Journal of General Practice

A 61 years-old woman treated with methylprednisolone due to arthritis mutilans was admitted to our hospital after being found to have complete atrioventricular block and vegetation on the mitral and aortic valves. Infective endocarditis was suspected, but offending bacteria was not detected by repetitive blood cultures. Despite intensive care, we could not control the infection and she died of complication of acute respiratory distress syndrome on the eleventh day. Autopsy findings revealed epitheloid cell granulomas and Mycobacterium tuberculosis in the heart. Therefore, she was diagnosed with tuberculous endocarditis.

Background: Hypertrophic cardiomyopathy (HCM) with midventricular hypertrophy is an uncommon phenotypic variant of the disease. Midventricular hypertrophy predisposes to intracavitary obstruction and downstream hemodynamic sequelae.
Case report: We present a case of HCM with midventricular hypertrophy and obstruction diagnosed after a CT scan of the abdomen incidentally revealed a filling defect in the left ventricular apex. Transthoracic echocardiography demonstrated mid left ventricular hypertrophy and obstruction, as well as an aneurysmal apex containing a large thrombus. Cardiovascular MRI showed a spade-shaped left ventricle with midcavitary obliteration, an infarcted apex and regions of myocardial fibrosis. Due to the risk of embolization and a relative contraindication to anticoagulation, the patient underwent surgery including thrombectomy, septal myectomy and aneurysmal ligation.
Conclusions: Hypertrophic cardiomyopathy with midventricular hypertrophy leads to cavity obstruction, increased apical wall tension, ischemia and ultimately fibrosis. Over time, patchy apical fibrosis can develop into a confluent scar resembling a transmural myocardial infarction in the left anterior descending coronary artery distribution. Aneurysmal remodeling of the left ventricular apex potentiates thrombus formation and risk of cardioembolism. For these reasons, hypertrophic cardiomyopathy with midventricular obstruction portends a particularly poor prognosis and should be recognized early in the disease process.

Pregnancy and birth can cause emotional transformation. It is a period of adaptation for biological, emotional and psychological changes. The relation between maternity and mood disorders are well described. The most studied emotional problems related to childbirth are the maternity or baby blues, the most common, and the least severe. The interest for baby blues started in 1950's when Moloney described a syndrome. Also the Postpartum depression, is an episode of depression that occurs in women shortly after childbirth. And the puerperal psychosis that is a severe psychiatric disorder. There is little evidence to explain the pathogenesis of these conditions. These emotional outcomes, can also affect the attachment development of the newborn, and can cause repercussion in child latter life. The emotional outcomes during postpartum, should be considered and evaluated by the clinicians, as the prevalence and risk for emotional problems during this period is high. Prevention and early intervention strategies could minimize the influence of postpartum maternal and emotional distress and also infant developmental outcomes.

Objective: Survivorship care plans (SCP), which describe a cancer survivor’s diagnosis, treatment and follow-up, are recommended. The study objective was to evaluate primary care providers’ (PCP) responses to SCPs developed for breast and colorectal cancer survivors in their practice and to determine whether PCP response to the SCPs varied according to characteristics of the practitioner and their practice.
Method: SCPs were created using the Journey Forward® Care Plan for breast and colorectal cancer patients in rural and urban settings. The SCP and a survey were sent to PCPs.
Participants: Primary care physicians.
Main Measures: Attitudes regarding survivorship care plans.
Results: Thirty-nine (70.9% response rate) surveys were completed. Most felt the SCP was useful (90%), that it enhanced understanding (75%) and that detail was sufficient (>80%). However, 15% disagreed that the care plan helped them understand their role, a perception especially prevalent among PCPs in the rural setting. Among PCPs with ≤ 18 years in practice, 95% agreed that the SCP would improve communication with patients, contrasted with 60% of those with >21 years in practice. The most common barrier to providing follow-up care was limited access to survivors. Conclusions: While SCPs appear to improve PCPs understanding of a cancer diagnosis and treatment, clear delineation of each provider’s role in follow-up care is needed. Additional detail on which tests are needed and education on late and long term effects of cancer may improve coordination of care.

Cesarean sections are being performed more frequently nowadays. In most cases, it is also the first visit to the operating room for the woman, with its associated anxieties and apprehensions. The young age and female gender, in addition, make them more vulnerable to pain. Also, new mothers cannot afford the luxury of prolonged convalescence. They are expected to actively take care of the new born. Because pregnancy is a risk factor for thromboembolic phenomena, early mobilization after delivery is recommended. Good pain relief is required for this. All of these have contributed to the search for newer and more effective methods of pain control after cesarean birth. The conventional methods of analgesia have centered on the use of opioids given via diverse routes like systemic and neuraxial. Patient-controlled analgesia with elastomeric pumps has made this more acceptable and satisfying to the patients. However, opioids have some unwanted effects like pruritus and respiratory depression. In addition, secretion into breast milk is a unique concern in this population. Drugs like Non-Steroidal Anti Inflammatory Drugs (NSAID) and paracetamol can only supplement other modes of analgesia and are not sufficient on their own. Neuraxial methods, though effective and safe, need to be performed by an experienced person and require a higher level of monitoring. Regional field blocks like Transversus Abdominis Plane (TAP) block and iliohypogastricilioinguinal nerve blocks are gaining in popularity, especially after the advent of ultrasound in anesthesia. Wound infiltration catheters are also in vogue.

The genomic profile of parous women has shown that genes which are activated only within the first five years after pregnancy, may contribute to the increased risk of breast cancer in certain women. At the same time, pregnancy’s protective effect is induced by a long-lasting genomic signature. This signature reveals that the differentiation process is centered around chromatin remodeling and represents a safeguard mechanism at genomic and post-transcriptional levels that maintains the fidelity of the transcription process, which could be the ultimate step mediating the protection of the breast conferred by full term pregnancy.

In this review, we focus on the diabetic heart rather than the vascular complications of diabetes. Focus is further narrowed to a specific, but widely used, animal model: the diabetic rat heart in which diabetes has been induced by a single injection of streptozotocin. Our experimental approach is primarily biophysical and ranges from measurements made in isolated working whole-hearts, to those made from isolated left-ventricular tissues and mitochondria. Our interest is on the effect of severe diabetes on cardiac energetics, in terms of efficiency of cardiac work performance, ATP synthesis and oxygen consumption. By designing experiments to test the energetic performance of the heart and its trabeculae across a wide range of protocols, we have revealed the dependence of efficiency on afterload. This has allowed us to clarify a long-standing uncertainty in the literature; whereas the diabetic heart is unable to work against high afterloads, it nevertheless retains normal peak efficiency. But a further anomaly has been revealed. Whereas there is no evidence that the diabetic myocardium loses peak mechanical efficiency, its mitochondria demonstrate a decreased P:O ratio - i.e., a decreased bioenergetic efficiency. This decrease is consistent with an increase in the rate of production of reactive oxygen species, together with elevated proton leakage across the inner mitochondrial membrane at near maximal phosphorylating respiration states.