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Infective endocarditis (IE) is a focus of infection which effects the endocardium, specifically the heart valves or intra-cardiac devices. A 64-year-old male with gastric carcinoma and no prior cardiac history presented to the emergency room with altered mental status. Initial investigations showed the patient had a leukocytosis with a left shift. Blood cultures taken upon arrival eventually grew Esherichia coli, thought to be from the urinary tract, although initial urinalysis was delayed until after initiation of antibiotics. Electrocardiogram showed sinus bradycardia with frequent premature atrial contractions. Chest X-Ray showed bilateral pleural effusions, which were eventually drained and found to be growing E. coli. Transthoracic echocardiogram was done which showed moderate-sized tricuspid valve vegetation with severe tricuspid regurgitation. IE has been increasing in incidence throughout the years. In prior decades IE was a disease primarily affecting patients with known rheumatic heart disease, prosthetic heart valves, and intravenous drug abusers however more commonly it is becoming healthcare acquired. E. coli is not often seen to be a culprit of IE. We present a rare case of E. coli endocarditis of a native tricuspid valve.

Papillary fibroelastomas are a rare cardiac neoplasm typically found on the left side of the heart, and most commonly on the aortic valve, which can present with cardiac or neurologic symptoms. A 51-year-old woman with no cardiac history presented to a resident clinic with complaints of left-sided facial paresthesias and palpitations for 1 month. Echocardiographic imaging showed a mass on the aortic annulus, concerning for a cardiac tumor. Due to the risk of possible embolization, if the tumor was a myxoma, the patient required intrathoracic surgery. During the intrathoracic procedure the mass was confirmed to be a papillary fibroelastoma and the patient had the mass removed without any complications. Papillary fibroelastomas are found in less than 1% of the population but can present clinically with a wide variety of symptoms. Patients with this neoplasm are at risk for severe complications, due to embolization, potentially causing cerebrovascular accidents or myocardial infarctions. We present a case of a papillary fibroelastoma producing both cardiac and neurologic symptoms.

Objectives Preoperative anticoagulation management (PAM) is a complex, multidisciplinary process important to patient safety. The Functional Resonance Analysis Method (FRAM) is a novel method to study how complex processes usually go right at the frontline (labeled Safety-II) and how this relates to predefined procedures. This study aimed to assess PAM in everyday practice and explore the usability and utility of FRAM. Methods The study was conducted at an Australian and European Cardiothoracic Surgery Department. A FRAM model of work-as-imagined was developed using (inter)national guidelines. Semistructured interviews with 18 involved professionals were used to develop models reflecting work-as-done at both sites, which were presented to staff for validation. Workload in hours was estimated per process step. Results In both centers, work-as-done differed from work-as-imagined, such as in the division of tasks among disciplines (e.g., nurses/registrars rather than medical specialists), but control mechanisms had been developed locally to ensure safe care (e.g., crosschecking with other clinicians). Centers had organized the process differently, revealing opportunities for improvement regarding patient information and clustering of clinic visits. Presenting FRAM models to staff initiated discussion on improvement of functions in the model that are vital for success. Overall workload was estimated at 47 hours per site. Conclusions This FRAM analysis provided insight into PAM from the perspective of frontline clinicians, revealing essential functions, interdependencies and variability, and the relation with guidelines. Future studies are warranted to study the potential of FRAM, such as for guiding improvements in complex systems.

Introduction Agenesis of the corpus callosum (AgCC) is characterized by the congenital partial or complete absence of the corpus callosum. Several strains of mice have been reported to carry AgCC, with the BTBR T+Itpr3tf/J (BTBR) inbred mouse strain consistently showing a complete absence of the corpus callosum, as well as a variable reduction in the size of the hippocampal commissure. While much research has focused on the social deficits of the BTBR strain, little research on its cognitive behavior has been conducted. The goal of our study was to compare two facets of executive functioning, spatial working memory, and sustained attention between the BTBR and C57BL/6J (B6) strains. Methods Spatial working memory was measured utilizing a delayed matching‐to‐position (DMTP) task and sustained attention was measured utilizing an operant task in which mice were trained to distinguish signal and nonsignal events. Results Both the BTBR and B6 mice demonstrated a predictable decline in performance on the DMTP task as the delay interval increased and predictable increase in performance on the sustained attention task as the duration of the signal event increased. Although no significant differences were found between strains on the performance of these tasks, there was a significant difference in learning the association between lever pressing and food reward. Histological investigation confirmed the complete absence of commissural fibers from the corpus callosum, but also the hippocampal commissure, counter to a previous study. Conclusion The results suggest spatial working memory and sustained attention are unaffected by the absence of these commissural fibers alone., The cognitive deficits associated with agenesis of the corpus callosum have been understudied in the BTBR mouse. We studied working memory and sustained attention in this mouse model of AgCC utilizing operant paradigms. Surprisingly, our results from mice with histologically confirmed absence of the corpus callosum and hippocampal commissure were similar to the results from B6 controls.

A 34-year-old African American female with a past medical history of hypertension and medical noncompliance presented to the emergency department after being found down and unresponsive by her son. On presentation, the patient's blood pressure was found to be 298/194 with a Glasgow coma score of 4, with decerebrate posturing. The computed tomography of the head showed large acute intraventricular hemorrhage in the right lateral ventricle extending along the frontal horn into the left lateral ventricle, third and fourth ventricles, causing a 4 mm leftward shift. The patient was managed with a Nicardipine drip and underwent a bilateral ventriculostomy placement, which improved the patient's neurologic status. Following a 24 day hospital stay, the patient was alert and oriented without any significant neurologic deficits and discharged to a subacute rehab facility. Hypertension is one of the most common medical conditions affecting 50 million people in the United States and approximately 1 billion people worldwide. Approximately 1% of patients with hypertension will have a hypertensive emergency at some point in their life. The clinical manifestations of hypertensive emergencies are seen with organ dysfunction, which typically require diastolic blood pressures greater than 130mmHg, in nonpregnant adults. A severe outcome of hypertensive emergency is an intracerebral hemorrhage. In these patients, when the bleed extends into the ventricles, the mortality ranges from 50-80%. One study examined medical compliance in hypertensive patients, which showed approximately 40% of patients discontinued treatment one year after initiation of their antihypertensive medication and 4% never initiated therapy. This case illustrates the importance of compliance in hypertensive patients, as well as the dramatic ramifications that can occur with uncontrolled hypertension leading to hypertensive emergency.

Background: At this institution, a delay occurs between the time the emergency department admits a patient and the admitting service’s evaluation of the patient. Since the emergency department is run on paper charting, the current system, at night, involves the emergency department writing a name and a diagnosis in the emergency department’s admission book. The night residents’ job is to admit teaching patients to the teaching service. The current system requires the night resident to physically go to the emergency department and look in the admissions book to find out about a new admission. This lack of communication can cause a great delay in evaluation of a new admission, which can be problematic. The catalyst for this study was an adverse event where a stroke was missed in the emergency department and the patient was not evaluated by the admitting service for 15 hours falling well outside the tPA window. Decreasing the delay in thorough evaluation is crucial in proper treatment of many cardiovascular conditions, which are time sensitive and can potentially prevent a catastrophic outcome. Intervention: Residents on the admitting service will be first asked to document their evaluation time without intervention, which will be documented with the emergency department admission time to establish a baseline. In addition to the current system of manually checking the admissions book in the emergency department, the ward clerk will page the night staff when new admissions are written in the book. Residents on the admitting service will then document their evaluation time with this new intervention, along with the emergency department admission time. The goal of this new system is to decrease the time the patient is waiting to be evaluated by the admitting service. Results: The mean lag time pre-intervention (N=20) was 73 minutes with a range of 0-279 minutes. Post-intervention (N=25) the mean lag time was 82 minutes with a range of 5- 337 minutes. The P-value of this study was 0.707. Residents on the admitting service were very compliant with documenting their evaluation times. Admitting residents did note the pages were inconsistent and were often missed. The rate of pages successfully sent out was not documented. Conclusion: The lag time before and after intervention was not found to be statistically significant. Pages were inconsistently sent out but did not impact the internal validity of the study. Since the study tested if paging the on-call residents improved the delay in evaluation, the ability to reliably send the page is as important as the response time. The paging system in this study was used as an augmentation to the current system out of some trepidation that pages could be missed and thus negatively impacting the response time. Due to the statistically insignificant data, it can be concluded that the paging system made no impact on the response time patients were seen by the admitting residents.

BACKGROUND: Denosumab is a monoclonal antibody used in the treatment of osteoporosis to prevent bony injuries by increasing bone density. It has a very rare side effect of severe hypocalcemia (1) and a patient should take supplemental Vitamin D and calcium for prevention. There is debate among experts on when denosumab should be discontinued and if so, whether an alternative therapy should be started (2). Case Report: A female in her 8th decade of life presented to the ED with a complaint of intermittent and diffuse numbness and confusion. She had a history of MGUS and osteoporosis; however, her most recent SPEP did not detect MGUS and her most recent bone scan showed a T score indicating osteopenia. She had been receiving denosumab for the past four years with her last injection three weeks prior. Physical exam revealed 5/5 strength and intact sensation in all four extremities. Her serum calcium level on presentation was 4.3 mg/dL (8.5-10.1), ionized calcium was 3.9 mg/dL (4.6-5.4), 25 Hydroxy Vitamin D 8.8 ng/ML (30-100), and intact PTH was appropriately elevated at 702.7 pg/mL (14.0-72.0). Her phosphorus level was also appropriately low at 2.1mg/dL (2.5/4.9). She had a serum creatinine level of 0.9 mg/dL (0.6-1.0) and an eGFR 63 mL/min. ECG showed normal sinus rhythm without any QT changes. She received 4 grams of calcium gluconate intravenously over the next 24 hours without improvement in her calcium, as trending chemistries continually showed a calcium level less than 5.0. She was started on a calcium gluconate continuous infusion along with calcitriol, Vitamin D3 5,000 IU per day, and oral calcium 500 mg with Vitamin D 600 IU three times daily. Her calcium levels improved, albeit still low, to 6.5 mg/dL and the calcium continuous infusion was stopped. A 1, 25-Dihydroxy Vitamin D level showed improvement as well resulting at 82 pg/mL (20-79). Her numbness and confusion symptoms resolved, and she was discharged on the aforementioned oral calcium and vitamin D regimen with instructions to follow up and discontinue use of denosumab. Conclusion: There are two primary takeaways from this clinical case. The first is to ensure a patient receiving denosumab is also taking supplemental Vitamin D and calcium to prevent hypocalcemia and to periodically measure serum levels to rule out deficiency. The second is the emphasis on having a provider-patient discussion on alternative therapies when the patient may no longer be a candidate for denosumab while considering the patient’s risk for fracture. References: Bone, Henry G. et al. 10 years of denosumab treatment in postmenopausal women with osteoporosis: results from the phase 3 randomised FREEDOM trail and open-label extension. Lancet Diabetes Endocrinology. 2017. 5: 513-23 Tsourdi, E. et al. Discontinuation of Denosumab therapy for osteoporosis: A systematic review and position statement by ECTS. Bone 2017. 105: 1-17.

BACKGROUND Acute bacterial pericarditis is rare, and the incidence numbers have been declining in the modern antibiotic era. Purulent bacterial pericarditis is a fatal disease in which mortality rates can reach 100% if left untreated. CASE REPORT We present a case of primary purulent bacterial pericarditis with polymicrobial growth including Micromonas micro, Prevotella intermedia and Fusobacterium species, all of which are anaerobic flora of the oral cavity. Constant re-accumulation of the purulent pericardial effusion led the patient to have recurrent echocardiographic and clinical cardiac tamponade requiring recurrent pericardiocentesis' and eventually a pericardial window. CONCLUSIONS Although rare, bacterial pericarditis has been noted to lead to clinical and echocardiographic tamponade. Early diagnosis and treatment are necessary for improving clinical outcomes. It is important to have a suspicion for purulent pericarditis, due to its high level of mortality, in patients who present with non-specific symptoms and pleuritic chest pain.

The authors investigate Berlin’s art auction market as it developed between 1930 and 1945. By analyzing Berlin’s auction data from the Getty Research Institute’s recently published database...

Neurocognitive and psychiatric complications are common following cardiac surgery and impact on patient quality of life, recovery from surgery, participation in rehabilitation and long-term mortality. Postoperative cognitive decline, depressive disorders, post-traumatic stress disorder and neurocognitive impairment related to silent brain infarcts have all been linked to the perioperative period of cardiac surgery, and potentially have serious consequences. The accurate assessment of these conditions, particularly in determining the aetiology, and impact on patients is difficult due to the poorly recognised nature of these complications as well as similarities in presentation with postoperative delirium. This review aims to summarise current understanding surrounding psychiatric disturbances following cardiac surgery including the impact on patient quality of life and long-term outcomes.

A patient with recent two-vessel coronary artery bypass graft (CABG) 11 days prior to admission presented with shortness of breath and orthopnea. The procedure was uncomplicated and tolerated well. On arrival he was hypoxic and initial ECG and cardiac enzymes were negative for active ischaemia.

Brugada pattern consists of incomplete RBBB and ST segment elevations in more than one of V1-V3 leads. It can be seen in Brugada Syndrome, due to medications, or electrolyte abnormalities. We present a case with Brugada ECG pattern due to structural abnormality of the RV. A 48-year-old man with a

Subcutaneous ICD (S-ICD) has recently emerged as an alternative to transvenous ICD. However, inappropriate ICD therapy remains a concern. A 72-year-old woman with history of heart failure with reduced ejection fraction (20-25%) presented for elective S-ICD placement for primary prevention of sudden

Thyrotoxic pericarditis with pericardial effusion and cardiac tamponade is a rare phenomenon. Establishing the diagnosis early and implementing treatment are necessary to improve outcomes. A 29-year-old woman with metastatic choriocarcinoma to brain, liver, lung, and bone presented with shortness

Anomalous origin of the right coronary artery originating from the pulmonary artery (ARCAPA) is a rare congenital coronary anomaly with an estimated prevalence of 0.002%. Most patients are asymptomatic and the anomaly is found incidentally. However, patients have been known to suffer adverse effects

Transcatheter aortic valve implantation (TAVI) in patients with bicuspid aortic valve disease is associated with higher rates of paravalvular aortic regurgitation, which may require subsequent surgical correction. We report a case of successful late surgical CoreValve explantation 1,389 days after TAVI in a patient with bicuspid aortic valve stenosis and McArdle's disease who developed severe paravalvular aortic regurgitation. We confirm that neoendothelialization and incorporation of the nitinol cage into the aortic wall had occurred at nearly 4 years postimplantation, although explantation with careful endarterectomy could still be performed without requiring simultaneous aortic root replacement.

An insulin-dependent diabetic woman of 42 years received a combined pancreas and kidney transplant five years prior to referral to our clinic for ophthalmic consultation. Her systemic immunosupression included oral steroids and she subsequently developed huge bilateral central serous retinal detachments affecting both posterior poles and the temporal midperiphery of the left eye. Her vision was reduced to count fingers (CF) in both eyes. Fluorescein angiography (FA) revealed diffuse mild retinal pigment epithelium (RPE) staining in both eyes. As an empiric treatment grid laser photocoagulation with an 810 nm diode laser (Iridex Corp., Mountain View, California) was performed with complete resorption of subretinal fluid in both eyes and visual improvement to 20/70 in the right eye and 20/200 in the left eye at 18 months post-treatment. In patients diagnosed with atypical central serous retinal detachment whose fluorescein angiogram displays widespread RPE damage and in whom systemic steroids are medically necessary, diode grid laser photocoagulation may be a reasonable treatment option.

The importance of receptor expression and protein kinase C to epidermal growth factor (EGF)-induced cell proliferation was studied in LLC-PK1 kidney cells. These cells have both high- and low-affinity binding sites for EGF. Neither transforming growth factor-beta nor tumor necrosis factor altered EGF receptor expression. On the other hand, retinoic acid induced a concentration-dependent increase in EGF binding that was maximal at 1 mumol/L. One micromolar of retinoic acid increased EGF binding from 0.38 +/- 0.01 fmol/10(6) cells in controls to 1.10 +/- 0.03 fmol/10(6) in treated cells at 18 hours (n = 8, P < 0.001). The increase in binding was the result of an increase in the Bmax of the high-affinity receptor. The upregulation of the EGF receptor induced by retinoic acid was associated with enhanced EGF-induced growth promotion. A 45-minute incubation of cells with phorbol 12-myristate 13-acetate caused a concentration-dependent decrease in EGF binding that was prevented by a 40-hour, 2 mumol/L pre-exposure to phorbol 12-myristate 13-acetate; 10(-8) mol/L EGF also caused a downregulation of the EGF receptor that was not prevented by phorbol 12-myristate 13-acetate or retinoic acid. Downregulation of protein kinase C did not interfere in the capacity of EGF to induce growth in these cells. These studies demonstrate that EGF receptor upregulation plays an important role in the control of EGF-induced cell growth. Protein kinase C regulates EGF binding in these cells; however, it is not necessary for EGF-induced growth promotion or receptor downregulation.