Unraveling the Uncommon: A Case Report of Giant Cell Myocarditis and Examination of Existing Literature

BACKGROUND Idiopathic giant cell myocarditis (IGCM) is an uncommon and frequently fatal type of myocarditis. It primarily affects young individuals and has the potential to result in heart failure and life-threatening arrhythmias. IGCM seems to be dependent on activation of CD4-positive T lymphocytes and can show improvement with treatment aimed at reducing T-cell function. We present a case of a 65-year-old patient who presented with features of acute heart failure refractory to guideline-directed medical therapy (GDMT), due to IGCM. A review of the natural history and treatment of IGCM is also presented. CASE REPORT A 65-year-old woman with multiple comorbidities was admitted to our hospital for ventricular tachycardia in the setting of progressive non-ischemic heart failure, unresponsive to GDMT. This led to further investigation, including an endomyocardial biopsy, which revealed inflammatory infiltration, with multinucleated giant cells and lymphocytes in the absence of granuloma formation, prompting a diagnosis of IGCM. An implantable cardioverter-defibrillator (ICD) was placed for secondary prevention of sudden cardiac death and the patient was initiated on combined immunosuppressive therapy. Owing to numerous comorbidities, she was determined to be unsuitable for a heart transplant. Unfortunately, she eventually died from complications secondary to the disease. CONCLUSIONS IGCM remains a challenging clinical diagnosis with a poor long-term outcome without heart transplantation. This case highlights the importance of considering atypical causes of heart failure in patients who do not respond to conventional therapies. Early recognition and appropriate management, involving medical and interventional approaches, are crucial in improving outcomes for patients with IGCM.

Visual art instruction in medical education: a narrative review

The humanities have been increasingly incorporated into medical school curricula in order to promote clinical skills and professional formation. To understand its current use, we reviewed the literature on visual arts training in medical education, including relevant qualitative and quantitative data. Common themes that emerged from this review included a focus on preclinical students; instruction promoting observation, diagnostic skills, empathy, team building, communication skills, resilience, and cultural sensitivity. Successful partnerships have involved local art museums, with sessions led primarily by art educators employing validated pedagogy such as Visual Thinking Strategies or Artful Thinking. There is evidence that structured visual arts curricula can facilitate the development of clinical observational skills, although these studies are limited in that they have been single-institution reports, short term, involved small numbers of students and often lacked controls. There is a paucity of rigorous published data demonstrating that medial student art education training promotes empathy, team building, communication skills, wellness and resilience, or cultural sensitivity. Given these concerns, recommendations are offered for fostering more robust, evidence-based approaches for using visual arts instruction in the training of medical students.

The Fostering Resilience through Art in Medical Education (FRAME) workshop: a partnership with the Philadelphia Museum of Art

Background: Provider burnout remains a serious problem facing medical training programs and has been shown to affect more than half of internal medicine residents. In addition to broader efforts to revamp a health care system that contributes to this epidemic, exposure to the medical humanities offers potential to promote engagement, resilience, and restoration of meaning in residents' daily lives. Objective: We aim to create a reproducible, evidence-based workshop utilizing artful thinking routines to prepare trainees to combat burnout with reflection, perspective-taking, and community-building. Methods: A single, 4-hour workshop for senior internal medicine residents, centered on visual artistic analysis, was offered in June 2017 at the Philadelphia Museum of Art. Pre- and post-workshop burnout metrics and survey evaluation data were analyzed using a mixed-methods approach. Results: Workshop participation was offered to 29 internal medicine residents, of whom 17 (59%) participated. All survey respondents (n=13) rated the workshop as excellent and would recommend it to colleagues. Moderate decreases in the observed frequencies of both high emotional exhaustion scores (64.7% before the workshop to 55.5% following the workshop) and high depersonalization scores (70.6% before the workshop to 55.5% following the workshop) were observed. Conclusions: While results are preliminary in nature, the workshop was received favorably and demonstrated modest decreases in emotional exhaustion and depersonalization. We are encouraged to explore and repeat this workshop with modifications to identify its optimal position in the broader landscape of emerging wellness curricula.

Pregnancy in women with congenital heart disease: the impact of a systemic right ventricle

OBJECTIVE

Individuals with a systemic right ventricle develop cardiac complications earlier in life. Limited data exists regarding the effect of a maternal systemic right ventricle on cardiac events during pregnancy. We sought to assess the effect of a systemic right ventricle on cardiac events and pregnancy outcomes.

DESIGN

The study was designed as a retrospective cohort study of pregnant women with maternal congenital heart disease.

SETTING

The study was set in a university, academic tertiary care referral center.

PATIENTS

Study subjects were identified by International Statistical Classification of Diseases and Related Health Problems-9 codes. Women with mitral valve prolapse only or noncongenital cardiac disease were excluded. The exposure was defined by systemic ventricle.

OUTCOME MEASURES

The primary outcome was a composite of congestive heart failure, arrhythmia, stroke, cardiac arrest/death during pregnancy or postpartum (CARDCOMP). The secondary outcome (PREGCOMP) was a composite of preterm delivery, preeclampsia, growth restriction, and stillbirth/pregnancy loss (PREGCOMP). Student's t-test or chi-square/Fisher's exact tests were used for comparison of continuous/categorical variables. Multivariable logistic regression was performed to control for possible confounders.

RESULTS

One hundred forty-six pregnancies in 114 women were included; 15 (10.3%) pregnancies involved a systemic right ventricle. CARDCOMP complicated 12.3% of these pregnancies. Women with a systemic right ventricle were more likely to develop CARDCOMP even after adjustment for confounders (odds ratio [OR] 6.32 [1.7-23.5], P= .006). PREGCOMP complicated 40.4% of all pregnancies. Women with a systemic right ventricle were also more likely to develop PREGCOMP (OR 5.37 [1.4-20.7], P= .015) compared with women with a systemic left ventricle after controlling for confounders.

CONCLUSION

  In women with congenital heart disease, a systemic right ventricle is associated with adverse cardiac and pregnancy outcomes. This information is critical for counseling and caring for these women. Further investigation is warranted regarding the effect of pregnancy on long-term health for this unique cohort of women.

N-terminal pro-brain natriuretic Peptide as a biomarker for hypertensive disorders of pregnancy

We tested the hypothesis that the cardiac biomarker N-terminal pro-brain natriuretic peptide would be elevated in hypertensive disorders of pregnancy, with an increase in levels of this biomarker across increasing gradations of disease severity. We performed a case-controlled study of women admitted to labor and delivery at the Hospital of the University of Pennsylvania between 24 and 42 weeks of gestation. Cases had hypertension that developed after 20 weeks of gestation, and controls were normotensive women presenting for delivery. N-terminal pro-brain natriuretic peptide levels were compared between cases ( N = 83) and controls ( N = 290). Cases were subclassified into gestational hypertension ( N = 20) and mild ( N = 15) and severe preeclampsia ( N = 48), and N-terminal pro-brain natriuretic peptide levels were compared between these subgroups. N-terminal pro-brain natriuretic peptide levels were higher in cases than in controls (81 pg/mL versus 37 pg/mL, P < 0.001), with a graded increase in levels from gestational hypertension (64 pg/mL) to preeclampsia (89 pg/mL) to severe preeclampsia (157 pg/mL; P < 0.001). Each log increase in N-terminal pro-brain natriuretic peptide doubled the risk of preeclampsia (odds ratio = 2.10 P < 0.001). N-terminal pro-brain natriuretic peptide levels were increased in hypertensive disorders of pregnancy and discriminate between subcategories of disease.

Global outcomes of ST-elevation myocardial infarction: comparisons of the Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment-Thrombolysis In Myocardial Infarction study 25 (ExTRACT-TIMI 25) registry and trial

BACKGROUND

Outcomes in patients with ST-elevation myocardial infarction (STEMI) differ between those in clinical trials and those in routine practice, as well as across different regions. We hypothesized that adjustment for baseline risk would minimize such variations.

METHODS

The Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment-Thrombolysis In Myocardial Infarction (ExTRACT-TIMI) 25 registry was an observational study of patients with STEMI presenting to hospitals participating in the ExTRACT-TIMI 25 randomized clinical trial. Consecutive patients with STEMI who were not enrolled in the trial were entered into the registry. Demographics, in-hospital therapies, and in-hospital events were collected. Baseline risk was assessed using the TIMI Risk Index for STEMI. To adjust for differences among the countries from which the patients presented, the gross national income per annum per capita (GNI) was used.

RESULTS

A total of 3726 patients were registered from 109 sites in 25 countries. Patients in the registry had a higher baseline risk than those in the trial; they had more extensive prior cardiac histories and more comorbidities. Unadjusted in-hospital mortality was higher in the registry (8.3%) than in the trial (6.6%) (hazard ratio, 1.30; P < .001); however, after adjusting for TIMI Risk Index, mortality was similar (hazard ratio(adj), 1.00; P = .97). The GNI was not significantly predictive of in-hospital mortality in the multivariable model of the registry.

CONCLUSION

Patients in the registry had higher mortality than those in the trial. This difference could be explained by the higher baseline risk of patients in the registry. After adjusting for baseline risk, the GNI of the country in which the patient presented did not contribute to predicting in-hospital mortality.

C-reactive protein and cardiovascular outcomes in smokers versus nonsmokers in non-ST-elevation acute coronary syndrome (from the TACTICS-TIMI 18 trial)

We investigated the role of inflammation, as measured by high-sensitivity C-reactive protein (CRP) levels, in cardiovascular risk in smokers who have acute coronary syndrome. Despite fewer traditional risk factors, smokers who had acute coronary syndrome had higher CRP levels than did nonsmokers (7.0 vs 5.1 mg/L, p <0.001). CRP was associated with adverse cardiovascular outcomes in smokers and nonsmokers, even when adjusted for the presence of pulmonary disease.

Fever phobia revisited: have parental misconceptions about fever changed in 20 years?

OBJECTIVES

Fever is one of the most common reasons that parents seek medical attention for their children. Parental concerns arise in part because of the belief that fever is a disease rather than a symptom or sign of illness. Twenty years ago, Barton Schmitt, MD, found that parents had numerous misconceptions about fever. These unrealistic concerns were termed "fever phobia." More recent concerns for occult bacteremia in febrile children have led to more aggressive laboratory testing and treatment. Our objectives for this study were to explore current parental attitudes toward fever, to compare these attitudes with those described by Schmitt in 1980, and to determine whether recent, more aggressive laboratory testing and presumptive treatment for occult bacteremia is associated with increased parental concern regarding fever.

METHODS

Between June and September 1999, a single research assistant administered a cross-sectional 29-item questionnaire to caregivers whose children were enrolled in 2 urban hospital-based pediatric clinics in Baltimore, Maryland. The questionnaire was administered before either health maintenance or acute care visits at both sites. Portions of the questionnaire were modeled after Schmitt's and elicited information about definition of fever, concerns about fever, and fever management. Additional information included home fever reduction techniques, frequency of temperature monitoring, and parental recall of past laboratory workup and treatment that these children had received during health care visits for fever.

RESULTS

A total of 340 caregivers were interviewed. Fifty-six percent of caregivers were very worried about the potential harm of fever in their children, 44% considered a temperature of 38.9 degrees C (102 degrees F) to be a "high" fever, and 7% thought that a temperature could rise to >/=43.4 degrees C (>/=110 degrees F) if left untreated. Ninety-one percent of caregivers believed that a fever could cause harmful effects; 21% listed brain damage, and 14% listed death. Strikingly, 52% of caregivers said that they would check their child's temperature </=1 hour when their child had a fever, 25% gave antipyretics for temperatures <37.8 degrees C (<100 degrees F), and 85% would awaken their child to give antipyretics. Fourteen percent of caregivers gave acetaminophen, and 44% gave ibuprofen at too frequent dosing intervals. Of the 73% of caregivers who said that they sponged their child to treat a fever, 24% sponged at temperatures </=37.8 degrees C (</=100 degrees F); 18% used alcohol. Forty-six percent of caregivers listed doctors as their primary resource for information about fever. Caregivers who stated that they were very worried about fever were more likely in the past to have had a child who was evaluated for a fever, to have had blood work performed on their child during a febrile illness, and to have perceived their doctors to be very worried about fever. Compared with 20 years ago, more caregivers listed seizure as a potential harm of fever, woke their children and checked temperatures more often during febrile illnesses, and gave antipyretics or initiated sponging more frequently for possible normal temperatures.

CONCLUSIONS

Fever phobia persists. Pediatric health care providers have a unique opportunity to make an impact on parental understanding of fever and its role in illness. Future studies are needed to evaluate educational interventions and to identify the types of medical care practices that foster fever phobia.fever, fever phobia, child, children, antipyretics, sponging, health care practices.