Coronary artery fistula following surgical myectomy for hypertrophic obstructive cardiomyopathy: a case report.

Background: Coronary artery fistula is a rare, but recognized complication of surgical myectomy. Although most communicate with the right heart, a large fistula into the left ventricular cavity may result in a shunt haemodynamically analogous to aortic regurgitation. Understanding the variable presentation of iatrogenic coronary fistulae and the optimal evaluation strategy is critical to obtaining a timely diagnosis and instituting treatment. Case summary: We report the case of a 57-year-old renal transplant recipient admitted for evaluation of presyncope, one-year post-surgical myectomy for hypertrophic obstructive cardiomyopathy. An iatrogenic coronary artery fistula was suspected by transthoracic echocardiography, and later confirmed with both non-invasive and invasive coronary angiography. Discussion: We highlight various cardiac imaging modalities that confirmed the diagnosis of coronary artery fistula and helped to determine the clinical significance. We report the tailored approach often required to determine the anatomic and haemodynamic characteristics of coronary fistulae and outline potential management strategies.

The Migration of Lynch Victims' Families, 1880-1930.

We examine the relationship between the lynching of African Americans in the southern United States and subsequent county out-migration of the victims' surviving family members. Using U.S. census records and machine learning methods, we identify the place of residence for family members of Black individuals who were killed by lynch mobs between 1882 and 1929 in the U.S. South. Over the entire period, our analysis finds that lynch victims' family members experienced a 10-percentage-point increase in the probability of migrating to a different county by the next decennial census relative to their same-race neighbors. We also find that surviving family members had a 12-percentage-point increase in the probability of county out-migration compared with their neighbors when the household head was a lynch victim. The out-migration response of the families of lynch victims was most pronounced between 1910 and 1930, suggesting that lynch victims' family members may have been disproportionately represented in the first Great Migration.

Weaving and Layering Funding: A Territorial Health Agency's Guide to Effective Health Financing.

CONTEXT: State and territorial health agencies can optimize programmatic funding through braiding and layering strategies. IMPLEMENTATION: The Commonwealth Healthcare Corporation, a territorial health agency located on the Pacific Island of Saipan, Commonwealth of the Northern Mariana Islands (CNMI), restructured its Non-Communicable Disease Bureau into 4 new units. Existing funding streams were braided and layered to support the restructuring. A shared vision of strengthening crosscutting connections to improve population health outcomes helped guide the restructuring process. Vision planning with leaders and funding partners, establishing buy-in within agency and external partners, and assessing immediate impacts were a few of the steps taken by the agency to ensure a successful restructuring. IMPACT: The immediate impact of the restructure has been positive. In both the CNMI and select states that have undertaken similar efforts, braiding and layering funding has facilitated more streamlined processes, coordinated approaches across programs and funding partners, and provided deeper levels of trust in partnerships. Although it is still too early to draw long-term assessments in the CNMI, the agency projects that coordinated funds will strengthen its foundational capabilities and promote a more community-centered, collaborative, and effective approach to public health. Restructuring the Non-Communicable Disease Bureau through braiding and layering funds gives the agency the flexibility it needs to more effectively address the social determinants of health and local population health priorities through a client-centered approach, ultimately improving health outcomes for the commonwealth. LESSONS LEARNED AND IMPLICATIONS: The agency experienced several challenges throughout the restructuring process that offer lessons learned for addressing effective health financing. For example, ample time is needed at the beginning of the braiding and layering process to establish policies and procedures for efficient accounting, documenting, and reporting. In addition, ongoing support and training opportunities for programmatic teams can smooth out the transition from siloed to braided and layered funding structures. These lessons, in addition to key elements mapped out by experienced state health agencies, can guide and prepare other agencies interested in implementing innovative funding mechanisms.

Clerkship Chiefs: Introducing Students to the Role of Physician Educator.

As a Clerkship Chief, senior medical students prepare for future roles as physician leaders and future medical educators. The Clerkship Chief elective offers senior students an opportunity to work with junior students on their core clerkships. Chiefs assume an educational leadership role as they mentor and provide supplemental formative feedback to junior students in real time. As educators, Chiefs answer questions, prepare study materials and didactics, and assist clerkship students with time management. This early experience and behind-the-scenes view of medical education may influence attitudes and decisions of senior students in pursuit of education leadership.

Absolute cardiovascular disease risk score and pharmacotherapy at the time of admission in patients presenting with acute coronary syndrome due to coronary artery disease in a single Australian tertiary centre: a cross-sectional study.

OBJECTIVES: To describe (1) absolute cardiovascular disease risk (ACVDR) scores in patients presenting to hospital with acute coronary syndrome (ACS) and (2) proportions of these patients on guideline-recommended pharmacotherapy according to their ACVDR score. DESIGN: Cross-sectional study. SETTING: Single-site tertiary centre hospital, Queensland, Australia over a 12-month period. PARTICIPANTS: Patients >18 years of age presenting to hospital with ACS due to coronary artery disease (CAD) confirmed by angiography. PRIMARY AND SECONDARY OUTCOME MEASURES: Proportion of patients without prior history of CVD with a high ACVDR score, and of patients with a prior history of CVD, who are on guideline-recommended pharmacotherapy. RESULTS: 527 ACS patients were included of whom the mean age was 63 years and 75% were male. Overall, 66% (350) had no prior CVD and 34% (177) patients had prior CVD.In patients with no prior CVD, the proportions of patients with low, intermediate and high CVD risk scores were 41%, 24% and 36%. In the no prior CVD, high-risk patient group, 48% were on no preventative pharmacotherapy, 32% on single pharmacotherapy and 20% patients on complete guideline-recommended pharmacotherapy. In the prior CVD group, 7% patients were on no pharmacotherapy, 40% on incomplete pharmacotherapy and 53% were on complete guideline-recommended pharmacotherapy. CONCLUSION: This study adds to the evidence on implementation gaps in guideline-recommended management of ACVDR, showing that a large proportion of patients presenting with ACS due to CAD were at high risk of developing CVD prior to the event and most were not on guideline-recommended treatment. A significant proportion of these events are likely to have been preventable, and therefore, increased assessment and appropriate treatment of ACVDR in primary care is needed to reduce the incidence of CVD events in the population.

Institutional Castling: Military Enlistment and Mass Incarceration in the United States.

The military is a major state provider of employment, occupational training, and educational subsidies. Yet military downsizing and its increased selectivity during penal expansion may have cleaved off employment opportunities for disadvantaged men. We show how institutional castling-the shifting prominence of competing institutions in the lives of specific demographic groups-has affected the underlying risk of military employment and penal confinement. Black veterans who have dropped out of high school are less likely to be incarcerated than their nonveteran counterparts, and declines in the employment rates of military servicemembers with less than a high school education are associated with large increases in incarceration rates. The military's critical role in providing institutional protection from the penal system has eroded for young, undereducated African American men.

Sleep-Disordered Breathing in Patients with Pulmonary Valve Incompetence Complicating Congenital Heart Disease.

OBJECTIVE: Long standing pulmonary regurgitation results in deleterious effects on right heart size and function with late consequences of right heart volume overload including ventricular dilatation, propensity to arrhythmia and right heart failure. As sleep disordered breathing may predispose to elevations in pulmonary vascular resistance and associated negative effects on right ventricular function, we sought to assess this in patients with underlying congenital heart disease. DESIGN: We performed a pilot study to evaluate the incidence of sleep-disordered breathing in a patient population with a history of long standing pulmonary valve incompetence in patients with congenital heart disease using overnight oximetry. PATIENTS: Patients with a background of tetralogy of Fallot repair or residual pulmonary incompetence following previous pulmonary valve intervention for congenital pulmonary stenosis were included. RESULTS: Twenty-two patients underwent overnight oximetry. The mean age of the cohort was 34.3 ± 15.2 years with no patients observed to have severe underlying pulmonary hypertension. Abnormal overnight oximetry was seen in 13/22 patients (59.1%) with 2/22 (9.1%) patients considered to have severe abnormalities. CONCLUSIONS: An important proportion of patients with a background of pulmonary incompetence complicating congenital heart disease are prone to the development of sleep-disordered breathing as assessed by overnight oximetry. Further study into the prevalence and mechanisms of sleep-disordered breathing in a larger cohort are warranted.

Truancy and injury-related mortality.

Truancy has well-documented short-term and long-term consequences, but there are few studies that look at its impact on injury-related mortality. This study evaluated the rate of injury-related mortality for 2006-2010 among youth (11-17 years old) with a history of severe truancy compared with youth without such history. There were 168 injury-related deaths (51 homicide, 29 suicide and 88 unintentional injury deaths) among youth in Dallas County. Fifteen of these deaths were among youth with a history of severe truancy. Injury-related mortality was more than five times higher among youth with history of severe truancy compared with youth without such history. Youth with a history of severe truancy have an increased risk of injury-related death. Further research may be warranted to evaluate the part of less severe levels of truancy on mortality and to study the effectiveness of truancy intervention programmes on the risk of death from injuries.

Targeting Lynch Victims: Social Marginality or Status Transgressions?

This paper presents the first evidence yielded by a newly-compiled database of known lynch victims. Using information from the original census enumerators' manuscripts, we identify the individual- and household-level characteristics of more than 900 black males lynched in ten southern states between 1882 and 1930. First, we use the information gathered for successfully linked cases to present a profile of individual-level and household-level characteristics of a large sample of lynch victims. Second, we compare these characteristics to a randomly-generated sample of black men living in the counties where lynchings occurred. We use our findings from this comparative analysis to assess the empirical support for alternative theoretical perspectives on the selection of individuals as victims of southern mob violence. Third, we consider whether the individual-level risk factors for being targeted as a lynch victim varied substantially over time or across space. Our results demonstrate that victims were generally less embedded within the social and economic fabric of their communities than were other black men, suggesting that social marginality increased the likelihood of being targeted for lynching. These findings were generally consistent across decades, and within different socio-demographic contexts.

Practicing What They Preach? Lynching and Religion in the American South, 1890 - 1929.

This project employs a moral solidarity framework to explore the relationship between organized religion and lynching in the American South. We ask whether a county's religious composition impacted its rate of lynching, net of demographic and economic controls. We find evidence for the solidarity thesis using three religious metrics. First, our findings show that counties with greater religious diversity experienced more lynching, supporting the notion that a pluralistic religious marketplace with competing religious denominations weakened the bonds of a cohesive moral community and might have enhanced white racial solidarity. Second, counties in which a larger share of the black population worshipped in churches controlled by blacks experienced higher levels of racial violence, indicating a threat to the prevailing moral community or inter-group racially based solidarity. Finally, we find a lower incidence of lynching in counties where a larger share of church members belonged to denominations with racially mixed denominations, suggesting that cross-racial solidarity served to reduce racial violence.

Neonatal long QT syndrome type 3 predicted by positive lidocaine challenge.

A female infant presented with bradycardia and an electrocardiogram demonstrating 2:1 atrioventricular depolarization, a prolonged QT interval, and T wave alternans. After propranolol therapy was initiated, a lidocaine challenge was performed with progressive shortening of the QT interval. This positive lidocaine challenge prompted clinical suspicion of long QT syndrome type 3 (LQT3) and early initiation of mexiletine therapy. Subsequent genetic testing confirmed the infant's diagnosis of LQT3.

How personal is the political? Democratic revolution and fertility decline.

Existing theory has identified the capacity of political revolutions to effect change in a variety of social institutions, although relationships between revolution and many institutions remain unexplored. Using historical data from twenty-two European and four diaspora countries, the author examines the temporal relationship between timing of revolution and onset of fertility decline. The author hypothesizes that specific kinds of revolutionary events affect fertility by engendering ideological changes in popular understandings of the individual's relationship to society and ultimately the legitimacy of couples' authority over their reproductive capacities. Results demonstrate that popular democratic revolutions -- but not institutionalized democratic structures -- predict the timing of the onset of fertility decline.