MyD88 appears to be a key contributor to cardiac inflammation, mediating cytokine production and T-helper-1/2 cytokine balance, increasing coxsackie-adenoviral receptor and p56(lck) expression and viral titers after CVB3 exposure. Absence of MyD88 confers host protection possibly through novel direct activation of IRF-3 and IFN-beta.

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The authors of this article report a case involving a 57-year-old man with longstanding HIV infection who presented with fever and acute chest pain, which was determined to be caused by an infection of the manubriosternal joint. The course of treatment is described and a literature review summarizing the published cases of this rare infection is presented.

A 55-year-old woman with no cardiac history presented with increasing shortness of breath on exertion, worsening cough and orthopnea for three weeks. A transthoracic echocardiogram identified two intracardiac masses. Transesophageal echocardiography demonstrated a 1.8 cm × 1.5 cm mass attached to the base of the posterior tricuspid leaflet ( Figure 1A) and a 1.0 cm × 0.5 cm mass attached to the atrial side of the left mitral leaflet ( Figure 1B). Both masses displayed indistinct surface features and neither was attached to the atrial wall or interatrial septum. No other intracardiac pathology was identified. The differential diagnosis included primary cardiac tumour, metastatic malignancy, thrombus or vegetation. After an extensive workup, the patient ultimately went on to have surgical excision of these masses. Surgical pathology confirmed the diagnosis: mitral and tricuspid valve cardiac papillary fibroelastomas (CPFs).CPFs are the second most common primary cardiac tumour in adults. They are benign avascular tumours made of papillary elastin fibrils in a hyaline stroma covered with a single layer of endothelium. These tumours occur most frequently on the aortic and mitral valves, and infrequently on the tricuspid and pulmonic valves. On echocardiography, CPFs are typically small, well-demarcated, highly mobile masses attached to the endocardium by a pedicle. They can have a highly refractive appearance, often with areas of echolucency and a 'speckled' appearance around the perimeter. Multiple CPFs are an exceedingly rare finding. While typically asymptomatic, CPFs can present with stroke, sudden death, myocardial infarction, heart failure, syncope, pulmonary embolism or peripheral infarction. To date, no recurrences of CPFs after surgical excision have been reported, and the long-term prognosis of these patients appears to be excellent (1-4).iMAges in cArdiology

We thank Dr. Gupta for his interest in our study on reducing unnecessary red blood cell (RBC) folate testing by restricting ordering in the electronic health record (EHR). 1 Serum folate testing was restricted many years before the study and only RBC folate could be ordered in our EHR prior to the intervention. We opted to restrict rather than eliminate RBC folate as we felt it might have a role in specialized settings such as hematology clinics. However, even after restricting testing to a presumably higher risk population, rates of folate deficiency did not increase, and a case could be made for eliminating testing completely. We are not aware of any resistance from gastroenterology or hematology clinicians; clinical leaders were consulted by e-mail prior to the intervention.Gupta is concerned that restricting testing may result in underdiagnosis and undertreatment of folate deficiency. While we acknowledged this possibility, the number of missed diagnoses would be low. In an earlier study at our institution, only 4/2563 (0.16%) of RBC folate results over 1 year showed folate deficiency, of which 1 was likely spurious. 2 In the remaining 3, RBC folate was only slightly below the normal range, making it unlikely that folate deficiency contributed to anemia. 3 Clinicians at our institution can still request RBC folate by phoning the laboratory or consulting a sub-specialist.Although we did not provide a message to clinicians in the EHR when attempting to order RBC folate, we agree that this could prompt consideration of empiric folate replacement. Although empiric folate replacement has been recommended for many years 4,5 and is incorporated into the Choosing Wisely guidelines, 6 an automated reminder might be beneficial.Finally, we wholeheartedly agree with D 1 X XGupta on the need to monitor balancing measures to avoid unintended consequences of quality improvement interventions. While we did not examine rates of folate supplementation, folate is inexpensive (a few cents per dose compared with $14.00 CAD per RBC folate test), making it unlikely that significant costs were incurred. Methylmalonic acid ordering is restricted in a similar fashion to RBC folate. Homocysteine is associated with an EHR alert that ordering is restricted and requires approval by telephone (although approval is not strictly enforced). Therefore, we did not expect to see significant increases in these tests.

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