Where on the Differential Is Eisenmenger Syndrome in a Patient Without Prior Cardiopulmonary Disease?

Pulmonary hypertension (PH) can occur in patients with undiagnosed congenital heart disease, like atrial septal defects (ASDs), causing chronic left-to-right shunting. This may ultimately result in Eisenmenger physiology or syndrome (ES), a reversal of left-to-right shunting, resulting in a right-to-left shunt, thereby causing deoxygenated blood to enter systemic circulation as it bypasses the lungs. Development of PH due to an ASD is uncommon, and the occurrence of ES is <1% as most ASDs are corrected early in life. We present a 28-year-old female presenting with new-onset dyspnea found to have an undiagnosed ASD with ES. A 28-year-old female without past medical history presented to the emergency department after a chest x-ray performed by her primary care physician (PCP) showed dilation of the pulmonary artery concerning PH. The patient reported a three-month history of progressively worsening intermittent palpitations and dyspnea, now unable to walk more than one block without becoming dyspneic. Further imaging studies revealed a 1.4 centimeters (cm) secundum ASD, 4.4 cm dilatation of the PA, a mean pulmonary artery pressure (PAPm) of 132 millimeters (mm) mercury (Hg), and Eisenmenger physiology. She was placed on pulmonary vasodilators and iron supplementation to address an underlying iron-deficiency anemia. The patient is stable on her current regimen and is undergoing evaluation for possible heart-lung transplantation at an outside hospital. Dyspnea is one of the top 10 most common indications for emergency room visits annually. The differential diagnosis for dyspnea is vast, with ES, affecting only 0.8 in 1 million, far down on the list of possibilities, thus requiring high clinical suspicion to prompt further evaluation. Ultimately, the condition is preventable with early identification of underlying structural abnormalities for which definitive treatment options exist and are readily available, dramatically improving the prognosis if implemented before ES develops.

Tuberculous myopericarditis: a rare presentation in an immunocompetent host.

Tuberculosis is a common cause of pericardial disease in India. Myocardial involvement, although well described in the literature, is a rare manifestation of tuberculosis. We report a patient with disseminated tuberculosis and myopericarditis manifesting as cardiogenic shock. The patient gradually improved on antituberculosis drug therapy, steroids and an evidence-based guideline driven therapy for heart failure. Follow-up imaging showed calcification of the pericardium and improvement of his left ventricular systolic function.

Idiopathic chylothorax in a young man.

Chylothorax refers to the presence of chyle in the pleural space owing to disruption or obstruction of the thoracic duct or one of its tributaries. We present a case of non-traumatic, idiopathic chylothorax in an 18-year-old man. Lymphoscintigraphy was used to identify the site of leak. We tried the full armamentarium of available non-surgical therapy on him, including a modified diet, chest tube insertion, total parenteral nutrition and octreotide. Yet, despite optimal medical therapy, his effusion continued to persist. He eventually required thoracic duct ligation, which resulted in resolution of the effusion.

Humanism at heart: preserving empathy in third-year medical students.

PURPOSE: Research suggests that medical student empathy erodes during undergraduate medical education. The authors evaluated the Jefferson Scale of Physician Empathy Medical Student Version (JSPE-MS) scores of two consecutive medical school classes to assess the impact of an educational intervention on the preservation of empathy. METHOD: The authors conducted a before-and-after study of 209 Robert Wood Johnson Medical School (RWJMS) students enrolled in the classes of 2009 and 2010. Students' clerkships included a mandatory, longitudinal "Humanism and Professionalism" (H&P) component, which included blogging about clerkship experiences, debriefing after significant events, and discussing journal articles, fiction, and film. Students completed the JSPE-MS during their first and last clerkships. RESULTS: The results showed that (1) contrary to previous studies' findings, third-year students did not show significant decline in empathy as measured by the JSPE-MS (these students, from two consecutive RWJMS classes, experienced the H&P intervention), (2) students selected for the Gold Humanism Honor Society (GHHS) were significantly different from their peers in empathy scores as measured by JSPE-MS, and (3) knowledge of selection for the GHHS seems to positively influence students' JSPE-MS scores. CONCLUSIONS: Maintaining empathy during the third year of medical school is possible through educational intervention. A curriculum that includes safe, protected time for third-year students to discuss their reactions to patient care situations during clerkships may have contributed to the preservation of empathy. Programs designed to validate humanism in medicine (such as the GHHS) may reverse the decline in empathy as measured by the JSPE-MS.

3-D X-ray diffraction imaging with nanoscale resolution using incoherent radiation.

A novel approach to X-ray diffraction data analysis for nondestructive determination of the shape of nanoscale particles and clusters in three-dimensions is illustrated with representative examples of composite nanostructures. The technique is insensitive to the X-ray coherence, which allows 3-D reconstruction of a modal image without tomographic synthesis and in situ analysis of large (over a several cubic millimeters) volume of material with a spatial resolution of few nanometers, rendering the approach suitable for laboratory facilities.