[Unusual diagnosis of an intrathoracic tumor, cavernosum lymphangioma. Case report]

BACKGROUND

Thoracic lymphangioma is a rare benign disease representing only 0.7-4.5% of all mediastinal tumors. Its etiology is currently unknown. Most are asymptomatic at first, and the condition is common in the pediatric age. We present a case to document this rare disease and describe the literature.

CLINICAL CASE

We present the case of a 5-year-old female without clinically significant medical history. The patient attended a routine physician visit where a heart murmur was discovered. A diagnostic protocol was initiated, finding a mass on chest x-rays, apparently with an intrathoracic localization. Chest computed tomography confirms a tumor of 13 × 11 cm localized in the anterior mediastinum. Laboratory studies were within normal parameters. Complete surgical resection was decided upon and histopathological diagnosis of cavernosum lymphangioma is confirmed. The patient experienced an adequate evolution without evidence of relapse at this timeConclusion: Characteristics of the case shown are consistent with those reported in the literature. Diagnostic management as well as the surgical plan was successful without presenting morbidity so far.

Application of Laser Doppler Vibrometery for human heart auscultation

In this study the potential of a Laser Doppler Vibrometer (LDV) was tested as a non-contact sensor for the classification of heart sounds. Of the twenty participants recorded using the LDV, five presented with Aortic Stenosis (AS), three were healthy and twelve presented with other pathologies. The recorded heart sounds were denoised and segmented using a combination of the Electrocardiogram (ECG) data and the complexity of the signal. Frequency domain features were extracted from the segmented heart sound cycles and used to train a K-nearest neighbor classifier. Due to the small number of participants, the classifier could not be trained to differentiate between normal and abnormal participants, but could successfully distinguish between participants who presented with AS and those who did not. A sensitivity of 80 % and a specificity of 100 % were achieved a test dataset.

Learning during simulation training is prone to retroactive interference

CONTEXT

Retroactive interference occurs when newly acquired information inhibits recall of previously learned information. This has been shown to influence recall of sounds, tastes and word associations, and is typically seen when learners receive training on one area of content and are then exposed to new content before being evaluated on the original content. Thus far, retroactive interference has received little attention in medical education and has not been studied during simulation training. Our objective was to evaluate whether retroactive interference occurs during simulation training.

METHODS

We randomised 167 Year 1 medical students to one of two training protocols. After training on a cardiac murmur, participants were tested either on the same cardiac murmur followed by a novel murmur (the non-interference protocol), or on the novel murmur followed by the training murmur (the interference protocol). We evaluated performance on both murmurs at 1 hour and 6 weeks post-training.

RESULTS

We found a significant interaction between training protocol and diagnostic performance on training versus novel murmurs at both testing time-points. Students in the non-interference protocol had increased odds of achieving success on the training murmur relative to the novel murmur at 1 hour (odds ratio [OR] 4.96; p < 0.001) and at 6 weeks (OR 4.23; p = 0.001) after training. By comparison, students in the interference protocol did not demonstrate improved performance on the training murmur relative to the novel murmur at either evaluation (1 hour post-training: OR 0.56 [p = 0.08]; 6 weeks post-training: OR 0.66 [p = 0.23]).

CONCLUSIONS

Consistent with the theory of retroactive interference, students who encountered a novel murmur between training and evaluation on the murmur on which they had been trained showed no improvement in diagnostic performance following simulation training. These findings should serve to warn educators to consider retroactive interference when designing simulation training sessions.

Severity of aortic stenosis assessed by carotid pulse recordings and phonocardiography

The external carotid pulse, the PCG, and the ECG were studied in 26 adult patients with valvular aortic stenosis whose systolic peak pressure gradients ranged from 18 to 165 mmHg. A significant correlation was found between the rapidity of the pulse upstroke, as measured by the T-time, and the location of the peak of the systolic murmur during ventricular ejection, on the one hand, and the gradient, on the other. The left ventricular ejection time (LVET) related directly and the pre-ejection period (PEP) indirectly with the gradient. There was a signficant inverse relationship between the PEP/LVET quotient and the pressure gradient but this quotient did not classify the patients according to the severity of the stenosis as well as the T-time and the location of the peak of murmur. When a combination of the T-time, the PEP/LVET, and the location of the peak of the murmur was used in each patient, a good discrimination between the patients was achieved. When the pressure gradient was above 50 mmHg, at lease one of the measurements was abnormal and when it exceeded 100 mmHg, at least two measurements were abnormal. The study further showed that it is possible to separate patients with valvular aortic stenosis from those with hypertrophic obstructive cardiomyopathy lidiopathic hypertrophic subaortic stenosis) or mitral insufficiency on the basis of carotid pulse tracings and PCGs.

Improvement in medical consultation responses with a structured request form

Physicians often do not provide adequate information regarding patients' medical conditions when presented with consultation requests (CR) generated by dental students and their instructors about the students' patients. We hypothesized that a structured CR form, which requests specific information by providing a checklist and/or closed-ended questions for physicians to answer, would lead to better communication and improved responses. We also hypothesized that providing in-service education to clinical faculty on the conditions that require and don't require CRs would reduce the number of unwarranted CRs sent to physicians. We assessed the responses obtained with the new form and compared them to findings over a similar period using our older, unstructured CR forms. We also evaluated the numbers of CRs written unnecessarily during both time periods. Improvements in the appropriateness of information provided by physicians were noted with the new CR forms for diabetes mellitus, hypertension, heart murmur, and anticoagulant therapy. The number of CRs written for conditions that did not need a consultation was approximately the same after provision of instruction as before. We conclude that structured CR forms improve the flow of information between dentists and physicians and should enhance student knowledge and skills in soliciting relevant information. Greater efforts must be taken to inform clinical faculty about the indications for CRs.

[The art of cardiac auscultation]

Auscultation of the heart should be performed systematically on the five standard auscultation points. During this procedure every sound must be exactly documented. Furthermore, splitting of the heart sounds and clicks, if present, must be noted. Frequently the interpretation of the various sounds is difficult. Clinically significant sounds and therefore requiring further clarification must be filtered out from the many innocent heart murmurs. This is possible only with time, patience and constant practice.

[Nutritional status of adopted Chinese girls in Spain]

INTRODUCTION

Given the increasing number of adoptions from China in countries such as Spain, a study was designed to know and assess the nutritional profile at arrival and its likely implication in global health status, growth, and development of adopted Chinese girls.

PATIENTS AND METHODS

Eighty-five Chinese girls adopted in Spain during the 2002-2003 period and ages ranging 7-33 months of life were studied at the Social Pediatrics Unit of the "Niño Jesús" Hospital, Madrid. Datas regarding institution of origin, nutritional parameters (anthropometrical and biochemical), presence of associated diseases, and developmental retardations (psychomotor/bone age) were gathered.

RESULTS

Waterlow's nutritional index showed a malnourishment rate of 11% based on Chinese reference tables, as compared to 58% based on Spanish tables, of which 82% was acute malnourishment. When comparing the efficacy of both nutritional assessment methods proposed by Waterlow and Gomez, there were no differences in detection of malnourishment in spite of the fact that the latter author gives priority to the weight/age index as a nutritional indicator at ages lower than 2 years. Eighteen percent of the girls were considered at (height/age < p10) of suffering chronic malnourishment, but this was only confirmed in 67% of the group according to Waterlow's criteria. Among assessed plasma parameters, decreased prealbumin, lymphocytes, iron, and transferrin stand out. The predominant pathological findings were thalassemia, dermatitis, psychomotor retardation, and ferropenic anemia.

CONCLUSIONS

These results make us believe in a possible improvement in the conditions at Chinese orphanages. The low age at the time of adoption may justify the low incidence of chronic nutritional deficiencies. As a whole, anthropometrical / nutritional impairments found may be related with the consequences of carelessness and vulnerability of the adoption process. In any case, early diagnosis and implementation of appropriate therapy as soon as possible, as it is being done, is essential to provide appropriate growth and development of these girls.