of age to ATVs has been ineffective and expired in April 1998. Significant morbidity and mortality continues to occur in children <16 years of age who operate these vehicles. Reform is needed, such as legislation that would mandate the sale of safety equipment on ATV purchase, as well as provide for ATV safety education.

Atraumatic lung hernia.

Lung hernia is a distinctly rare event, regardless of its location and cause. Most lung hernias are acquired traumatic thoracic hernias. All previously reported cases of acquired spontaneous lung hernia involve some aspect of trauma, most commonly caused by vigorous coughing with a subsequent rib fracture. We report a case of totally atraumatic, acquired spontaneous lung hernia.

Herpes zoster and multiple sclerosis.

BACKGROUND: Clinical experience suggests that young multiple sclerosis patients may have herpes zoster (HZ) earlier and more often than the general population. As there is evidence of a relationship between varicella zoster virus (VZV) and MS, a study of HZ and MS was undertaken. METHODS: Eight hundred and twenty-nine patient-members of the Manitoba Chapter of the Canadian Multiple Sclerosis Society were surveyed by mail. Six hundred and thirty-three (76%) responded. Questions included: age at diagnosis of MS, history of HZ (yes, no, probably), number of episodes of HZ and age at each occurrence, date of birth, and sex of respondent. The controls were consecutive patients with other neurological diseases (OND) attending local neurological or neurosurgical clinics, plus practice-based and population-based surveys of herpes zoster without reference to any other disease. The OND controls were assessed at the time of their outpatient visits. RESULTS: In the MS group with a positive/probable history of HZ, the HZ/MS rate was 106/633 (16.8%); in the practice-based survey the rate was 192/3534 (5.4%); and among the patients with OND it was 42/616 (6.8%). The HZ occurred at an earlier age in the MS group. The majority of male patients had HZ prior to the diagnosis of MS. The date of diagnosis is more likely to be a precise memory as opposed to the onset of symptoms. More than one attack of HZ was also more common in the MS group. CONCLUSIONS: This survey adds to the evidence that patients with MS have a unique relationship with the herpes zoster virus.

Acute intracranial boxing-related injuries in U.S. Marine Corps recruits: report of two cases.

Serious acute intracranial injuries from boxing are a recognized, albeit rare, event. Acute brain injuries such as concussion, hemorrhage, and contusion are easily recognized because of their rapid onset of neurological impairment. The sequelae of such injuries range from transient diminished cognitive function to irreversible brain damage and, on occasion, death. The more serious injuries are certainly minimized as a result of regulatory policy, improved medical awareness, and the use of safety equipment. The incidence of serious acute head injury in amateur boxing and noncompetitive boxing is lower than that found in the professional ranks. Our survey of instructional boxing in U.S. Marine Corps basic training during an 8-year period detected only three serious acute brain injuries incurred by approximately 180,000 participants, equating to one serious head injury per 60,000 participants. Serious head injuries constituted an extremely small percentage (0.3%) of the approximately 1,100 total boxing-related injuries surveyed during the period. We present two cases of serious acute brain injury incurred during noncompetitive boxing skills instruction as a part of U.S. Marine Corps basic training. A review of the data leads us to conclude that the risk of serious head injury in a well-supervised, instructional boxing program is relatively minimal. In any case, we recommend that any boxing be appropriately supervised and that specialized trauma care and an adequate transport mechanism to secure that care be readily available.

The varicella-zoster virus and multiple sclerosis.

This article is a review of the evidence suggesting a unique relationship between the varicella-zoster virus (as a possible antigen or antigen mimic) and multiple sclerosis (MS). Both MS and varicella have increased prevalences in temperate zones and both are rare in countries closer to the equator. Migration studies suggest an infectious agent acquired prior to age 14 plays a role in the risk of subsequent MS. Hutterites, who educate their children at home, have less varicella, MS, and herpes zoster than their neighbors and have the appropriate reduced varicella-zoster seropositivity matching these clinical observations. Paradoxically, patients with MS report more herpes zoster, and at an earlier age and more often, than a group of non-MS patients.

Varicella zoster antibodies after herpes zoster, varicella and multiple sclerosis.

BACKGROUND: We previously showed that Manitoba Hutterites seek physician care for varicella zoster virus infection significantly less than non-Hutterites. The current study was undertaken to measure varicella zoster virus seroprevalence for Hutterite and non-Hutterite controls. METHODS: Blood was obtained from 315 Hutterites and 259 similar age and sex controls at the time of blood donations to The Canadian Red Cross Society. The controls were from the same or a contiguous postal code area and were collected at the same time as the Hutterite samples. The immune status of the specimens was determined by the ELISA method (enzyme linked immunosorbent assay). RESULTS: Twenty-eight per cent of 315 Hutterites had no immunity and an additional 25% had only marginal immunity. Among the 259 controls, 10% had no immunity and an additional 10% had only marginal immunity (p < .0001). CONCLUSIONS: Manitoba Hutterites have significantly decreased seroprevalence to varicella zoster virus infection. This study of serum varicella zoster virus antibodies verifies a previous population based study that demonstrated the relative rarity of varicella and herpes zoster among a particular population group.

Common infectious diseases in a population with low multiple sclerosis and varicella occurrence.

A previous study revealed the rarity of varicella zoster virus (VZV) diseases among 5601 Hutterite Brethren living in a high-risk area for these diseases. The current study was established to determine the frequency of other common infectious diseases. The information was gathered from a population-based study of a unique group of Manitoba citizens and compared with an equal number of their age and sex-matched neighbors. The data were contained in the records of the Manitoba Health Services Commission (MHSC). The MHSC, the sole paying agency for medical diseases in Manitoba, contained 94,383,972 records for all of Manitoba for the years 1985 to 1991 inclusive. From these, the records of a cohort of 5601 Hutterites and an equal number of non-Hutterite age- and sex-matched controls were examined for the frequency of 14 diseases of interest. To be eligible a Hutterite subject must have one of the 22 unique family names and live on a Colony with the precise address. A control must be age (within 10 years) and sex-matched, live in the same or a contiguous postal code, and use the same medical practitioners. There were no interventions or identification of any member of the study. Mumps, acute coryza, and rubella are of the same frequency among the two groups. Only herpes simplex and cellulitis are more common among the Hutterites. All of the other nine common infectious diseases are significantly more common among the controls. The VZV diseases are not exclusively less common among the Hutterite Brethren. Nine other common infectious diseases are also less common but the degree of significant difference does not reach the level of the VZV diseases. The reduction in numbers of these diseases among the Hutterites is not related to the vaccination habits of the group and is not due to physical isolation. The Hutterites appear to have a more effective immune system relative to their neighbors.

The varicella zoster virus: a pilot trial of a potential therapeutic agent in multiple sclerosis.

There are a number of similarities in the geographic, latitudinal, and epidemiological features of multiple sclerosis (MS) and varicella (V). In the experimental model of MS, repeated high antigen doses (myelin basic protein) have deleted both the clinical and pathological manifestations of the disease. Therefore, it seemed appropriate to explore the effects of varicella zoster vaccine on patients with MS. Fifty patients with chronic progressive MS were vaccinated with attenuated varicella virus vaccine and followed for one year. Fourteen patients improved, four became worse, and twenty-nine were unchanged. All patients were seropositive for varicella before vaccination and all had a rise in varicella antibodies after the vaccinations. There were no major untoward results from the vaccine. Four patients developed mild chicken-pox after vaccination. This was a short-term pilot trial without control subjects. Thus, the apparently favourable clinical and magnetic imaging changes must be assessed with caution, as must the lack of adverse effects.

Varicella zoster virus and multiple sclerosis in a Hutterite population.

There are similarities between multiple sclerosis and varicella. They are common in the same parts of the world and both are scarce in other areas. Immigration studies suggest the environmental cause of multiple sclerosis (MS) must be contracted prior to age 15 years and will usually remain dormant for years. At age 10 years varicella has occurred in greater than 95% of children living in the high-risk areas for both of these diseases. The varicella zoster virus (VZV) could be etiologically important in multiple sclerosis. The known host containment of the virus for decades with recrudescence and the variable cell-mediated immunity of the host, which can wax and wane without clinical manifestations, all lend themselves to the natural history of multiple sclerosis. A population-based study of the medical records of 5601 Hutterite Brethren was performed to determine the occurrence of multiple sclerosis, varicella, and herpes zoster. Compared to their matched non-Hutterite neighbors who acted as controls, these events were significantly less common among the Hutterites. Included in the study was an assessment of other common neurological diseases and "autoimmune" diseases among the Hutterites and the controls. There is evidence of a relationship between MS and VZV that may not be coincidental.

Geographic similarities between varicella and multiple sclerosis: an hypothesis on the environmental factor of multiple sclerosis.

The environmental factor causing multiple sclerosis (MS) is unknown. Kurtzke et al. (Neurology 1979; 29: 1228-1235) depicted a north to south diminishing gradient in the case/control ratios for MS among American veterans in the United States. A similar, but less precise, gradient emerged when the incidence rates of varicella from 37 states during 1978-91 were compared. A loose correlation appears to exist between the mean incidence of varicella and the MS risk ratio (n = 0.344 Spearman rank correlation coefficient, p = 0.037). Further, the data on the fat of migrants moving from a high risk MS country to a low risk country and the reverse, plus the great importance of the age at migration, raise the question of a possible connection between the two diseases. Because of these epidemiological and other similarities between the two diseases a further comparative study was suggested.