Simulation-based training in echocardiography.

The knowledge gained from echocardiography is paramount for the clinician in diagnosing, interpreting, and treating various forms of disease. While cardiologists traditionally have undergone training in this imaging modality during their fellowship, many other specialties are beginning to show interest as well, including intensive care, anesthesia, and primary care trainees, in both transesophageal and transthoracic echocardiography. Advances in technology have led to the development of simulation programs accessible to trainees to help gain proficiency in the nuances of obtaining quality images, in a low stress, pressure free environment, often with a functioning ultrasound probe and mannequin that can mimic many of the pathologies seen in living patients. Although there are various training simulation programs each with their own benefits and drawbacks, it is clear that these programs are a powerful tool in educating the trainee and likely will lead to improved patient outcomes.

Wearing the mask of ST-elevation myocardial infarction: postpericardiotomy syndrome.

INTRODUCTION: Postpericardiotomy syndrome (PPS) is an inflammatory process, affecting 15% to 20% of patients, after surgery involving pleura, pericardium, or both. The role of electrocardiogram (ECG) in diagnosing PPS is uncertain because ECG is rarely normal (especially after cardiac surgery). We report a case of PPS that presented initially with localized ST-segment elevation and also discuss proposed mechanisms. CLINICAL CASE: A 60-year-old White man presented to the emergency department (ED) after having chest pain, shortness of breath, and palpitation for approximately 2 hours. Patient had known coronary artery disease, status postcoronary artery bypass graft a month earlier with a graft to right coronary artery, and 2 grafts to marginal arteries. In the ED, ECG revealed localized ST-segment elevations in leads II, III, and aVF. Coronary angiography did not reveal significant coronary artery stenosis, and all the grafts were found to be patent. Following ECG showed PR depression along with diffuse ST elevation consistent with pericarditis. Patient was started on nonsteroidal anti-inflammatory drugs and colchicine with significant improvement of his symptoms in a few days. DISCUSSION: In our patient, injury or surgical manipulation to the area perfused by right coronary artery might have initiated a process, initially localized to the inferior wall with subsequent diffuse involvement of the entire pericardium. The presentation of our patient shortly after the development of chest pain and availability of 2 ECGs a few minutes apart may have shed light on the pathophysiology of PPS.

Treatment of pulmonary hypertension.

Pulmonary arterial hypertension (PAH) is a chronic progressive disease of the pulmonary vasculature characterized by elevated pulmonary arterial pressure and secondary right ventricular failure. PAH is considered a life-threatening condition unless treated. This article provides a comprehensive review of controlled and uncontrolled trials to define the risk-benefit for different therapeutic options of this clinical disorder. Relevant published articles were identified through searches of the National Center for Biotechnology PubMed database. All therapeutic measures for PAH were discussed. Six drugs have been approved in the United States for the treatment of PAH. Extensive medical advancement has been achieved in treatment of PAH. However, none of the approved therapies have shown ability to cure the disease. New research should be performed to develop promising new therapies.

Adult Onset Still's Disease and Rocky Mountain Spotted Fever.

Adult Still's Disease was first described in 1971 by Bywaters in fourteen adult female patients who presented with symptoms indistinguishable from that of classic childhood Still's Disease (Bywaters, 1971). George Still in 1896 first recognized this triad of quotidian (daily) fevers, evanescent rash, and arthritis in children with what later became known as juvenile inflammatory arthritis (Still, 1990). Adult Onset Still's Disease (AOSD) is an inflammatory condition of unknown etiology characterized by an evanescent rash, quotidian fevers, and arthralgias. Numerous infectious agents have been associated with its presentation. This case is to our knowledge the first presentation of AOSD in the setting of Rocky Mountain Spotted Fever. Although numerous infectious agents have been suggested, the etiology of this disorder remains elusive. Nevertheless, infection may in fact play a role in triggering the onset of symptoms in those with this disorder. Our case presentation is, to our knowledge, the first case of Adult Onset Still's Disease associated with Rocky Mountain spotted fever (RMSF).

Explosive nasofacial cryptococosis.

Cryptococcal skin infection in persons with AIDS has been demonstrated. We describe a patient with nasal and facial infection with cryptococci after traumatic injury with battery acid.

The effect of student training on accuracy of completion of death certificates.

BACKGROUND: Death certificates are an invaluable source of statistical and medical information, as well as important legal documents. However, few physicians receive formal training on how to accurately complete them. PURPOSE: To determine if a simple intervention can improve the accuracy of death certificate completion by medical students. METHODS: Participants included all third year medical students undergoing their core Internal Medicine rotation at Mercer University School of Medicine at the Medical Center of Central Georgia. Participation was voluntary and participants completed an approved informed consent. Students were presented a tutorial from the National Association of Medical Examiners website. They were asked to complete a death certificate both before and after the tutorial along with subjective questionnaires. The primary outcome measurement was the difference in scores pre- and post-tutorial. RESULTS: The mean score before the tutorial was 11.75 (+/-3.20) and the mean score post-tutorial was 18.85 (+/-2.56), indicating an increase in scores. The mean difference in pre- and post-tutorial scores was significant (t = 20.39, p < 0.0001). CONCLUSIONS: We found that using a tutorial to teach students how to correctly complete a death certificate was effective.

Resolution of MRI findings in central pontine myelinosis associated with hypokalemia.

We report a case of a 20-year-old African-American female, hospitalized and treated for hyperemesis gravidarum and hypokalemia with a normal serum sodium level. Two to 3 days into her hospitalization, she developed urinary incontinence, weakness, and pain in her lower extremities. An MRI brain scan showed central pontine signal alteration, leading to a diagnosis of CPM. A 4-month follow-up MRI brain scan showed complete resolution of the central pontine signal, with symptomatic improvement manifested by resolution of urinary incontinence and increased strength. Our case describes CPM occurring secondary to hypokalemia, with resolution of characteristic MRI findings at follow-up. Sole hypokalemia-induced CPM is very rare. What makes our patient even more unique is the complete resolution of the central pontine lesion on follow-up MRI. The cause of this cannot be completely explained and warrants further study.

Health-behavior induced disease: return of the milk-alkali syndrome.

The milk-alkali syndrome is a well-documented consequence of excessive calcium and alkali intake first recognized in association with early 20th century antacid regimens. The syndrome became rare after widespread implementation of modern peptic ulcer disease therapies. With recent trends in osteoporosis therapy coupled with widely available calcium-containing supplements, the milk-alkali syndrome has reemerged as an important clinical entity. Our case illustrates a patient who self-medicated his peptic ulcer disease with a regimen resembling a common early 20th century dyspepsia regimen. When superimposed upon chronic high calcium supplementation, the patient became acutely ill from the milk-alkali syndrome. When taken to excess, or used inappropriately, medications and supplements ordinarily considered beneficial, can have harmful effects. Our case underscores the importance of obtaining a thorough medication history including use of over-the-counter supplementation.

Popular sweetner sucralose as a migraine trigger.

Sucralose (trichlorogalactosucrose, or better known as Splenda) is an artificial sweetener from native sucrose that was approved by the FDA on April 1, 1998 (April Fool's Day). This observation of a potential causal relationship between sucralose and migraines may be important for physicians to remember this can be a possible trigger during dietary history taking. Identifying further triggers for migraine headaches, in this case sucralose, may help alleviate some of the cost burden (through expensive medical therapy or missed work opportunity) as well as provide relief to migraineurs.