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Background Progressive left ventricular (LV) diastolic dysfunction due to hypertension (HTN) alters left atrial (LA) contractile function in a predictable manner. While increased LA size is a marker of LV diastolic dysfunction and has been shown to be predictive of adverse cardiovascular outcomes, the prognostic significance of altered LA contractile function is unknown. Methods A consecutive group of patients with chronic hypertension but without significant valvular disease or prior MI underwent clinically-indicated CMR for assessment of left ventricular (LV) function, myocardial ischemia, or viability. Calculation of LA volumes used in determining LA emptying functions was performed using the biplane area-length method. Results Two-hundred and ten patients were included in this study. During a median follow-up of 19 months, 48 patients experienced major adverse cardiac events (MACE), including 24 deaths. Decreased LA contractile function (LAEFContractile) demonstrated strong unadjusted associations with patient mortality, non-fatal events, and all MACE. For every 10% reduction of LAEFContractile, unadjusted hazards to MACE, all-cause mortality, and non-fatal events increased by 1.8, 1.5, and 1.4-folds, respectively. In addition, preservation of the proportional contribution from LA contraction to total diastolic filling (Contractile/Total ratio) was strongly associated with lower MACE and patient mortality. By multivariable analyses, LAEFContractile was the strongest predictor in each of the best overall models of MACE, all-cause mortality, and non-fatal events. Even after adjustment for age, gender, left atrial volume, and LVEF, LAEFContractile maintained strong independent associations with MACE (p < 0.0004), all-cause mortality (p < 0.0004), and non-fatal events (p < 0.0004). Conclusions In hypertensive patients at risk for left ventricular diastolic dysfunction, a decreased contribution of LA contractile function to ventricular filling during diastole is strongly predictive of adverse cardiac events and death.

We aimed to establish whether there was a variation in orocecal transit time (OCTT) in Myanmar children and whether shortened transit time correlated with malnutrition. OCTT was measured in 90 healthy Myanmar children aged 1-5 years, using the hydrogen breath test (10g in 10% aqueous solution). The relationships between OCTT, sex, age, and malnutrition status were assessed. OCTT for 1 to 5-year old children was 90.2 +/- 20min (mean +/- SD). There was no significant difference in mean OCTT between boys and girls, breast-fed and weaned children, malnourished and non-malnourished children. There was also no difference between age groups (1-2 years, 2-3 years, 3-4 years, and 4-5 years), and no correlation was found between age and orocecal transit time. The assessment of OCTT using the lactulose breath hydrogen test was found to be feasible and acceptable in the field setting. The OCTT of Myanmar children with rice as a staple food is similar to that of children from developed countries having a different diet, and no shortening of transit time was demonstrated in children with malnutrition.

Ten patients with uncomplicated malaria, ten with cerebral malaria and 37 controls (blood donors from blood bank) were included in the study. The serum cortisol levels of the patients were determined daily for 7 days while they were at the hospital. A radio-immunoassay method was used for quantitative measurement of cortisol in human serum. The mean serum cortisol level of patients with uncomplicated malaria was 528.2 +/- 123.9 nmol/l, with cerebral malaria was 516.0 +/- 80.5 nmol/l, and in controls was 393.8 +/- 141.0 nmol/l. There was a significant rise of serum cortisol levels in patients with malaria when compared to controls at the day of admission to hospital. There was no significant difference between uncomplicated malaria patients and those with cerebral malaria. There was also no significant difference between the different days of treatment up till day 7. We found no cortisol insufficiency in cases with falciparum malaria during acute and convalescent stages of illness.

Forty-eight Russell's viper bite patients (40 males, 8 females), age ranging from 16-76 years were studied. Out of 48 patients, 14 were found to have a prolonged whole blood clotting time test (WBCT) (i.e. incoagulable blood) (Group 1); 23 had a normal WBCT (i.e. clotted blood) (Group II); and 11 patients had a normal WBCT on admission which changed to non-clotting during the clinical course (Group III). Four patients from group I developed hypotension and 2 expired. The serum cortisol concentration (mean +/- SEM) on admission among groups I and II were 639 +/- 45.6 and 424 +/- 33.2 nmol/l respectively. The blood cortisol level in 35 subjects (controls) were 370.7 +/- 17.7 nmol/l (mean +/- SEM). There was a significant rise of blood cortisol in patients with incoagulable blood when compared to controls at the time of admission to the hospital (p0.05); but there was no significant difference among those patients with clotted blood. A much higher mean serum cortisol level was observed in 4 patients with hypotension as compared to 10 patients without shock. These patients with hypotension according to our study shown to have a favorable response to steroid therapy and eventually recovered. Whether higher doses of steroid in addition to antiserum confer extra benefit in suppressing nonspecific venom effects on the pituitary and/or adrenal is not known.

Robert J. Hariman, MD; Maung M. Khin, MD; Robert G. Zoble, MD, PhD; Department of Cardiology, James A. Haley VA Hospital, Tampa, Florida. Dr Hariman is now with the Department of Medicine, University of Illinois College of Medicine at Peoria. A 22-YEAR-OLD HISPANIC MAN PRESENTED to the emergency department with palpitation after playing basketball. He had similar episodes of palpitation associated with exercise, which disappeared spontaneously. He denied any previous cardiac history. On examination, he appeared diaphoretic with a blood pressure of 96/60 mm Hg. His heart rate was above 200 beats/min. His lungs were clear to percussion and auscultation. The rest of his examination findings were normal. His complete blood cell count and serum electrolyte, creatinine, glucose, and troponin-I levels were normal. The presenting electrocardiogram (ECG) is shown in Figure 1. Questions: What is the treatment for this patient? What is the etiology for his rapid heart rate?

A total of 49 consecutive specimens of lung cancer were collected prospectively at surgical resection or autopsy from 40 men and nine women, aged 40-74 years. Of the 49 tumors, the gross appearance of 22 fitted the description of a scar cancer, i.e., a tumor with pleural puckering and central pigmentation. Nineteen of the "scar cancers" were peripheral (17 adenocarcinomas and two squamous cell carcinomas); three were central (one squamous cell carcinoma and two adenocarcinomas). In the 19 peripheral "scar cancers," elastic stains demonstrated the presence of collapsed, unfibrosed lung tissue at the center with traction of the overlying pleura toward it. Elsewhere in the tumor, the elastic framework was either destroyed or expanded by tumor filling the alveolar spaces. None of the "scar cancers" had a significant desmoplastic reaction that might otherwise explain the scarred appearance. It appeared that local atelectasis was solely responsible for the pleural puckering and central pigmentation. On the other hand, atelectatic lung tissue was not seen in the 27 cancers that did not have the appearance of a scar cancer. Tuberculosis was found in 10 of the 49 lung specimens. In only one specimen was the tuberculous lesion anatomically associated with the tumor. There was no evidence of pulmonary infarct in any of the specimens. The term "scar cancer" was considered inappropriate as there was no preformed fibrous tissue. The scarred appearance was thought to be the result of localized pulmonary atelectasis owing to small airways obstruction by tumor. Association with tuberculosis was considered incidental.