Echo Features of Posteromedial Papillary Muscle Rupture without Papillary Muscle Prolapse into the Left Atrium

A 67-year-old male presented to the hospital emergency department with a 3-day history of decreased exercise tolerance, fatigue and exertional chest tightness. These symptoms began after an initial episode of prolonged chest pain associated with diaphoresis and dyspnea.. The admission electrocardiogram (EKG) and cardiac "markers" were consistent with a recent inferolateral myocardial infarction (MI). There was no history of cardiovascular disease. Risk factors were that of a family history of heart disease, long-standing tobacco use and elevated lipids. The patient was on no medications. Bedside echocardiography (TTE) revealed left ventricular (LV) basal inferior-inferolateral aneurysmal formation with mild mitral regurgitation (MR). Significant aortic sclerosis was noted (movie clip S1). Because of continued exertional chest pain up through admission, diagnostic angiography was performed. The coronary tree was codominant, with only disease in the circumflex system noted. A large obtuse marginal (OM) branch of the circumflex artery was occluded and could not be opened percutaneously. Left ventriculography was consistent with findings by TTE, with inferobasal dyskinesis noted. The following morning, the patient developed sudden dyspnea, hypotension and pulmonary edema. Cardiac auscultation revealed only a soft systolic murmur, heard at the left sternal border and also apex. The EKG was unchanged, except that Mobitz Type I AV block developed. The patient required endotracheal intubation with mechanical ventilation, along with inotropic support. Address for correspondence and reprint requests: Edmund Kenneth Kerut, M.D., Heart Clinic of Louisiana, 1111 Medical Center Blvd, Suite N613, Marrero, LA 70072. Fax: 504-349-6621; E-mail: [email protected] A second bedside TTE was performed. Twodimensional imaging revealed new prolapse of the posterior mitral valve leaflet, "erratic" reverberations within the LV cavity, and evidence of severe MR by Doppler interrogation Based on the clinical scenario and suggestive findings by TTE, transesophageal echocardiography (TEE) was performed. Findings confirmed rupture of the posteromedial (PM) papillary muscle An intraaortic balloon pump (IABP) was placed and the patient taken to the operating room, where the PM papillary muscle was found to be ruptured In the setting of myocardial infarction, papillary muscle rupture is rather an uncommon event, occurring in 1% to 3% of patients with acute MI

Cohort Profile: Pregnancy And Childhood Epigenetics (PACE) Consortium.

Development Psychopathology in context: famil

Optimum size in grid soil sampling for variable rate application in site-specific management Tamanho ideal em grades de amostragem de solos para aplicação em taxa variável em manejo localizado

The importance of understanding spatial variability of soils is connected to crop management planning. This understanding makes it possible to treat soil not as a uniform, but a variable entity, and it enables site-specific management to increase production efficiency, which is the target of precision agriculture. Questions remain as the optimum soil sampling interval needed to make site-specific fertilizer recommendations in Brazil. The objectives of this study were: i) to evaluate the spatial variability of the main attributes that influence fertilization recommendations, using georeferenced soil samples arranged in grid patterns of different resolutions; ii) to compare the spatial maps generated with those obtained with the standard sampling of 1 sample ha-1, in order to verify the appropriateness of the spatial resolution. The attributes evaluated were phosphorus (P), potassium (K), organic matter (OM), base saturation (V%) and clay. Soil samples were collected in a 100 × 100 m georeferenced grid. Thinning was performed in order to create a grid with one sample every 2.07, 2.88, 3.75 and 7.20 ha. Geostatistical techniques, such as semivariogram and interpolation using kriging, were used to analyze the attributes at the different grid resolutions. This analysis was performed with the Vesper software package. The maps created by this method were compared using the kappa statistics. Additionally, correlation graphs were drawn by plotting the observed values against the estimated values using cross-validation. P, K and V%, a finer sampling resolution than the one using 1 sample ha-1 is required, while for OM and clay coarser resolutions of one sample every two and three hectares, respectively, may be acceptable.<br>A importância de compreender a variabilidade espacial do solo está conectada ao planejamento do manejo das culturas. Este entendimento faz com que seja possível tratar o solo não como uma entidade uniforme, mas variável, e permite o gerenciamento de sítios específicos para aumentar a eficiência de produção, que é o objetivo da agricultura de precisão. Questões relacionadas com a otimização do intervalo de amostragem do solo se faz necessário para a realização das recomendações de adubações no Brasil. Os objetivos deste estudo foram: i) avaliar a variabilidade espacial dos principais atributos que influenciam as recomendações de adubação, usando amostras de solos georreferenciadas dispostas em padrões de grades de diferentes resoluções; ii) comparar os mapas espaciais gerados com o mapa padrão obtido com amostragem de 1 amostra ha-1, a fim de verificar a adequação da resolução espacial. Os atributos avaliados foram fósforo (P), potássio (K), matéria orgânica (MO), saturação por bases (V%) e argila. As amostras de solos foram coletadas numa grade de 100 × 100 m e georreferenciadas. Um desbaste foi realizado, criando-se uma grade com 1 amostra a cada 2,07, 2,88, 3,75 e 7,20 ha. Técnicas de geoestatística, como semivariograma e interpolação usando krigagem, foram utilizadas para analisar os atributos nas grades com diferentes resoluções. Esta análise foi realizada com o programa computacional Vesper. Os mapas criados por este método foram comparados utilizando-se a estatística kappa. Além disso, gráficos de correlação foram construídos plotando-se os valores observados pelos valores estimados utilizando-se a validação cruzada. Para P, K e V%, uma amostragem de resolução mais fina do que aquela usando 1 amostra ha-1 foi necessária, enquanto que para MO e argila, resoluções mais grosseiras de uma amostra ou dois em dois e três hectares, respectivamente, pode ser aceitável