Introduction Fatigue and its effects on performance have long been a concern in medicine. Evidence exists that current duty-hour restrictions for resident trainees have a limited impact on physician wellbeing and patient safety, prompting renewed efforts to address this threat. In this study, sleep patterns of general-surgery residents were used to optimize a biomathematical model of performance for use as a tool for fatigue risk management with residents. Methods General surgery residents based at a multi-hospital, general surgery residency program were approached for participation in this study. Enrolled residents wore actigraph devices for 8 weeks and completed subjective sleep assessments. Sleep data and shift schedules were then input into the Sleep, Activity, Fatigue and Task Effectiveness (SAFTE) Model to assess predicted cognitive performance. Performance was compared to an “effectiveness” level of 77 (equivalent to a blood-alcohol content of 0.05g/dL). Eight hours of sleep debt was considered “below reservoir criteria”. Results Sleep actigraphy data was collected from 22 general surgery residents. Modeling results showed that as shift lengths increased, effectiveness scores generally decreased, and the time spent below criterion (77) increased. Additionally, 11.13% of time on shift was below the effectiveness criterion and 42.7% of shifts included time spent below the reservoir criterion. Adjustments to the sleep prediction were made based on actual sleep, and performance predictions from actual sleep and the adjusted model were significantly correlated (p<.0001). Conclusion Despite adherence to national standards limiting work hours, current surgical resident sleep patterns and shift schedules create concerning levels of fatigue. This study illustrates how biomathematical fatigue models can predict resident physician sleep patterns and performance. Modeling represents a novel and important tool for medical educators seeking to create shift schedules that maintain physician preparedness and minimize fatigue risk. Support N/A

SummaryIn intravenous drug abusers, infective endocarditis usually involves right-sided valves, with Staphylococcus aureus being the most common etiologic agent. We present a patient who is an intravenous drug abuser with left-sided (aortic valve) endocarditis caused by Enterococcus faecalis who subsequently developed an anterior mitral valve aneurysm, which is an exceedingly rare complication. A systematic literature search was conducted which identified only five reported cases in the literature of mitral valve aneurysmal rupture in the setting of E. faecalis endocarditis. Real-time 3D-transesophageal echocardiography was critical in making an accurate diagnosis leading to timely intervention.Learning objectivesEarly recognition of a mitral valve aneurysm (MVA) is important because it may rupture and produce catastrophic mitral regurgitation (MR) in an already seriously ill patient requiring emergency surgery, or it may be overlooked at the time of aortic valve replacement (AVR).Real-time 3D-transesophageal echocardiography (RT-3DTEE) is much more advanced and accurate than transthoracic echocardiography for the diagnosis and management of MVA.

Agenesis of the ductus venosus is a rare anomaly that was first reported in literature within the past decade. Color/ Doppler sonography is an important tool for mapping blood flow in determining this aberrant anastomosis. Careful observation of the fetus for signs of congestive heart failure can lead to a positive outcome. In the following case, cardiomegaly was detected and digoxin was introduced, which arrested progression into congestive heart failure.

Foramen ovale aneurysm was first documented in 1966. In the case presented, the aneurysm caused restriction of flow across the mitral valve, which in turn caused cardiac ventricular disproportion. Cardiac ventricular disproportion is defined as any subjective visual difference between the right and left chambers of the heart. During the patient's detailed sonogram, a prominent pericardial effusion was documented; the patient was then scheduled to return for a fetal echocardiogram. During the fetal echocardiogram, ventricular disproportion was noticed, and upon further examination, a foramen ovale aneurysm was detected. At birth, the infant presented with respiratory difficulty, failure to respond to oxygen, and pulmonary hypertension.

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