Medical Malpractice Stress Syndrome: A "Forme Fruste" of Posttraumatic Stress Disorder.

Physicians practicing medicine face many challenges in today's healthcare arena. The stress of practicing medicine is increasing exponentially as new medical information is exploding on a daily basis and new stresses to practicing are occurring in a burgeoning telecommunication world. The impact of rapidly increasing medical information and the era of electronic medical records allowing physicians to communicate with patients and physicians electronically, without the benefit of observing body language or clarifying misunderstandings, has had a huge impact on practicing physician-patient risk for misinterpretation of the electronically transmitted medical information. The risk of malpractice allegations is real even under the best circumstances. The potential risk to physicians alleged to be negligent has resulted in a clinical entity called medical malpractice stress syndrome; it is a "forme fruste" of posttraumatic stress disorder.

Should doctors still examine patients?

The physical examination skills of young physicians in training need careful examination as advancing technology seems to have replaced those skills compared to prior generations of physicians. A question to ponder is how should medical education address the convincing evidence that physician trainees of today are less astute at the physical examination than those that came before them? This inquiry must address whether the decline in physical examination skills hinders accurate, cost effective, and timely diagnoses. Additionally, it must consider whether the absence of a comprehensive physical examination impairs the patient-physician relationship. This type of inquiry leads to the conclusion that the physical examination and technology must be merged as the clinical situation dictates to provide accurate, cost effective and accurate diagnoses. The carefully performed physical examination in conjunction with a detailed history should dictate the use of our ever-advancing technologic advances in medicine.

Malpractice Considerations: New Concerns on the Horizon.

Physicians practicing medicine in today's ever-shifting and advancing medical world are at risk for malpractice liability. The introduction of a vast array of telecommunication media into the physician world is creating a growing area of malpractice risk for physicians. This article explores the new malpractice considerations facing physicians in our constantly evolving digital world. Although they are novel and just on the horizon, these risks are real, and it is prudent for every practicing physician to consider them carefully.

The MOGE(S) classification of cardiomyopathy for clinicians.

Most cardiomyopathies are familial diseases. Cascade family screening identifies asymptomatic patients and family members with early traits of disease. The inheritance is autosomal dominant in a majority of cases, and recessive, X-linked, or matrilinear in the remaining. For the last 50 years, cardiomyopathy classifications have been based on the morphofunctional phenotypes, allowing cardiologists to conveniently group them in broad descriptive categories. However, the phenotype may not always conform to the genetic characteristics, may not allow risk stratification, and may not provide pre-clinical diagnoses in the family members. Because genetic testing is now increasingly becoming a part of clinical work-up, and based on the genetic heterogeneity, numerous new names are being coined for the description of cardiomyopathies associated with mutations in different genes; a comprehensive nosology is needed that could inform the clinical phenotype and involvement of organs other than the heart, as well as the genotype and the mode of inheritance. The recently proposed MOGE(S) nosology system embodies all of these characteristics, and describes the morphofunctional phenotype (M), organ(s) involvement (O), genetic inheritance pattern (G), etiological annotation (E) including genetic defect or underlying disease/substrate, and the functional status (S) of the disease using both the American College of Cardiology/American Heart Association stage and New York Heart Association functional class. The proposed nomenclature is supported by a web-assisted application and assists in the description of cardiomyopathy in symptomatic or asymptomatic patients and family members in the context of genetic testing. It is expected that such a nomenclature would help group cardiomyopathies on their etiological basis, describe complex genetics, and create collaborative registries.

Aneurysmal dilatation of the inferior vena cava.

AIM: Inferior vena cava aneurysms (IVCA) are rare, unlike aortic aneurysms. The diagnosis and treatment is challenging. This study defines clinical and echocardiographic findings in a prospective cohort of sixteen patients with fusiform IVCA. METHODS AND RESULTS: All patients referred to the Mayo Clinic between January 2006 and July 2009 for a clinically indicated echocardiogram (36,128 patients) were screened for a dilated IVC. Sixteen cases of fusiform IVCA were identified. Eleven cases (68.8%) were female. Mean age at presentation was 76 years (range 51-89). Eleven (68.8%) had structural heart disease: with right ventricular (RV) dysfunction in 45.5% (n = 5), moderate or greater tricuspid regurgitation (TR) was seen in 36.4% (n = 4) and RV enlargement was seen in 18.2% (n = 2). The most common clinical indication for echocardiography was dyspnea (25%; n = 4) and heart failure (18.8%; n = 3). The mean IVCA diameter was 4.1 cm (range 3.8-5 cm) and the mean length of the aneurysms was 6.2 cm (range 3.5-8.7 cm), with mean right ventricular systolic pressure of 55 mmHg (range 31-105 mmHg). Five (31.3%) had at least a moderate reduction in right ventricular ejection fraction and five (31.3%) had significant TR. Among these five patients with significant TR, severe TR was present in 80%; (n = 4) and moderate to severe TR was present in 20%; (n = 1). CONCLUSIONS: IVC aneurysms are more common in the elderly, and is associated with an increase in right sided heart pressures, significant TR, and RV dysfunction.

Mitral and tricuspid annular velocities before and after pericardiectomy in patients with constrictive pericarditis.

BACKGROUND: Previous studies have demonstrated that mitral annulus early diastolic (e') velocity is increased in constrictive pericarditis (CP) and reduced in restrictive cardiomyopathy. However, those studies did not comprehensively evaluate mitral and tricuspid annular velocities before and after pericardiectomy. METHODS AND RESULTS: We performed comprehensive echocardiography before and after pericardiectomy in 99 patients with CP, 52 with primary (idiopathic or postpericarditis etiology) and 47 with secondary CP (due to surgery or radiation). Overall, mean ± SD mitral medial, mitral lateral, and tricuspid lateral e' velocities were 12.2 ± 4.2, 10.0 ± 5.4, and 11.6 ± 3.5 cm/s, respectively; annular late diastolic velocities were 10.3 ± 4.3, 12.2 ± 4.9, and 11.7 ± 5.4 cm/s, respectively; and annular systolic (s') velocities were 7.8 ± 2.8, 8.2 ± 2.1, and 11.2 ± 3.8 cm/s, respectively. Medial e' was equal to or greater than mitral lateral e' in 74% of analyzable cases. With the exception of tricuspid s', there were significant differences in all s' and e'velocities between primary and secondary CP before pericardiectomy. After pericardiectomy, all annular velocities decreased significantly (P < 0.02 for all comparisons). The reduction in medial e' velocity was greater than that of mitral lateral e' velocity (P < 0.0001 and P = 0.0004, respectively), and the mitral lateral/medial e' ratio normalized (P = 0.0002). CONCLUSIONS: The mitral lateral/medial e' ratio is reversed in three fourths of patients with CP. All annular velocities are lower in secondary compared to primary CP before pericardiectomy. After pericardiectomy, there is reduction of all annular velocities and normalization of the mitral lateral/medial e' ratio.

Real-time three-dimensional transesophageal echocardiography assessment of the mitral valve: perioperative advantages and game-changing findings.

Real-time three-dimensional transesophageal echocardiography (RT-3D-TEE) represents a unique perioperative cardiovascular imaging tool which, without any need for off-line reconstruction, has been shown to be highly valuable for evaluating mitral valve and other intracardiac structures. It is highly probable that, in the near future, RT-3D-TEE will have a positive effect on the perioperative assessment of complex 3D mitral valve structures, as it provides important approaches to the pathophysiology of various mitral valve diseases, including prosthetic valves, and will become incorporated into everyday perioperative practice. The clinical applications and therapeutic implications of perioperative RT-3D-TEE in the thorough assessment of the mitral valve are briefly summarized in this review.

Parachute mitral valve in adults-a systematic overview.

Parachute mitral valve (PMV) is a rare congenital anomaly of the mitral valve apparatus seen in infants and young children. In most instances PMV is associated with other congenital anomalies of the heart, in particular obstructive lesions of the mitral inflow (mitral valve ring) and left ventricular outflow tract (subaortic stenosis), and coarctation of aorta and is referred to as Shone's complex or Shone's anomaly. PMV may also occur as an isolated lesion or in association with other congenital cardiac anomalies. Not much is known about PMV in adults as an isolated anomaly or in association with other congenital cardiac anomalies. We reviewed the literature to identify cases of PMV (isolated or associated with other lesions) in adults, to address prevalence, clinical presentation, diagnosis, treatment, and outcome of such patients. (Echocardiography 2010;27:581-586).

Rheumatic tricuspid valve disease: an evidence-based systematic overview.

BACKGROUND AND AIM OF THE STUDY: Right-sided valve abnormalities are less common than their left-sided counterparts. Furthermore, whilst organic rheumatic involvement of the tricuspid valve is not uncommon, it receives less attention than left-sided heart valves. An evidence-based systematic overview was carried out to assess the epidemiology, diagnosis and management of organic rheumatic tricuspid valve disease (RTVD) over the past half century. METHODS: A computed search spanning more than four decades was conducted to identify articles on various aspects of RTVD. The bibliographies of all relevant articles were also searched. RESULTS: A total of 2,497 rheumatic heart disease patients (mean age 25.5 years; female:male ratio 1.3:1) was included. RTVD was detected in 193 patients (7.7%). Echocardiography was used to detect tricuspid valve involvement in all patients. Associated mitral valve disease was present in 99.3% of the patients with RTVD. A total of 1,092 patients (mean age 45.4 years) was included from six studies on surgical correction of the tricuspid valve. Of these patients, 278 (25.4%) underwent tricuspid valve replacement, while 814 (74.5%) had tricuspid valve repair. The in-hospital mortality was 9.9%, and late mortality 33.2% CONCLUSION: RTVD is not uncommon among patients with rheumatic heart disease, but attracts less attention and might, therefore, be overlooked. Echocardiography is the most common diagnostic tool. Although indications for surgical intervention are not well defined, valve repair may have a better outcome than replacement.

Evaluation of right ventricular global and regional function during stress echocardiography using novel velocity vector imaging.

AIMS: This study tested the feasibility of velocity vector imaging (VVI) analysis to quantitatively assess right ventricular (RV) function during stress echocardiography (SE). METHODS AND RESULTS: We prospectively enrolled 73 patients (treadmill 38, dobutamine 35) undergoing SE using an Acuson C512 ultrasound system. The RV ejection fraction was measured for global RV function. The radial velocity, circumferential strain, and strain rate (SR) of four segments from the mid-level RV short-axis view, and the longitudinal velocity, strain, and SR of six segments from the RV apical four-chamber view were used to evaluate regional RV function. The VVI analysis successfully in 70 of 73 cases (96%). Fifty (71%) of the 70 demonstrated a normal response to stress, showing an increased RV ejection fraction (P < 0.001), and longitudinal velocity and SR in the basal lateral walls at peak stress (7.7 +/- 2.0-10.3 +/- 2.9 cm/s, -1.9 +/- 0.7 to -3.2 +/- 1.4/s, P < 0.001); the longitudinal displacement and strain of the same segment did not show a significant increase. CONCLUSION: Quantitative assessment of global and regional RV function during SE was feasible using VVI analysis. Longitudinal velocity and SR of the RV basal lateral wall were significantly better than longitudinal displacement or strain for detecting RV response during SE.

Infectious pericarditis: an experience spanning a decade.

BACKGROUND: Although recent literature suggests a changing spectrum for infectious pericarditis (IP), this view has not been proven. In this report, we aim to review the features of IP in cases from a large tertiary centre. METHODS: A retrospective review of our institution's database was conducted to identify cases with IP between January 1994 and December 2004. All pericardial biopsy tissue results from the same period were also reviewed. RESULTS: One hundred and thirty-eight cases were identified, of which 14 cases were identified by pathology. The mean age was 53 +/- 18 years, and 74% were men. The most frequently identified causative organisms were Propionibacterium acnes (P. acnes), staphylococci and streptococci. A common predisposing factor was an immune-compromised state, followed by cardiac surgery. Fifty-five patients were treated with antibiotics (medical group) while 63 cases (surgical group) underwent surgical drainage (pericardial window) and/or pericardiectomy. In comparison to the medical group, the surgical group was more critically ill and immunocompromised (40% versus 24%, respectively). There were 52 late deaths during follow-up. Mortality in the medical group was 67% while in the surgical group it was 24% (P < 0.0001). CONCLUSIONS: In contradistinction to the literature reports, the most prevalent organism for IP was P. acnes. Patients managed aggressively with both antibiotics and surgery, demonstrated lower mortality rates. Therefore, clinicians should maintain a high index of suspicion for IP so that timely and appropriate mortality-reducing strategies can be offered.

Left atrial remodelling in mitral regurgitation--methodologic approach, physiological determinants, and outcome implications: a prospective quantitative Doppler-echocardiographic and electron beam-computed tomographic study.

AIMS: To define accurate and normal range of echocardiographic left atrial (LA) volume measurement and to assess the prevalence, determinants, and outcome implications of LA enlargement in mitral regurgitation (MR). METHODS AND RESULTS: We prospectively compared LA volume obtained simultaneously by electron beam-computed tomography (EBCT) and by four echocardiographic methods in 33 test patients. Accurate echocardiographic LA volume measurements were obtained only by biplane area-length method with vertical longitudinal-length (r = 0.95, P < 0.0001; 145 +/- 57 vs. 143 +/- 55 mL, P = 0.57). Using this method, the normal range in 100 normal subjects, the physiological determinants and outcome implications of LA enlargement in 320 patients with organic MR were analysed. In normal subjects, indexed to body surface area, LA index (27 +/- 6 mL/m(2)) was not influenced by age or gender and values > or = 40 mL/m(2) were beyond the upper limit of normal. In MR, the most powerful determinants of LA enlargement were higher regurgitant volume (RVol) and atrial fibrillation (AF) (P < 0.0001), followed by older age, female gender, higher left ventricular end-systolic volume, and mass (all P < 0.001). After diagnosis in sinus rhythm, LA index > or = 40 mL/m(2) predicted superiorly and independently to LA diameter the occurrence of AF [adjusted RR 1.48 (1.06-2.16), P < 0.01] and the combined endpoint of death or need for mitral surgery [adjusted RR 1.61 (1.3-2.0), P < 0.0001]. CONCLUSION: LA remodelling can be accurately assessed by echocardiography and LA index > or = 40 mL/m(2) is beyond the normal range. In organic MR, higher LA index is the combined result of multiple physiological effects, provides independent prognostic information, and therefore should be part of a comprehensive echocardiographic examination.

Left ventricular form and function revisited: applied translational science to cardiovascular ultrasound imaging.

Doppler tissue imaging (DTI) and DTI-derived strain imaging are robust physiologic tools used for the noninvasive assessment of regional myocardial function. As a result of high temporal and spatial resolution, regional function can be assessed for each phase of the cardiac cycle and within the transmural layers of the myocardial wall. Newer techniques that measure myocardial motion by speckle tracking in gray-scale images have overcome the angle dependence of DTI strain, allowing for measurement of 2-dimensional strain and cardiac rotation. DTI, DTI strain, and speckle tracking may provide unique information that deciphers the deformation sequence of complexly oriented myofibers in the left ventricular wall. The data are, however, limited. This review examines the structure and function of the left ventricle relative to the potential clinical application of DTI and speckle tracking in assessing the global mechanical sequence of the left ventricle in vivo.

Diagnostic features of cardiac hemangioma on cardiovascular magnetic resonance, a case report.

Cardiac hemangiomas are benign cardiac tumors that account for 5-10% of all benign tumors of the heart (Grebenc ML, Rosado de Christenson ML, Burke AP, Green CE, Galvin JR. Radiographics 2000; 20(4): 1073-1103). They occur in any cardiac location, including the pericardium (Brodwater B, Erasmus J, McAdams HP, Dodd L. J Comput Assist Tomogr 1996; 20(6): 954-956). Magnetic resonance imaging (MRI) has an excellent contrast resolution and multiplanar capability to allow optimal evaluation of myocardial infiltration, pericardial involvement and/or extracardiac extension (Brown JI, Barakos JA, Higgins CB. J Thorac Imaging 1989; 4(2): 58-64). This is a case report of cardiac hemangioma involving the ventricular septum with radiological and pathological correlation. It illustrates the capability of the MRI to non-invasively detect histological and flow characteristics of the tumor.

Relation of tissue displacement and strain to invasively determined right ventricular stroke volume.

The role of echocardiography in the clinical assessment of right ventricular (RV) systolic function remains limited. Limited data exist on the potential use of newer techniques for RV function assessment. Conventional echocardiography and tissue Doppler echocardiography (TDE) were performed during right-sided cardiac catheterization in 46 patients. Thermodilution or the Fick-derived RV stroke volume indexed (RVSVI) indexed to body surface area was used as the reference standard. Univariate and multivariate regression analyses were used to test correlations between RVSVI and various echocardiographic and TDE-derived parameters. In a subset of 12 subjects, changes in echocardiographic and TDE variables to reduced afterload from intravenous epoprostenol were measured. TDE-derived RV tissue displacement and systolic strain best predicted the RVSVI (r = 0.63, p = 0.001; r = 0.48, p = 0.002, respectively). The prediction improved after adjustment for tricuspid regurgitation jet vena contracta width (r = 0.74, p < 0.0001; r = 0.60, p < 0.001, respectively). Assuming a RVSVI of > or =30 ml/m(2) as normal, a RV displacement cutoff of 15 mm yielded a sensitivity of 100% and a specificity of 41% for RV dysfunction, and an RV systolic strain cutoff of 20% yielded a sensitivity of 91% and a specificity of 63%. The percentage change of RV systolic displacement correlated well with the percentage change of RVSVI after epoprostenol infusion (r = 0.75, p < 0.001). In conclusion, TDE-derived RV displacement and strain closely correlate with RVSVI and appropriately track load-related changes in RV function. These new parameters may help provide the noninvasive, quantitative assessment of RV function.

Contribution of ischemic mitral regurgitation to congestive heart failure after myocardial infarction.

OBJECTIVES: The purpose of this study was to define the contribution of ischemic mitral regurgitation (IMR) to the occurrence of congestive heart failure (CHF) after myocardial infarction (MI). BACKGROUND: After MI, CHF is a frequent and serious complication, but its determinants and, particularly, the role of IMR are poorly defined. METHODS: We analyzed 173 asymptomatic patients with previous Q-wave MI (>16 days) with echocardiographic quantitation of IMR (measuring effective regurgitant orifice [ERO] and regurgitant volume). The 102 patients with IMR were matched to 71 patients without IMR for age (71 +/- 11 years vs. 68 +/- 9 years; p = 0.11), gender (76% vs. 82% males; p = 0.41), and left ventricular ejection fraction (EF) (37 +/- 14% vs. 36 +/- 11%; p = 0.92). RESULTS: Five-year rates of CHF and of CHF or cardiac death (CD) were 36 +/- 5% and 52 +/- 5%, respectively. Independent determinants of CHF were EF, sodium plasma level, and presence and degree of IMR (p < 0.0001). Five-year CHF rates were 18 +/- 5% without mitral regurgitation (MR), 53 +/- 7% with IMR, 46 +/- 9% with ERO 1 to 19 mm(2) and 68 +/- 12% with ERO > or =20 mm(2) (all p < 0.0001). The adjusted relative risk of CHF was 3.65 (95% confidence interval [CI] 1.86 to 7.75) for IMR presence and 4.42 (95% CI 1.9 to 10.5) for ERO > or =20 mm(2). The adjusted relative risk of CHF/CD was 2.97 (95% CI 1.77 to 5.16) for IMR presence and 4.4 (95% CI 2.4 to 8.2) for ERO > or =20 mm(2). CONCLUSIONS: After MI, incidence of CHF and of CHF/CD are high even in patients with no or minimal symptoms at baseline and are higher in patients with IMR. Congestive heart failure is independently determined by larger ERO of IMR. These data suggest that detecting and quantifying IMR is essential for risk stratification after MI. Value of IMR treatment in improving post-MI outcome should be investigated.