Disseminated fungal infections are still rare conditions, mostly caused by Candida spp. during immunosuppression. Infection of immunocompetent individuals is uncommon. Endocarditis is a rare manifestation during candidaemia, mostly in patients with prosthetic valves. Affection of previously unaltered valves is uncommon.We presented a case of a young, previously healthy female patient with endocarditis, caused by Candida parapsilosis. The initial symptom, fever, was present four months before hospital admittance. She was febrile without other symptoms and during observation in a local hospital. After her condition deteriorated, she was transferred to the Institute for infectious and tropical diseases, Belgrade. Clinical findings on admission include petechial skin rash and moderate hepatosplenomegaly. Newly developed systolic murmur was noted, and Candida parapsilosis was isolated in multiple blood cultures. Echocardiography revealed 15 × 14 mm vegetations on the right aortic vellum. She was treated with antifungal drugs (fluconasole, liposomal amphotericin B), and the affected valve was successfully replaced. The same strain of Candida parapsilosis was isolated from the intraoperative material of the valve. There were no markers of immunosuppression or other conditions which could affect the immune system.After a prolonged period of treatment she was successfully cured, and she received a long-term intermittent suppressive fluconasole therapy for the time being.

The Smith-Lemli-Opitz syndrome (SLOS) is an autosomal recessive multiple congenital anomaly/mental retardation syndrome caused by a defect in cholesterol synthesis. Affected individuals have dysmorphism, short stature, failure to thrive, microcephaly, multiple congenital malformations, and mental retardation. Diagnostic biochemical features include low plasma cholesterol levels and elevated levels of cholesterol precursors, including 7-dehydrocholesterol (7DHC).The aim of this study is to report a case of SLOS with hypercortisolism and hypothyroidism.This is a case report from the genetic and metabolic unit of a tertiary care teaching hospital in north India.A 5-month-old male child presented with progressively increasing weight since birth. On examination, he had cyanosis, facial dysmorphism, obesity, bilateral cryptorchidism, hypospadias, inverted nipples, and systolic murmur over the left parasternal area. Investigations revealed a decreased serum cholesterol and elevated 7DHC. His serum cortisol and adrenocorticotropic hormone levels were elevated, and there was suppression of cortisol after the high-dose dexamethasone test. Magnetic resonance imaging of the brain and the pituitary region was normal. The thyroid-stimulating hormone was also elevated. Echocardiography revealed a double-outlet right ventricle with ventricular septal defect and pulmonary stenosis.SLOS is an inborn error of cholesterol synthesis associated with failure to thrive and malformations involving almost all the systems of the body. The occurrence of hypercortisolism, hypothyroidism, obesity, and complex cyanotic cardiac lesion in association with SLOS has not been described earlier.

A case of neonatal cholestasis associated with Trisomy 18 (Edward's syndrome) is presented. A 3-day-old boy was referred to our clinic due to respiratory distress, elevated serum direct bilirubin levels, a systolic heart murmur, growth restriction and micrognathia. Liver biopsy and chromosomal analysis revealed paucity of intrahepatic bile ducts and Trisomy 18. Extrahepatic biliary atresia was reported in only a few patients with Trisomy 18. To our knowledge, we described for the first time a patient with Trisomy 18 and neonatal cholestasis associated with paucity of interlobular bile ducts.

To analyze the clinical and cardiac imaging characteristics of patients with left ventricular apical hypoplasia (LVAH).From January 2008 to January 2012, seven patients [3 male/4 female, age: 6 - 44 (19.9 ± 14.2) years] with LVAH were included in this cohort. Transthoracic echocardiogram was performed in all patients, cardiovascular MRI was performed in 3 patients and cardiovascular CT in another 2 patients. In addition, one LVAH patient underwent cardiac catheterization and angiography examination.Four out of 7 patients complained chest discomfort. Precordial murmur was heard in 3 patients. Atrial fibrillation was evidenced by electrocardiogram in 3 patients. Left ventricular end-diastolic diameter [(57.9 ± 11.6) mm] increased while left ventricule (LV) longitudinal diameter reduced in all patients. Left ventricular systolic function was reduced in 2 patients and mean LVEF was (47.6 ± 17.2)%. The interventricular septum bulged towards the right, and the ventricular septum thickness was (7.3 ± 1.2) mm. The papillary muscles were dominant on the flattened LV anteroapical region. The right ventricle elongated and wrapped around the hypoplastic left ventricular apex, and the dimension of right ventricle was (19.7 ± 7.6) mm. Focal fat replacement of the left ventricular apical wall was evidenced in 5 patients underwent cardiovascular MRI or CT examinations.Clinical symptoms are non-specific in LVAH patients. Truncated and spherical LV, abnormal origin of papillary muscles in the flattened LV anterior apex and an elongated right ventricle wrapping around the LV apex as well as focal fat replacement of the left ventricular apical wall are typical imaging characteristics of LVAH.

Simulation-based medical education allows trainees to engage in self-regulated learning (SRL), yet research aimed at elucidating the mechanisms of SRL in this context is relatively absent. We compared 'unguided' SRL with 'directed' SRL (DSRL), wherein learners followed an expert-designed booklet.Year 1 medical students (n = 37) were randomly assigned to practise identifying seven cardiac murmurs using a simulator and video only (SRL group) or a simulator and video plus the booklet (DSRL group). All participants completed a 22-item test 3 weeks later. To compare interventions, we analysed students' diagnostic accuracy. As a novel source of evidence, we documented how participants autonomously sequenced the seven murmurs during initial and delayed practice sessions. In addition, we surveyed clinical educators (n = 17) to find out how they would sequence their teaching of these murmurs.The DSRL group used 50% more training time than the SRL group (p < 0.001). The groups' diagnostic accuracy, however, did not differ significantly on the post-test, retention test or transfer test items (p > 0.12). Despite practising with the expert-defined 'timing-based' approach to murmur diagnosis (i.e. systolic versus diastolic), 84% of DSRL participants implemented a location-based approach (i.e. practising aortic murmurs separately from mitral murmurs) during a second, unguided practice session. Notably, most SRL participants used that same approach spontaneously. By contrast, clinical educators were split in their use of the timing-based (n = 10) and the location-based (n = 6) approaches. Chi-squared analyses suggested educators' conceptions for organising murmurs differed significantly from students' conceptions.Contrary to our predictions, directing students' SRL produced no additional benefit and increased their practice time. Our findings suggest one potential source of these results was a divergence between student and educator conceptions for structuring the practice of cardiac auscultation skills. This phenomenon has not been well articulated in the medical education literature, and may have important implications in many (especially technology-mediated) educational contexts.

STUDY RATIONALE: Veterinary practitioners often perform geriatric health screening in cats. Unfortunately, scientific information regarding clinical and laboratory abnormalities and normal blood pressure values in elderly cats is scarce. This prospective study evaluated routine health screening tests in apparently healthy middle-aged and old cats.One hundred cats of 6 years and older underwent blood pressure measurement, physical examination, blood and urine analysis, indirect fundoscopy and bilateral Schirmer tear tests.Mean systolic blood pressure (SBP) was 133.6 ± 21.5 mmHg. Increased SBP (>160 mmHg) was observed in eight cats, submandibular lymphadenopathy in 32, gingivitis in 72, heart murmur in 11, thyroid goitre in 20, increased creatinine in 29, hyperglycaemia in 25, increased total thyroxine in three, feline immunodeficiency virus positivity in 14, crystalluria in 41, borderline proteinuria in 25 and overt proteinuria in two. Mean tear production was very similar for both eyes and none of the cats had ocular lesions secondary to hypertension.Old cats (>10 years) had significantly higher SBP, heart rate, murmur frequency, thrombocyte count, urine protein:creatinine ratio and serum urea and bilirubin concentrations, and significantly lower body condition score, haematocrit, albumin and total calcium concentrations than middle-aged cats (6-10 years). The common occurrence of physical examination and laboratory abnormalities in apparently healthy old cats underlines the need for regular health checks and the development of age-dependent laboratory reference intervals.

Physiological principles that directly apply to physical diagnosis provide opportune occasions to bring basic science to the bedside. In this article, we describe the effect of cardiac maneuvers on systolic murmurs and how physiological principles apply to the explanation of the changes noted at the bedside. We discuss the effect of Valsalva, squatting, and hand grip maneuvers on different physiological parameters influencing preload, afterload, chamber dimensions, and pressure gradients. The clinical manifestations noted during the aforementioned maneuvers are described in common cardiac conditions responsible for the production of certain systolic murmurs.

Auscultation skills are in decline, but few studies have shown which specific aspects are most difficult for trainees. We evaluated individual aspects of cardiac auscultation among pediatric residents using recorded heart sounds to determine which elements pose the most difficulty.Auscultation proficiency was assessed among 34 trainees following a pediatric cardiology rotation using an open-set format evaluation module, similar to the actual clinical auscultation description process.Diagnostic accuracy for distinguishing normal from abnormal cases was 73%. Findings most commonly correctly identified included pathological systolic and diastolic murmurs and widely split second heart sounds. Those least likely to be identified included continuous murmurs and clicks. Accuracy was low for identifying specific diagnoses.Given time constraints for clinical skills teaching, this suggests that focusing on distinguishing normal from abnormal heart sounds and murmurs instead of making specific diagnoses may be a more realistic goal for pediatric resident auscultation training.

The heart is the principal organ that circulates blood. In normal conditions it produces four sounds for each cardiac cycle. However, most often only two sounds appear essential: S1 and S2. Two other sounds: S3 and S4, with lower amplitude than S1 or S2, appear occasionally in the cardiac cycle by the effect of disease or age. The presence of abnormal sounds in one cardiac cycle provide valuable information on various diseases. The aortic stenosis (AS), as being a valvular pathology, is characterized by a systolic murmur due to a narrowing of the aortic valve. The mitral stenosis (MS) is characterized by a diastolic murmur due to a reduction in the mitral valve. Early screening of these diseases is necessary; it's done by a simple technique known as: phonocardiography. Analysis of phonocardiograms signals using signal processing techniques can provide for clinicians useful information considered as a platform for significant decisions in their medical diagnosis. In this work two types of diseases were studied: aortic stenosis (AS) and mitral stenosis (MS). Each one presents six different cases. The application of the discrete wavelet transform (DWT) to analyse pathological severity of the (AS and MS was presented. Then, the calculation of various parameters was performed for each patient. This study examines the possibility of using the DWT in the analysis of pathological severity of AS and MS.

This report describes a case of an asymptomatic 18-year-old boy with a grade 1/6 ejection systolic murmur in the aortic area referred for an echocardiographic study to rule out a congenital heart disease. The patient had situs solitus, levocardia, bicuspid aortic valve, dilation of the proximal portions of the right coronary artery, and arteriovenous coronary fistula of the anomalous coronary branch originating from the anterior descending coronary artery into the main pulmonary artery. In addition he had a unique aortic arterial meshwork constituted by arteries originating from the inferior and posterior aspect of the distal portion of the transverse aortic arch, intersegmentary arteries originating from the lateral and anterior aspect of the proximal portion of the descending aorta, and the true bronchial artery with a major arteriovenous collateral artery draining into the superior vena cava and the superior division of the left lower pulmonary vein as well as a major aortopulmonary collateral artery anastomosed with a bronchial artery and draining into the posterior aspect of the right pulmonary artery. The use of transthoracic two-dimensional color flow Doppler echocardiography, magnetic resonance angiography and multislice computed tomography to establish a detailed morphologic analysis and the presence of associated anomalies in patients with a bicuspid aortic valve are discussed.