Cor triatriatum sinistrum: a rare congenital cardiac anomaly presenting in an adult with chronic atrial fibrillation

Cor triatriatum is a rare congenital cardiac anomaly in which the left atrium is divided into proximal (dorsal or upper) and distal (ventral or lower) chambers by a fibromuscular septum. The upper chamber receives the pulmonary veins and the lower chamber contains the atrial appendage and the mitral valve. The 2 chambers communicate through a defect in the membrane. Cor triatriatum is often associated with other congenital cardiac anomalies. Most frequently, the upper chamber communicates with the right atrium through a patent foramen ovale or atrial septal defect, and the clinical symptoms simulate anomalous pulmonary venous return. Less commonly, the foramen ovale communicates with the distal chamber and the clinical features mimic mitral stenosis. When cor triatriatum is the only abnormality, the clinical findings are also similar to mitral stenosis with development of pulmonary hypertension and subsequent right ventricular hypertrophy and atrial enlargement. The diagnosis is usually made in infancy or childhood, and the lack of treatment results in death in 75% of patients.We report the case of a woman who presented much later in life. The patient was a 57-year-old female with a clinical history of chronic atrial fibrillation who presented to the emergency department because of a "funny sensation" in her chest, though she denied chest pain, nausea, vomiting, or diaphoresis. EKG revealed atrial fibrillation with a rapid ventricular response and a tachycardic rate of 157. She had a therapeutic level of digoxin, and cardiac enzymes were normal. The patient was admitted and placed on Cardizem drip. Serial EKGs remained normal and heart rate control was achieved. On hospital day 2, the patient became dyspneic and cyanotic. She went into cardiac arrest and died.Autopsy revealed cardiomegaly (610 g) with 4-chamber dilatation. A septum divided the left atrium into 2 chambers. The defect in the dividing membrane measured 1 cm in diameter. No other congenital defects were noted. The large size of the defect in the membrane likely accounted for the late onset of symptoms that allowed this patient to survive into adulthood without previous diagnosis or surgical intervention (which is usually required in childhood).     

Agency Fever? Analysis of an International Policy Fashion

In the last 15 years, the governments of many OECD countries have transferred a wide range of functions to new, agency-type organizations. Allowing for the fact that, for comparative purposes, it is difficult precisely to define agencies, and further acknowledging that in many countries agencies are far from being new, it nevertheless remains the case that there seems to have been a strong fashion for this particular organizational solution.This article investigates the apparent international convergence towards agencification. It seeks to identify the reasons for, and depth of, the trend. It asks to what extent practice has followed rhetoric. The emerging picture is a complex one. On the one hand, there seems to be a widespread belief, derived from a variety of theoretical traditions, that agencification can unleash performance improvements. On the other hand, systematic evidence for some of the hypothetical benefits is very patchy. Furthermore, the diversity of actual practice in different countries has been so great that there must sometimes be considerable doubt as to whether the basic requirements for successful performance management are being met.     

MAKING IT WORK

With the prevalence of divorce in our country, there is a serious need of services for divorcing families to be readily available and offered in a manner to increase the use of the services. Early intervention with the divorcing family is critical to help alleviate levels of parental conflict and decrease potential litigation. This article is an evaluation of the first year of court-mandated parenting psychoeducational workshops. The results demonstrate the positive effects of the workshops for most divorcing parents in terms of levels of ongoing conflict between parents, children's adjustment as observed by the parents, parents' adjustment, and parents' ability to settle the legal issues of the divorce and keep the children out of the middle of the conflict.     

Minority Set-Aside Programs in the States After City of Richmond v. J. A. Croson Co.

In a series of decisions handed down during the 1988–1989term, the U.S. Supreme Court sent clear signals that its equalprotection analysis and affirmative action jurisprudence areundergoing reexamination. The most important affirmative actiondecision during the term was City of Richmond v. J. A. CrosonCo. The Court ruled that Richmond's minority business enterpriseprogram, which set aside 30 percent of the dollar amount ofgovernment construction contracts for minority-owned firms,violated the Fourteenth Amendment. In the wake of Croson, federaland state courts have considered other cases involving set-asideprograms, while a number of other programs have been abandoned,placed under evaluation, or modified to meet the guidelineslaid down by the Court.     

Preemployment screening and training could reduce excessive force litigation cases

Police officers enter law enforcement with enthusiasm. However, at some point, their idealism dissipates to the point of apathy causing some to become aggressive with the general public. During this period, some officer’s performance declines. This raises concerns for superior officers and management with how these problems could lead to legal liabilities if out-of-control officers engage in excessive force.