Decreased Exercise Tolerance Research Articles

An Incidental Finding of Rectal Carcinoid Tumor

Adenocarcinoma is the most common malignancy found in the rectum. However, the incidence of rectal carcinoid has been rising after implementation of screening colonoscopy. The rectum is the second most common anatomic site for carcinoid tumor. Embryologically, rectal carcinoids are hindgut tumors which are non secretory. Hence, they rarely present with carcinoid syndrome even in patients with metastatic disease. A recent systematic review of rectal carcinoid by McDermott et.al was unable to perform a metaanalysis on optimal treatment strategies for localized and widespread disease due to the wide variety of data recorded from various sources. Our aim is to make physicians aware that the rectal carcinoid is becoming a common diagnosis thus clinicians should have current knowledge of classification, management and treatment options available. A 62-year-old African American male with a significant past medical history of hypertension and tobacco abuse presented to the gastrointestinal (GI) lab for colorectal cancer screening colonoscopy. Patient had no specific GI complaints and a 10-point review of symptoms was unremarkable except for decreased exercise tolerance. Physical examination was unremarkable including digital rectal exam. During colonoscopy, a 7-10 mm firm polypoid submucosal lesion was noted in distal rectum and was resected using an electrocautery snare and ERBE endocut current. Histologic evaluation of the resected polyp demonstrated a well-differentiated neuroendocrine neoplasm that stained positive for chromogramin, synaptophysin, and Ki-67 proliferation marker. Patient underwent repeat colonoscopy about a month later. Biopsy obtained from previous polypectomy site was negative for carcinoid tumor cells. The rectal carcinoid classification, management and treatment options have been defined based on the size and aggressiveness of the lesion. As there is no defined TNM system classification, there is no homogenous data available yet on how to manage rectal carcinoid. Treatment strategy is based on tumor size, radiologic testing and surveillance examination including use of rectal EUS.Figure 1

Specyfika opieki pielęgniarskiej nad pacjentem starszym leczonym chirurgicznie

The aging of the human body is a continuous and progressive process, leading to dysfunction of organs and systems and disturbing homeostasis. Aging without additional pathology (physiological aging) occurs relatively rarely. In the case of co-morbidities (pathological aging) additional organ damage can be diagnosed, which deteriorate the condition of the elderly patient. Age-related illnesses can create complicated problems for therapeutic teams. The most common diseases include cardiovascular disease and pathology of the respiratory, digestive, nervous and immune systems. The overall deterioration of health (often named the frailty syndrome) can be accompanied by loss of muscle mass, malnutrition, decreased physical activity, decreased exercise tolerance, deterioration of the cognitive function and increased sensitivity to stressors. Due to specificity of the aged physiology and the presence of co-morbidity, elderly patients require an interdisciplinary treatment, which often requires surgery, with special need for specific preparation for the surgery, postoperative care and rehabilitation. The elderly are at particular risk for various complications after surgery from the organ systems: hypoxia, infection, hypoproteinaemia, hyponatremia, hypovolemia. Proper nursing care should include accurate preoperative preparation, including an assessment of the physical and mental status of the patient and proper postoperative management and rehabilitation, thus reducing the risk of serious postoperative complications and improve the well-being of the patient.

Pulmonary hypertension: diagnostic and therapeutic challenges.

Pulmonary hypertension (PH) is a hemodynamic and pathophysiologic state that can be found in multiple conditions with associated symptoms of dyspnea, decreased exercise tolerance, and progression to right heart failure. The World Health Organization has classified PH into five groups. The first group is pulmonary arterial hypertension (PAH), which can be idiopathic, heritable, due to drugs and toxins, or associated with conditions such as connective tissue diseases, congenital heart disease, portal hypertension, and others. The development of PAH is believed to result from smooth muscle cells and endothelial dysfunction that impairs production of vasodilators, including nitric oxide and prostacyclin. The importance of distinguishing this group from the other groups of PH is that there are PAH-specific drugs that target the molecular pathways that are pathogenic in the vascular derangements, leading to arterial hypertension, which should not be used in the other forms of PH. Other groups of PH include PH due to left heart disease, lung disease, chronic thromboembolic disease, as well as a miscellaneous category. Echocardiography is used to screen for PH and has varying sensitivity and specificity in detecting PH. Additionally, the right heart pressures estimated during echocardiogram often differ from those obtained during confirmatory testing with right heart catheterization. The most challenging PH diagnosis is in a case that does not fit one group of PH, but meets criteria that overlap between several groups. This also makes the treatment challenging because each group of PH is managed differently. This review provides an overview of the five groups of PH and discusses the diagnostic and therapeutic challenges of each.

Abnormalities in three-dimensional capillary architecture and imbalance between vascular endothelial growth factor-A and thrombospondin-1 in soleus muscle of ovariectomized rat

Reduced ovarian hormone levels associated with menopause or ovariectomy (OVX) not only result in vascular dysfunction but also lead to structural abnormalities in capillaries. Therefore, the effect of OVX on the three-dimensional (3-D) architecture of capillary networks and the underlying molecular mechanisms were investigated in rat soleus muscle. Seven-week-old female Wistar rats were divided into the OVX and sham-treated (Sham) groups. The OVX group exhibited lower endurance exercise capacity compared to the sham group and resulted in decreased capillary diameter, number of anastomoses and capillary/anastomosis volume in soleus muscle, indicating 3-D structural abnormalities of capillary networks. Furthermore, OVX led to increased concentrations of thrombospondin-1 (TSP-1) protein and a decreased VEGF-A/TSP-1 ratio, an indicator of angio-adaptations, in soleus muscle compared with the Sham group. These results indicate OVX may induce 3-D capillary regression in soleus muscle through an imbalance between VEGF-A and TSP-1 expression, possibly associated with decreased exercise tolerance in ovariectomized rats.

330 Hepatopulmonary syndrome may mask cystic fibrosis

Clinically significant hepatobiliary manifestations of CF are reported to occur in 15–30% of children and cirrhosis is reported in 5–10% of pediatric populations. A 7 year-old boy consultated to pediatric pulmonology clinic with chronic cough, decreased exercise tolerance for six months and cyanosis for 15 days, in terms of hepatopulmonary syndrome. He was under investigation because of hepatosplenomegaly for one year. Physical examination demonstrated tachypnea, mild clubbing, orthodeoxia (saturation 81–82% in the upright position and 86–88% in the supine position) and common crepitan crackles on the auscaltation. On abdominal examination hepatosplenomegaly were present. The calculated alveolar-arterial oxygen gradient was 43 mmHg. Chest x-ray and CT demonstrated dilated peripheral vasculature and bronchiectasis. Liver function tests, coagulation profiles, serum ceruloplasmin, alpha-1 antitrypsin, antinuclear antibodies, anti smooth muscle antibody were all normal. Endoscopy of upper gastrointestinal tract showed no esophageal varices. Liver biopsy findings resulted as cirrhotic liver showing signs of ascending cholangitis. But definitive diagnosis was not determined for one year. Contrast-enhanced echocardography with agitated saline was compatible with intrapulmonary shunting. Although patient denied recurrent lower respiratory tract infection, diarrhea, malnutrition, CF was diagnosed with p.G85E (c.254G>A), p.I148T (c443T>C) mutation. Cystic fibrosis should be investigated in cirrhotic patients with respiratory signs. Hepatosplenomegaly may be the first sign of CF.

Policy Options to Promote Smokefree Environments for Children and Adolescents

Secondhand smoke (SHS) exposure among children is associated with a wide variety of adverse health risks, including: asthma, otitis media, respiratory infections, impaired lung growth and function, decreased exercise tolerance, cognitive impairments, behavior problems, and sudden infant death syndrome. Unfortunately, over 40% of children aged 3-11 years-15.1 million children-are currently exposed to SHS, with nearly 70% of black children in this age group being exposed. Over the past three decades, great strides have been made in establishing smokefree environments for adults, ultimately reducing their SHS exposure. Regulations have been passed at the organizational, local, and state levels that increasingly ban smoking in the workplace and public places. Children's SHS exposure patterns, however, differ from adults' exposures, with greater time spent in the home and other potentially unregulated venues (school, child care, and car). This means that children have been afforded relatively less protection from SHS by these smokefree regulations. It is imperative, therefore, to seek alternative options for promoting smokefree environments for children throughout the United States. This article explores policy options that promote smokefree environments for children and adolescents: comprehensive smokefree/tobacco-free policies covering indoor/outdoor public places, housing, private vehicles, and child care, as well as Clinical Guidelines regarding patient/family interviews on smoking, SHS, cessation, and voluntary smokefree efforts. The policy section highlights the role of child and adolescent health practitioners in promoting these policies with the hope of fostering engagement of these key stakeholders in the policy process. Note, there are a wide range of important policy and regulatory strategies aimed at reducing tobacco initiation and use among children, adolescents, and young adults; while essential in tobacco prevention and control efforts, a discussion of these strategies is beyond the scope of this article.

ÇOCUKLARDA ASTIM ATAK TEDAVİSİ: REHBERLERLE PRATİK YAKLAŞIM

Asthma is the most common chronic disease of childhood that causes hospital and emergency admissions and school absences. Asthma exacerbation is characterized by an increase in symptoms of shortness of breath, wheezing, chest tightness, nocturnal cough; decrease in exercise tolerance; reduced daily activities; increase in need of bronchodilators and decrease of expiratory flow rate. Management of chronic asthma and exacerbation shows some varieties, because the anatomical and physiological characteristics are quite different in children who are younger and older than 5 years old. In this article we evaluated current guidelines of asthma exacerbation in children

P49 Toxic cardiomyopathy in a stable hiv patient with a history of amphetamine misuse-a case report

Background/introduction Amphetamine (AM) use is associated with HIV infection among MSM. There are various toxic effects of AM, cardiotoxicity being one of them. Aim(s)/objectives To present a case of report of cardiomyopathy secondary to AM misuse in a patient with well-controlled HIV. Case report A 51 year old HIV positive MSM was admitted to hospital with dyspnoea, orthopnoea and decreased exercise tolerance. He was HIV positive since 1990 and this is stable on ARVs. CD4 count pre-admission was 514 with undetectable viral load. He used 25–30 grams of AM per week over a period of 20 years and had multiple casual unprotected MSM partners. On admission, the patient was tachycardic and hypoxic. Chest X-Ray on admission showed cardiomegaly and bi-basal opacification. Echocardiogram demonstrated severe left and right ventricular dysfunction, at a level requiring cardiac transplant. ECG showed prolonged QT interval. The patient was diagnosed with toxic dilated cardiomyopathy secondary to long term AM abuse. UK guidelines for Heart transplantation in adults deem chronic viral infection and ongoing substance misuse as relative contraindications to transplant. He was consequently commenced on medication for cardiac failure and received benzodiazepine as inpatient for managing withdrawal symptoms. On discharge, psychiatry follow-up was organised for support to help reduction of AM. At follow up, the patient reported reduced AM use by quarter, but felt he could never abstain. Discussion/conclusion AM related cardiac fatalities are caused by acute myocardial necrosis, ventricular rupture, cardiomyopathy or arrhythmia. Evidence is mostly derived from case-reports. Patients using AM should be fully counselled regarding possible toxic effects.

A Rare Cause of Postoperative Hypotension

A 62-year-old woman presented with a 3-month history of abdominal distension and decreased exercise tolerance. A chest radiograph showed a probable left pleural effusion (Fig 1). A CT scan of the abdomen revealed a solid ovarian mass with omental caking and a large volume of ascites; there was also confirmation of a left pleural effusion. Three days before surgery a CT pulmonary angiogram (CTPA) showed no evidence of pulmonary thromboembolism (PTE). The patient had some improvement in her symptoms after paracentesis and thoracentesis with drainage of 2,000 mL and 250 mL of fluid, respectively. She underwent total abdominal hysterectomy, bilateral oophorectomy, and partial sigmoid resection with an estimated blood loss of 850 mL. During the operation, she received 5 L of crystalloid and required phenylephrine at 40 to 80 μg/min to maintain a mean arterial pressure > 65 mm Hg. She was extubated after surgery, but immediately after extubation, she became markedly hypotensive and hypoxemic with a BP of 50/20 mm Hg and an oxygen saturation of 70%. An ECG showed T-wave inversions from V1 to V5 and an S1Q3T3 pattern (Fig 2). A bedside echocardiogram showed an enlarged right ventricle (RV), septal dyskinesia, and obliteration of the left ventricle, all consistent with systolic and diastolic RV overload (Fig 3).

The evaluation tool to predict decreased exercise tolerance in elderly patients with chronic heart failure

Purpose: The purpose of this study is to clarify the effect of CHKB on the walking speed and knee function of stroke patients. Methods: Eleven stroke patients who could walk at least 50m without assistance participated. We used 2-D motion analysis tomeasurewalking speed andminimumkneeflexion angle at mid-stance on the hemiplegic side. The participants walked 10m under two conditions, with a hinged knee brace (KB) andwithCHKB.Themeasurement sequencewas determined randomly. We examined each condition twice, and investigated the average walking speed and minimum knee flexion angle at mid-stance on the hemiplegic side. Results: The average walking speed in the two condition was 0.78m/swithKBand 0.82m/swithCHKB.A significant difference was observed between KB and CHKB. Five of eleven participants hadwalking speed improvements of more than 10%with CHKB compared with KB. Seven participants had abnormal knee-patterns with KB; one had a stiff-knee pattern, two had a buckling-knee pattern and four had an extension-thrust pattern. In five of these seven participants, twowith a buckling-knee pattern and threewith an extensionthrust pattern, the abnormal knee motion was improved with CHKB. Conclusion(s): This study suggests that CHKB can improve walking speed and reduce abnormal knee patterns at mid-stance on the hemiplegic side in stroke patients. Implications: To improve walking speed and abnormal knee pattern,CHKBmight useful in cases ofmild hemiplegia. CHKB may promote acute stroke rehabilitation.

Muscle dysfunction in patients with lung diseases: a growing epidemic.

The lung is tasked with the provision of oxygen to fuel oxidative phosphorylation and with the removal of its byproduct carbon dioxide and is therefore a key player in organismal metabolism. When viewed from this perspective, it is unsurprising that lung dysfunction is associated with suboptimal function of other metabolic organs, most notably of skeletal muscle. A prevalent example is observed in patients with chronic obstructive pulmonary disease (COPD), which is a leading cause of death worldwide and one of the few major diseases for which mortality continues to climb (1). Skeletal muscle dysfunction, defined as the loss of either muscle strength or endurance, is a prominent comorbidity in patients with COPD that impairs their exercise capacity, quality of life, and disease prognosis (2–8). For example, quadriceps muscle dysfunction, which is primarily characterized by reduced muscle force generation, is observed in one-third of all patients with COPD even at very early stages of their disease, where it is associated with decreased exercise tolerance, a reduced quality of life, and increased mortality (2–8). In patients with COPD, other comorbidities, including muscle wasting, malnutrition, chronic heart failure, exacerbations, and reduced physical activity, can further impair muscle function (4, 7). Sarcopenia, the age-associated loss of skeletal muscle mass and function, is present in as many as 10% of older hospitalized adults (9, 10). Although limb muscle dysfunction is often the most clinically evident problem in patients with COPD, respiratory muscle dysfunction is also present and may contribute to the development and persistence of hypoventilatory respiratory failure in these patients (11, 12). Combined, the presence of respiratory and peripheral muscle dysfunction and underlying sarcopenia results in prolonged hospitalizations and reduced rates of physical activity, creating a vicious circle of progressive muscle dysfunction and morbidity.

Emerging spectrum of deployment-related respiratory diseases.

Military personnel and civilian contractors who have deployed to Iraq, Afghanistan, and other south-west Asia locations since 2001 may be at risk for a spectrum of disorders collectively known as deployment-related respiratory diseases. Diagnosis is often challenging as typical symptoms of cough, dyspnea, and decreased exercise tolerance may be accompanied by subtle abnormalities on noninvasive diagnostic testing despite significant histopathologic abnormalities identified on lung biopsy. This review describes the emerging spectrum of deployment-related respiratory diseases, addresses diagnostic challenges, and updates recommendations for evaluation and management. Investigators from Vanderbilt University, Nashville, TN, found constrictive bronchiolitis on 38 surgical lung biopsies in a case series of army deployers with unexplained chest symptoms. More recently, in a group of 50 consecutive deployed patients evaluated at San Antonio Military Medical Center, 36% were found to have airway hyperreactivity, whereas 42% were undiagnosed. We propose a diagnostic and management algorithm for evaluation of the patient with postdeployment respiratory symptoms who are at risk of deployment-related lung disease.

FoxO transcription factors and endurance training: a role for FoxO1 and FoxO3 in exercise-induced angiogenesis.

FoxO transcription factors and endurance training: a role for FoxO1 and FoxO3 in exercise-induced angiogenesis.

Serum endostatin is a genetically determined predictor of survival in pulmonary arterial hypertension.

Pulmonary arterial hypertension (PAH) is a medically incurable disease resulting in death from right ventricular (RV) failure. Both pulmonary vascular and RV remodeling are linked to dynamic changes in the microvasculature. Therefore, we hypothesized that circulating angiostatic factors could be linked to outcomes and represent novel biomarkers of disease severity in PAH. We sought to determine the relationship of a potent angiostatic factor, endostatin (ES), with disease severity and mortality in PAH. Furthermore, we assessed genetic predictors of ES expression and/or function and their association with outcomes in PAH. We measured levels of serum ES in two independent cohorts of patients with PAH. Contemporaneous clinical data included New York Heart Association functional class, 6-minute-walk distance, invasive hemodynamics, and laboratory chemistries. Serum ES correlated with poor functional status, decreased exercise tolerance, and invasive hemodynamics variables. Furthermore, serum ES was a strong predictor of mortality. A loss-of-function, missense variant in the gene encoding ES, Col18a1, was linked to lower circulating protein and was independently associated with reduced mortality. Our data link increased expression of ES to disease severity in PAH and demonstrate a significant relationship with adverse outcomes. Circulating ES levels can be genetically influenced, implicating ES as a genetically determined modifier of disease severity impacting on survival. These observations support serum ES as a potential biomarker in PAH with the capacity to predict poor outcomes. More importantly, this study implicates Col18a1/ES as a potential new therapeutic target in PAH.

Influence of ambient music on perceived exertion during a pulmonary rehabilitation session: a randomized crossover study.

Pulmonary rehabilitation is a key element in the treatment of COPD. Music has been shown to have a positive effect on parameters related to a decrease in exercise tolerance. The aim of this study was to evaluate the effect of listening to ambient music on perceived exertion during a pulmonary rehabilitation session for COPD subjects. COPD subjects randomly performed a session of pulmonary rehabilitation with or without ambient music. Perceived exertion (Borg scales), anxiety (Hospital Anxiety and Depression Scale-Anxiety Subscale), dyspnea (visual analog scale), and cardiorespiratory parameters were compared at the end of both sessions. Forty-one subjects were analyzed. The characteristics of the COPD subjects were as follows: age, 70.5 ± 8.4 y; body mass index, 22.7 ± 3.9 kg/m(2); and FEV1, 38.6 ± 12.5 % predicted. Perceived exertion was not modified by ambient music, but anxiety was improved (P = .02). Dyspnea, fatigue and cardiorespiratory parameters were not influenced by music during a typical session of the pulmonary rehabilitation program. This study demonstrates that perceived exertion during one pulmonary rehabilitation session was not influenced by ambient music. However, a positive effect on anxiety was observed. (ClinicalTrials.gov registration NCT01833260.).

Controversies in pulmonary hypertension due to left heart disease.

Left heart failure is currently the most prevalent cause of pulmonary hypertension (PH) worldwide and this is due mainly to the increased left ventricular and pulmonary venous pressures seen in this condition. Still, a quota of patients with left heart failure will have a pulmonary arterial disease “disproportionate” to the initial increase of left-sided pressures. Whatever the mechanism involved, the appearance of PH is a powerful marker, as it determines decreased exercise tolerance and survival. To date, all trials using therapies approved for pulmonary arterial hypertension (PAH) failed to demonstrate a benefit in the context of heart failure (HF) without or with PH. In addition, the comparison among studies is limited by relevant differences in definitions, methodology, and timing of assessment. A novel rigorous hemodynamic classification based on the diastolic pulmonary gradient has been recently proposed to better characterize this form of PH. This will promote uniformity in patient populations and end-points for future clinical trials.

Mild clinical manifestation and unusual recovery upon coenzyme Q₁₀ treatment in the first Chinese Leigh syndrome pedigree with mutation m.10197 G>A.

The Leigh syndrome (LS), characterized by psychomotor retardation, seizures, nystagmus, ophthalmoparesis, optic atrophy, ataxia, dystonia, or respiratory failure, is one of the most severe mitochondrial diseases. In the majority of cases, the disease is fatal and patients die before age 5. Mutation m.10197 G>A was found to relate to the severe phenotype of the Leigh syndrome. Here, we describe the first Chinese Leigh syndrome pedigree with this mutation. The proband had the characteristic brain lesions of the Leigh syndrome and presented a decrease in exercise tolerance and mild face paralysis. Sequencing the NADH dehydrogenase, subunit 3 (ND3) gene in the pedigree, revealed that the proband, as well as her unaffected brother, have a high mutant load in the ND3 gene, compared to their mother. Following one‑year treatment with the coenzyme Q10, an obvious improvement in clinical features was observed by magnetic resonance imaging (MRI) in the proband. Our study and previous reports highlight the variability of phenotypic expression of the m.10197 G>A mutation, and suggest that pathogenesis of the syndrome may be affected by a number of factors. This is the first report on successful treatment of an LS patient carrying the mutation m.10197 G>A with the coenzyme Q10, indicating that Q10 may attenuate the mitochondrial dysfunctions caused by the m.10197 G>A mutation.

Acute shortness of breath in an adult.

A 44-year-old male presents with shortness of breath, non-productive cough, and chest tightness to the ski clinic in Winter Park, Colorado. He flew from his home town, San Antonio, Texas, three days earlier. Symptoms began the day after arrival and progressively worsened over the course of the last 2 days. Shortness of breath is exacerbated by physical activity and relieved by rest. He tried his son’s albuterol inhaler with no improvement in his symptoms. He denied fevers, chills, and sick contacts. He is in excellent shape and has never experienced these symptoms before despite many similar ski trips. His past medical, family, and social histories are unremarkable, and he takes no medications. On arrival he appears generally healthy, but exhibits significantly labored breathing. He is afebrile and normotensive, but tachycardic (104 BPM) and hypoxic with an oxygen saturation of 61% on room air. His lung examination is significant for diffuse rales. Chest radiography was performed (Figure 1). Figure 1. Chest Radiography 2. Arguments Against Based on the patient's history, physical examination, and radiographs, which one of the following is the most likely diagnosis? Atypical pneumonia Pulmonary embolism High altitude pulmonary edema Exercise induced bronchospasm Pneumothorax 3. Conclusions The answer is C: High altitude pulmonary edema (HAPE) is the leading cause of altitude-related death (1). It is characterized by non-cardiogenic pulmonary edema occurring with rapid ascent to altitudes above 2,500 m (1-3). This patient travelled from San Antonio, TX with altitude of 235 m to Winter Park, CO with altitude of 2,800 m. Risk factors for development of HAPE include prior history of altitude illness, higher altitude, rapid ascent, male sex, cold ambient temperatures, pre-existing respiratory infections, and intense exercise (1-3). Estimates of HAPE incidence vary, but have been reported as high as 4% in un-acclimatized mountaineers above 4,600 m (2). Onset of HAPE typically occurs within 1-4 days of ascent to altitude (3). Symptoms include fatigue, dyspnea on exertion, decreased exercise tolerance, low-grade fever, and dry cough which sometimes progresses to become productive of pink, frothy, sputum (2, 3). On physical examination, patients with HAPE are tachycardic, tachypneic, and hypoxic, frequently with low-grade fevers (1-3). Pulmonary examination reveals inspiratory crackles, initially in the right middle lobe, and becoming more diffuse and bilateral later in the illness (1-3). Chest x-ray (CXR) classically shows patchy perihilar opacities, sometimes with interstitial edema and pleural effusions. Heart size is normal, which is consistent with no cardiogenic pulmonary edema (3). The cornerstones of HAPE treatment are immediate descent to lower altitude and supplemental oxygen (1-3). If descent is not possible or supplemental oxygen not available, pharmacotherapy with nifedipine may be considered as the next line of treatment, with the goal being to decrease pulmonary artery pressure (1, 3) Several studies have suggested benefit with long acting beta agonists (e.g. salmeterol) and with phosphodiesterase-5 inhibitors, but no strong evidence for either exists (1, 3). Similarly, HAPE is best prevented by gradual ascent to altitude (1-3). Pharmacologic prophylaxis can be considered, particularly in those with a history of HAPE, with nifedipine as the first-line agent and other potential options including phosphodiesterase-5 inhibitors, long acting beta agonists, and dexamethasone (1-3). Atypical organisms account for up to 40% of community-acquired pneumonia (4). Patients usually present with fevers and productive cough (4). Lung examination may reveal rales and wheezing (4). Hypoxia is rare (4). CXR may reveal patchy or circumscribed opacities (4). Pulmonary embolism (PE) may present with a sudden episode of SOB at rest (5). CXR is non-diagnostic in patients with PE and most commonly shows atelectasis, non-specific parenchymal abnormalities, or pleural effusions (5). Less commonly, the classic signs of a peripheral wedge-shaped opacity may be seen (5). Exercise-induced bronchospasm causes dyspnea and chest tightness during or after exercise (6). Physical examination is usually unremarkable with occasional wheezing (6). CXR is usually normal or may show increased bronchial wall thickening or flattening of the diaphragm (6). Pneumothorax is a relatively common condition among adults and can present with dyspnea and pleuritic chest pain (5). Physical examination typically reveals decreased chest excursion as well as decreased breath sounds on the affected side (5). CXR usually demonstrates a visceral pleural line, beyond which no pulmonary markings are present and possible mediastinal shift (5, 7). Table 1. Summary table Acknowledgments The authors would like to thank Dr. James Borgstede for his contribution.

The Simple Model to Predict Decreased Exercise Tolerance in Elderly Patients with Chronic Heart Failure

The Simple Model to Predict Decreased Exercise Tolerance in Elderly Patients with Chronic Heart Failure

Left Ventricular Hypertrophy in a Runner

A 63-year-old male runner presented for outpatient cardiology evaluation of decreased exercise tolerance and increased left ventricular (LV) wall thickness noted on an echocardiogram obtained by his primary care provider. The patient had been an avid runner since a young age; however, over the previous months he had noted decreased exercise tolerance prompting evaluation by his primary physician. His medical history was only significant for hypertension that had been well controlled with a single medication. ECG revealed sinus bradycardia with markedly elevated voltage in the anterolateral precordial leads (Figure 1). Echocardiography with strain imaging demonstrated increased LV wall thickness measuring 1.8 cm at the basal septum and 1.7 cm at the basal inferolateral wall (Figure 2A). Ejection fraction was noted to be normal; however, longitudinal strain imaging was markedly abnormal throughout the septum, extending into adjacent regions of the anterior and inferior walls and normalizing in the lateral wall and apex (Figure 2B and 2C). Figure 1. ECG demonstrating sinus bradycardia with increased voltage throughout the anterolateral precordial leads. Figure 2. A , Two-dimensional …