Acute Onset Shortness of Breath with New Murmur: An ED Case Study

Background: Shortness of breath especially acute onset, is an anxiety inducing symptom for both patients and physicians alike, and it accounts for the 6th most common reason for emergency department visits in the United States. Upon initial presentation to ED, it is the job of the ED physician to make critical decisions in the acute management of that patient, but also lay the groundwork further treatment by consultants either medically or surgically. Clinical Presentation: A 70 year old female with past medical history of hypertension presented to the emergency department via EMS for complaint of acute onset shortness of breath. Patient was sitting at a restaurant eating lunch, when she suddenly became short of breath. Upon arrival to ED, patient was hypoxic on room air to 83% and respiratory rate in the mid 20s. On initial evaluation, patient had increased work of breathing, however SpO2 improved with non-rebreather and was weened to 4L NC with improvement to SpO2 in the mid 90s. On exam, patient had a new loud systolic murmur radiating to axilla as well as crackles in bilateral lung base with conversational dyspnea appreciated. After Initial resuscitation, cardiac workup was ordered and patient had EKG consistent for sinus tachycardia with no T or ST changes as well as a chest x-ray which showed new pulmonary edema with pleural effusions. Bedside cardiac echo performed consistent with preserved LV function with no pericardial effusion, however valve abnormality was appreciated. Laboratory findings showed BNP of 200 and negative troponin. Cardiology was consulted due new murmur with acute heart failure and patient was subsequently admitted to the ICU and underwent TEE which was consistent for flail leaflet of the P2 scallop of the posterior mitral leaflet with severe mitral regurgitation likely causing acute heart failure. While admitted Cardiothoracic surgery was consulted and patient underwent successful urgent Median Sternotomy with Mitral Valve replacement. Conclusion: This case exemplifies the importance of a prudent ED history and physical exam on initial patient presentation as well as careful use of adjunct studies to further strengthen an initial diagnosis while in the emergency department. This patient was able to receive appropriate consultation as well as treatment by specialists after initial resuscitation in emergency department, and had successful outcome of newly diagnosed murmur to eventual replacement.https://scholarlycommons.henryford.com/merf2020caserpt/1027/thumbnail.jp

Optimistic Concurrency Control for Distributed Unsupervised Learning

Research on distributed machine learning algorithms has focused primarily on one of two extremes - algorithms that obey strict concurrency constraints or algorithms that obey few or no such constraints. We consider an intermediate alternative in which algorithms optimistically assume that conflicts are unlikely and if conflicts do arise a conflict-resolution protocol is invoked. We view this "optimistic concurrency control" paradigm as particularly appropriate for large-scale machine learning algorithms, particularly in the unsupervised setting. We demonstrate our approach in three problem areas: clustering, feature learning and online facility location. We evaluate our methods via large-scale experiments in a cluster computing environment.Comment: 25 pages, 5 figure

Tracking chemical processing pathways in combinatorial polymer libraries via data mining

Changes in the molecular structure and composition of interpenetrating polymer networks (IPNs) can be used to tailor their properties. While the properties of IPNs are typically different than polymer blends, a clear understanding of the impact of changing polymerization sequence on the physical properties and the corresponding molecular bonding is needed. To address this issue, a data mining approach is used to identify the change with polymerization sequence of tensile and rheological properties of acrylate-epoxy IPNs. The experimental approach used to study the molecular structure is high throughput Fourier transform infrared (FTIR) spectroscopy. Analysis of the FTIR spectra of IPNs synthesized with different polymerization sequences leads to an understanding of the molecular bonding responsible for the tensile and rheological properties. From the interpretation of the wavenumber bands and associated molecular bonds, we find that the polymerization sequence most affects hydrogen bonding and aromatic ring bond energies. This work defines the relationships between chemistry, structure, processing, and properties of the IPN samples

Unique probe of dark matter in the core of M87 with the Event Horizon Telescope

We demonstrate the unprecedented capabilities of the Event Horizon Telescope (EHT) to image the innermost dark matter profile in the vicinity of the supermassive black hole at the center of the M87 radio galaxy. We present the first model of the synchrotron emission induced by dark matter annihilations from a spiky profile in the close vicinity of a supermassive black hole, accounting for strong gravitational lensing effects. Our results show that the EHT should readily resolve dark matter spikes if present. Moreover, the photon ring surrounding the silhouette of the black hole is clearly visible in the spike emission, which introduces observable small-scale structure into the signal. We find that the dark matter-induced emission provides an adequate fit to the existing EHT data, implying that in addition to the jet, a dark matter spike may account for a sizable portion of the millimeter emission from the innermost (subparsec) region of M87. Regardless, our results show that the EHT can probe very weakly annihilating dark matter. Current EHT observations already constrain very small cross sections, typically down to a few 10−31 cm3 s−1 for a 10 GeV candidate, close to characteristic values for p-wave-suppressed annihilation. Future EHT observations will further improve constraints on the DM scenario

Temporal trends in symptom experience predict the accuracy of recall PROs

Objective - Patient-reported outcome measures with reporting periods of a week or more are often used to evaluate the change of symptoms over time, but the accuracy of recall in the context of change is not well understood. This study examined whether temporal trends in symptoms that occur during the reporting period impact the accuracy of 7-day recall reports. Methods - Women with premenstrual symptoms (n = 95) completed daily reports of anger, depression, fatigue, and pain intensity for 4 weeks, as well as 7-day recall reports at the end of each week. Latent class growth analysis was used to categorize recall periods based on the direction and rate of change in the daily reports. Agreement (level differences and correlations) between 7-day recall and aggregated daily scores was compared for recall periods with different temporal trends. Results - Recall periods with positive, negative, and flat temporal trends were identified and they varied in accordance with weeks of the menstrual cycle. Replicating previous research, 7-day recall scores were consistently higher than aggregated daily scores, but this level difference was more pronounced for recall periods involving positive and negative trends compared with flat trends. Moreover, correlations between 7-day recall and aggregated daily scores were lower in the presence of positive and negative trends compared with flat trends. These findings were largely consistent for anger, depression, fatigue, and pain intensity. Conclusion - Temporal trends in symptoms can influence the accuracy of recall reports and this should be considered in research designs involving change

Relationship of national institutes of health stroke scale to 30-day mortality in medicare beneficiaries with acute ischemic stroke.

BackgroundThe National Institutes of Health Stroke Scale (NIHSS), a well-validated tool for assessing initial stroke severity, has previously been shown to be associated with mortality in acute ischemic stroke. However, the relationship, optimal categorization, and risk discrimination with the NIHSS for predicting 30-day mortality among Medicare beneficiaries with acute ischemic stroke has not been well studied.Methods and resultsWe analyzed data from 33102 fee-for-service Medicare beneficiaries treated at 404 Get With The Guidelines-Stroke hospitals between April 2003 and December 2006 with NIHSS documented. The 30-day mortality rate by NIHSS as a continuous variable and by risk-tree determined or prespecified categories were analyzed, with discrimination of risk quantified by the c-statistic. In this cohort, mean age was 79.0 years and 58% were female. The median NIHSS score was 5 (25th to 75th percentile 2 to 12). There were 4496 deaths in the first 30 days (13.6%). There was a strong graded relation between increasing NIHSS score and higher 30-day mortality. The 30-day mortality rates for acute ischemic stroke by NIHSS categories were as follows: 0 to 7, 4.2%; 8 to 13, 13.9%; 14 to 21, 31.6%; 22 to 42, 53.5%. A model with NIHSS alone provided excellent discrimination whether included as a continuous variable (c-statistic 0.82 [0.81 to 0.83]), 4 categories (c-statistic 0.80 [0.79 to 0.80]), or 3 categories (c-statistic 0.79 [0.78 to 0.79]).ConclusionsThe NIHSS provides substantial prognostic information regarding 30-day mortality risk in Medicare beneficiaries with acute ischemic stroke. This index of stroke severity is a very strong discriminator of mortality risk, even in the absence of other clinical information, whether used as a continuous or categorical risk determinant. (J Am Heart Assoc. 2012;1:42-50.)