Neuro-ophthalmic complications of acute varicella

In 16 patients suffering from migraine without aura, we examined quantitative EEG and steady-state visual evoked potentials (SSVEPs) at 27 Hz stimulation during the critical phase of migraine and in attack-free periods. The main spontaneous EEG abnormalities found during the critical phase were the slowing and asymmetry of the dominant frequency in the alpha range. The amplitude of the SSVEP F1 component was significantly reduced during the attack phase compared with the intercritical phase; in the latter condition the visual reactivity to 27 Hz stimulus was increased over almost the entire scalp compared with normal subjects. The EEG abnormalities confirm a fluctuating modification of alpha activity during the migraine attack, probably related to a functional disorder. The suppression of visual reactivity during the migraine attack could be related to a phenomenon of neuronal depolarization such as spreading depression, occurring in a situation of central neuronal increased excitability predisposing to migraine attacks.     

Bacterial complications of primary varicella in children

Bacterial complications of varicella in 84 patients younger than 16 years of age (48 females; median age, 2.9 years) who required hospitalization between 1985 and 1995 were retrospectively analyzed. The purpose of the study was to describe demographics, clinical manifestations, bacteriology, and factors affecting outcome. Seventy-six percent of patients were younger than 5 years of age. The eldest children in households were significantly underrepresented (P = .00025). Skin infections occurred in 61 patients (73%), and deep-seated infections and/or shock occurred in 23 (27%). The latter complications were significantly associated with thrombocytopenia (P = .011) and bacteremia (P = .014) at the time of admission, prolonged fever (P = .001), prolonged hospitalization (P < .0001), intensive care management (P < .0001), and fatal outcome (P = .019). Group A beta-hemolytic streptococcus (59% of isolates) and Staphylococcus aureus (28%) were the predominant isolates. Before and after 1990, five (31%) of 16 and 13 (62%) of 21 streptococcal complications, respectively, were invasive infections (P = .09). These data underscore the need for universal immunization against chickenpox.     

Musculoskeletal rehabilitation

Musculoskeletal problems are common, disabling, and cause great suffering in older adults. Rehabilitation services are frequently indicated and can usually be offered in an outpatient setting. The role of the physician is to make an accurate diagnosis, recognize disability, and refer for rehabilitation services when indicated. There are many diagnostic tests available to assist the physician, but none is as useful and practical as the office examination, including the functional history. Treatment goals with musculoskeletal conditions often are modest and include reduced pain and improved function. Frequently, conditions can flare up or persist in smoldering forms, requiring recurrent interactions with the rehabilitation team. The primary care physician can make use of many of the following resources available to treat musculoskeletal pain and limitations: exercise, medication, physical modalities, adaptive equipment, and arthritis education, including self-help and support groups. Used in combination, these treatments can contribute to increased well-being. The key for the physician is knowing that these options exist and being familiar with their use.     

The merits of varicella vaccination for varicella non-immune health care workers

Immunity against varicella can be reliably established by history and, if negative, confirmed or refuted by serology. If non-immune, the merits of varicella vaccine for a health care worker (HCW) can be stated clearly: Protection from a disease which may be particularly severe in an adult, and evading the inconvenience (investigation time and possible work restriction) and cost of managing an exposure. This paper discusses implementation of a varicella immunity program for HCWs at Columbia Presbyterian Hospital in Oklahoma City.     

Musculoskeletal system neoplasia

Tumors of the musculoskeletal system are rare in horses; however, they must be taken seriously. Diagnosis requires observation of clinical signs, radiographic findings, and histological examination. Veterinarians must realize prognosis is not favorable for most tumors; however, some of these tumors can be treated or at least ameliorated. Tumors discussed in this article include: osteoma and osteosarcoma; osteoblastoma; chondrosarcoma; fibroma and fibrosarcoma; plasma cell myeloma; synovioma; rhabdomyosarcoma and tumors metastatic to the musculoskeletal system.     

Pseudotumour cerebri after varicella

Thrombotic complications in children with varicella are well known. Transient protein S deficiency due to the presence of an anti-protein S antibody seems to be responsible at least in part. In an 8-year-old girl, pseudotumour cerebri with abducens palsy and ileofemoral vein thrombosis occurred 3 weeks after chickenpox. A transient elevation of anti-protein S auto-antibodies was identified. Under treatment with heparin the pseudotumour cerebri rapidly disappeared but the iliofemoral thrombosis persisted. CONCLUSION: Thrombotic complications after varicella might be mediated at least in part by antibodies against protein S. Early recognition of this condition permits appropriate treatment with recombinant tissue-type plasminogen activator.     

Epidemiologic effects of varicella vaccination

For a plausible range of values for the different efficacy characteristics of the live varicella (Oka) vaccine at different levels of coverage, modeling results suggest that routine immunization of preschool children would greatly reduce the number of primary varicella cases, whereas the shift in age distribution of cases would not result in increased overall morbidity as measured by number of hospitalizations. Although information about some of the vaccine assumptions is scanty, the combinations of assumptions leading to an increase in morbidity seem unlikely. A catch-up program in older children who have not yet had chickenpox will be important. The number and age distribution of the cases in vaccinees are sensitive to assumptions about the vaccine, especially the degree and distribution of partial protection against infection, relative residual infectiousness, and waning of immunity. Responsiveness to boosting by wild-type VZV infection was especially important in reducing the number of older cases. The advantage conferred by responsiveness to boosting depends on the level of transmission. The direct and indirect effects of vaccines and vaccination programs interact. Understanding how a vaccine works at the individual level is important for the vaccinated individual, but it also influences the overall public health benefits of an immunization programs. Lieu et al based a cost-effectiveness analysis of varicella vaccines on this model of varicella dynamics and assumptions about how the vaccines work. Models cannot replace biologic understanding. The purpose of such models is not to predict the number of cases of varicella, but to examine some possible consequences of introducing a vaccine into the routine immunization schedule of preschool children in the United States, effects of different vaccination strategies, and the benefits of a temporary catch-up program for older children. Modeling exercises of this sort force us to formalize our thinking, for instance about the vaccine mechanisms, and to admit our uncertainties, such as about the vaccine efficacy assumptions. Such models also show where more data need to be collected, for example, on boosting and waning of immunity and relative residual infectiousness. Improvements in the design of vaccine efficacy studies are necessary to provide the input to these models for looking at the long-term effects of vaccination programs. Frailty models can be used to analyze the data in the presence of heterogeneities in susceptibility. Waning can also be estimated using appropriate methods. Relative infectiousness of vaccinees with breakthrough cases can be measured by comparing the relative secondary attack rates when the index infected person is vaccinated and when the index infected person is unvaccinated. More studies are needed to understand how to evaluate responsiveness to boosting. Vaccine efficacy studies in the field should be designed to obtain better estimates of residual susceptibility, residual infectiousness, duration of protection, and the effects of boosting by reinfection with wild-type VZV.     

Musculoskeletal abnormalities and ichthyosis

Musculoskeletal abnormalities and the associated findings of ichthyosis were seen in three patients between 1972 and 1975. Review of the literature revealed that musculoskeletal abnormalities had previously been recognized in patients with ichthyosis, but not emphasized because of the more frequent and profound neurological abnormalities. Interestingly, our patients had no neurological abnormalities. Ichthyotics should have thorough musculoskeletal as well as neurological and dermatological examinations.     

Controlling varicella in the healthcare setting: the cost effectiveness of using varicella vaccine in healthcare workers

OBJECTIVE: To determine if varicella vaccination of healthcare workers would result in a net cost savings. DESIGN: A Markov-based decision analysis. SETTING: The analysis was based on a hypothetical population of healthcare workers. Data were obtained from exposure records of a tertiary-care hospital and from the literature. Workers were considered potentially susceptible if they had no past history of varicella. RESULTS: Vaccination of potentially susceptible workers would result in a net cost savings of $59 per person. Serological testing prior to vaccination resulted in smaller net savings. The results were robust across a wide range of assumptions. Importantly, however, the result was very dependent on infection control policy regarding work restrictions for vaccine recipients. If more than 3% of vaccinees were removed from work due to vaccine-associated rash, vaccination no longer would result in a net cost savings. CONCLUSION: Varicella vaccination of potentially susceptible healthcare workers can reduce costs and decrease morbidity. Infection control policy regarding work restrictions for vaccine recipients will play a key role in the feasibility of vaccination.     

Chickenpox: varicella pneumonia in adults

Two patients, a man aged 33 years and a woman aged 30, suffered from a varicella zoster induced pneumonia. In adults a varicella zoster infection may be accompanied by a very severe pneumonia. In one patient mechanical ventilation was necessary. A chest X-ray and blood gas analysis must be made in adults suffering from a varicella zoster virus infection who have pulmonary complaints. In case of abnormalities in one of these two examinations the patient must be observed in a clinical setting. The pneumonia can be treated with aciclovir.