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PubMed2003

Instrumental colonisation in modern medicine.

Stethoscopes, x-rays and other medical technologies are two-edged swords. They make medical treatment and diagnosis more accurate and effective, but do at the same time reveal our perceptual inadequacy. By transcending our senses, these technologies reveal that we can be seriously diseased without experiencing any symptoms at all. This situation has changed our attitude towards our relations and ourselves. The situation can be analysed using Jürgen Habermas' conception of "systems colonisation of the lifeworld." Medical technologies colonise our lifeworld. They change the way we think and act. They make us all accept that we can become patients almost any minute, even if we feel perfectly healthy. Sense transcending technologies turn us all into proto-patient.

Biomedical Technology↗
PubMed2006

[Heart murmur--auscultation or echocardiography in the diagnostic assessment of congenital or valvular heart disease?].

The incidence of patients with degenerative valvular but also of patients with congenital heart disease surviving until adulthood or even old age will increase in the next decades. Auscultation with the stethoscope remains an important diagnostic means in the detection and treatment of heart disease. Heart murmurs (especially systolic heart murmurs) are extremely common. There are helpful clues to differentiate heart murmurs. It can occasionally be relatively simple to differentiate a systolic murmur due to valvular heart disease from an innocent, ejection murmur; however, there are important limitations of auscultation. Overall, auscultation and clinical examination alone do not suffice to correctly diagnose and treat patients with heart failure or a murmur Clinically significant aortic stenosis, aortic regurgitation and mitral regurgitation as well as hypertrophic cardiomyopathy are not uncommonly missed or misinterpreted. An echocardiographic exam is mandatory in all patients with more than a soft systolic murmur, any diastolic murmur, cardiac symptoms and/or ECG changes.

Auscultation↗
PubMed2006

[Anatomy by ultrasound of the veins in the leg: essentials].

Studying the anatomy of lower extremity veins is a tedious and complex task. Although huge efforts have been undertaken to create harmonization, any global description of the venous network is encumbered by the large number of superficial and deep veins, anastomoses and collaterals, and not least by a vastly broad nomenclature. Innumerable anatomic variants contribute to creating a complicated picture. What is needed is a description that correspondingly reflects the reality. Yet, does our description reproduce the actual anatomic and pathologic circumstances? As a rule, a phlebography is performed to localize an acute or chronic venous condition. The examiner must have learn about the "healthy" to What the stethoscope is to a cardiologist, the Doppler sonography transducer was to the phlebologist, an indispensable tool. Nowadays, duplex sonography has to be called the gold standard in that it supplies the most comprehensive information for diagnosing functional disorders of the venous system, thereby enabling a clear therapeutic strategy to be delineated. Most qualitatively average or high-grade ultrasound machines are equipped with duplex sonography, which today's specialists can employ to highly efficiently render a differential diagnosis of deep vein thrombosis. Given the ethic and forensic background and the potentially lethal outcome of a misdiagnosis, the use of this diagnostic tool must be exclusively reserved for physicians with a particularly high level of skill and training. The specialist societies for ultrasonography, angiology and phlebology have published strict guidelines for teaching Doppler sonography in Switzerland.

Collateral Circulation↗
PubMed2006

Thermal radiation scanning tunnelling microscopy.

In standard near-field scanning optical microscopy (NSOM), a subwavelength probe acts as an optical 'stethoscope' to map the near field produced at the sample surface by external illumination. This technique has been applied using visible, infrared, terahertz and gigahertz radiation to illuminate the sample, providing a resolution well beyond the diffraction limit. NSOM is well suited to study surface waves such as surface plasmons or surface-phonon polaritons. Using an aperture NSOM with visible laser illumination, a near-field interference pattern around a corral structure has been observed, whose features were similar to the scanning tunnelling microscope image of the electronic waves in a quantum corral. Here we describe an infrared NSOM that operates without any external illumination: it is a near-field analogue of a night-vision camera, making use of the thermal infrared evanescent fields emitted by the surface, and behaves as an optical scanning tunnelling microscope. We therefore term this instrument a 'thermal radiation scanning tunnelling microscope' (TRSTM). We show the first TRSTM images of thermally excited surface plasmons, and demonstrate spatial coherence effects in near-field thermal emission.

Journal Article↗
PubMed1996

The role of occlusal auscultation in assessing dental occlusions.

Little attention is paid to the noises made when the teeth occlude, yet there is a wealth of information stored in these sounds. It is remarkable how quickly the ear can learn to discern the difference between a good occlusion and one which is disrupted, by using a stethoscope. With the addition of relatively inexpensive instrumentation, occlusal sounds may also be recorded for later reference, analysis, comparison or audit.

Auscultation↗
PubMed2000

Accuracy of the OMRON M4 automatic blood pressure measuring device.

Despite widespread use of the automatic blood pressure (BP) measuring device OMRON M4, there is little formal validation on its accuracy. A study was conducted to assess the accuracy of the OMRON M4 compared with the true indirect BP measured by mercury sphygmomanometer (MS). A rapid method for the evaluation of automatic blood pressure measurement devices (READ) was applied for this study. The READ is based on numerous BP measurements at rest and during a standardised postural challenge in a small number of subjects who exhibit a wide range of BPs. Blood pressure measurements were done in supine position for 10 min followed by head-up tilt for 30 min and again supine for 10 min. The automatic device (AU) and the MS were connected to one arm-cuff by means of a T connector. A stethoscope with dual sets of ear-pieces was used for duplicate MS measurements (MS1 and MS2). The MS1, MS2 and AU measurements were taken simultaneously in a blinded manner. Three units of the automatic instrument were evaluated. An average of 111 measurements per unit were performed, every BP category being present in >/=15 MS measurements. The differences between MS1 and MS2 measurements (DeltaBP: MS1-MS2) were utilized to assess the consistency of true indirect BP and the differences between AU and MS measurements (DeltaBP:AU-MS2) were utilized to assess the accuracy of the AU. The following characteristics of the OMRON M4 were assessed: (1) grade of accuracy, (2) aberration pattern, (3) consistency of the aberration-pattern, and (4) correlation between levels of BP and DeltaBP: AU-MS. For MS paired readings, 92-100% of systolic and 99-100% of diastolic readings fell within 5 mm Hg difference range, that is consistent with a British Hypertension Society grade A of both. For AU compared to MS2, 29-64% of systolic and 73-94% of diastolic readings fell within 5 mm Hg and 49-86% of systolic and 86-99% of diastolic readings fell within 10 mm Hg and the devices qualified C, D and C, respectively. All devices exhibited irregular and inconsistent aberration patterns, making the design of correction formulas impractical. In conclusion, the OMRON M4 device did not meet the requirements of the British Hypertension Society and, therefore, cannot be recommended for clinical use.

Adult↗
PubMed2001

A clinical study of the Korotkoff phases of blood pressure in children.

BACKGROUND: Five Korotkoff phases are described in adults, but there are no studies of the Korotkoff phase distribution in children. This study determines the presence and length of Korotkoff phases in children, providing data on the repeatability of these measurements, the relationship between the phases, and finally the relationship between the phases and heart rate, blood pressure and arm circumference. METHODS: Seventy, 11-year-old children were studied. The Korotkoff sounds were recorded from the bell of a stethoscope to a MiniDisc system and each sound described twice on separate occasions as phase I, II, III or IV, with phase V meaning disappearance of the sound. RESULTS: Phases I, II, III, IV and V were present in 97% (68/70), 61% (43/70), 51% (36/70), 88% (62/70) and 80% (56/70) respectively. When the recordings were blindly re-assessed there was no significant difference in the phase distribution of the sounds. All five phases were present in 40% (28/70). Phase III only occurred in the presence of phase II (P < 0.0001). There was no significant relationship between the presence of the different phases and heart rate or blood pressure. Arm circumference was significantly larger in children with phase V present (P < 0.02). CONCLUSIONS: The Korotkoff sounds and phase distribution present in normal children is described. Korotkoff sounds were consistently allocated to the various Korotkoff phases. This study provides insights into the problems of accurate diastolic blood pressure measurement. Phase V was more likely to be present with increasing arm circumference, but the variation in the occurrence of phases II and III remains unexplained.

Arm↗
PubMed2001

Anomalous origin of the left coronary artery: discovery during an ambulatory surgical procedure in a 3-month old, previously healthy infant.

We report a rare coronary anomaly in a 3-month old symptomless infant with an anomalous origin of the left coronary artery, that became manifest during anaesthesia for an ambulatory procedure, leading to circulatory arrest. Precordial stethoscope and pulse oximeter unequivocally showed a circulatory arrest. Even in ambulatory procedures, a presumed healthy patient may quickly develop a life-threatening condition because of occult disease. The successful management of such cases depends on efficient and coordinated teamwork.

Ambulatory Surgical Procedures↗
PubMed2001

Effects of i.v. metoclopramide, atropine and their combination on gastric insufflation in children anaesthetized with sevoflurane and nitrous oxide.

METHODS: To determine effects of i.v. metoclopramide, atropine and their combination on the airway pressures at which gastric insufflation occurs in children, 45 healthy infants and children (ASA I) received an inhalational induction of anaesthesia with sevoflurane, N2O and O2. A blinded observer used a stethoscope to auscultate over the upper abdomen for any air entry. First, proximal airway pressure was slowly increased by closing the pop-off valve of the anaesthesia machine until gas was heard entering the stomach (pop-off point, control measurement). If the peak inspiratory pressure reached 40 cm H2O, the patient was to be excluded from the study. Then, all subjects randomly received i.v. atropine 0.01 mg.kg-1, metoclopramide 0.2 mg.kg-1, or atropine 0.01 mg.kg-1 plus metoclopramide 0.2 mg.kg-1 (n=15 each), and determination of the pop-off point was repeated 5 min later. The stomach was evacuated before each measurement. RESULTS: Atropine significantly decreased the pop-off point [from 21 +/- 3 to 19 +/- 2 cm H2O (mean +/- SD), P < 0.05], while metoclopramide significantly increased the pop-off point (from 20 +/- 3 to 26 +/- 6 cm H2O, P < 0.05). The combination of metoclopramide and atropine did not alter the pop-off point (from 20 +/- 2 to 19 +/- 5 cm H2O). CONCLUSION: Since metoclopramide exerts only mild effect on the pop-off point, cricoid pressure still remains the standard anaesthetic practice to prevent gastric insufflation in children. Prophylactic i.v. metoclopramide may be restricted to, and its clinical usefulness should be determined in, symptomatic patients with gastro-oesophageal reflux.

Anesthesia, General↗
PubMed2001

Assessment of blood pressure in patients with Type 2 diabetes: comparison between home blood pressure monitoring, clinic blood pressure measurement and 24-h ambulatory blood pressure monitoring.

AIMS: To compare a home blood pressure (BP) monitoring device and clinic BP measurement with 24-h ambulatory BP monitoring in patients with Type 2 diabetes mellitus (DM). METHODS: Fifty-five patients with type 2 DM had BP measured at three consecutive visits to the DM clinic by nurses using a stethoscope and mercury sphygmomanometer (CBP). Twenty-four-hour ambulatory BP was measured using a Spacelabs 90207 automatic cuff-oscillometric device (ABPM). Subjects were then instructed in how to use a Boots HEM 732B semiautomatic cuff-oscillometric home BP monitoring device and measured BP at home on three specified occasions on each of 4 consecutive days at varying times (HBPM). RESULTS: Correlations between HBPM and ABPM were r = 0.88, P < 0.001 for systolic BP and r = 0.76, P < 0.001 for diastolic BP, with correlations between CBP and ABPM being systolic r = 0.59, P < 0.001, diastolic r = 0.47, P < 0.001. HBPM agreed with ABPM more closely compared with CBP (CBP +10.9/+3.8 (95% confidence intervals (CI) 6.9, 14.8/1.6, 6.1) vs. HBPM +8.2/+3.7 (95% CI 6.0, 10.3/2.0, 5.4)). The sensitivity, specificity and positive predictive value of HBPM in detecting hypertension were 100%, 79% and 90%, respectively, compared with CBP (85%, 46% and 58%, respectively). CONCLUSIONS: In patients with Type 2 DM, home BP monitoring is superior to clinic BP measurement, when compared with 24-h ambulatory BP, and allows better detection of hypertension. It would be a rational addition to the annual review process. Diabet. Med. 18, 431-437 (2001)

Adult↗
PubMed2003

Utility of hand-carried ultrasound for consultative cardiology.

Although the stethoscope has been an important part of the bedside cardiac diagnostic examination for generations of physicians, this clinical tool has been relatively unchanged in over 150 years. Echocardiography is established as an essential diagnostic imaging method for patients with known or suspected cardiovascular diseases. However, routine echocardiography systems are large and heavy, and although they are portable, they remain inconvenient for bedside patient rounds. Technologic advances have resulted in miniaturization of electronic components and small, lightweight ultrasound systems have been recently introduced. These hand-carried units offer clinically acceptable two-dimensional image quality for rapid "quick-look" bedside diagnostics, in particular focusing on global and regional left ventricular function and presence or absence of pericardial effusion. This article proposes a general approach to the rapid hand-carried ultrasound cardiac exam as an extension of the physical examination. It details case examples and reviews the initial clinical experience of hand-carried ultrasound on cardiac consultation rounds. Hand-carried ultrasound has promise to have an immediate impact on bedside patient management though expediting and facilitating the delivery of medical care.

Aged↗
PubMed2001

Lapses in measures recommended for preventing hospital-acquired infection.

This study was carried out in a rural tertiary care referral hospital in central India, to ascertain lapses made by people caring for neonates in measures recommended for preventing hospital-acquired infections. Unobtrusive observation of the healthcare personnel (doctors, nurses, mothers and hospital attendants) during care of the newborn was undertaken. Lapse in handwashing by healthcare personnel was observed around 41% of the time, although mothers practiced their instructions meticulously. Lapses in methods of hand drying were seen around 7-8% of the time, in those who did wash their hands. Gloves were not used around 21% of the time, when they should have been; and of those using gloves, they were unsterile in around 22% cases. At delivery babies were received unhygienically on approximately 67% of occasions observed. Lapses during cord care ranged from 14.2% to 28.6% and during resuscitation from 16.6% to 60% of occasions. An uncleaned stethoscope was used 75% of the time. The practice of putting a finger in the baby's mouth was observed on 18 occasions. Considerable lapses by all, in every measure recommended for the prevention of hospital-acquired infections were observed. It is concluded that nothing other than an individual's commitment is likely to be successful in preventing hospital-acquired infections.

Cross Infection↗
PubMed2000

[Accuracy of intraoperative urinary bladder temperature monitoring during intra-abdominal operations].

OBJECTIVE: This study investigates whether the site of abdominal surgery or the urine flow rate affects the accuracy of urinary bladder temperature monitoring. METHODS: After approval by the local ethics committee we studied 7 patients during upper abdominal and 10 patients during lower abdominal surgery. Temperatures were recorded with a Hi-Lo Temp Esophageal-Stethoscope (Mallinckrodt Medical) and a Foley Catheter Temperature Sensor FC400-18 (Respiratory Support Products, Mallinckrodt Medical). Each probe and its recording unit were calibrated over a range of 30-40 degrees C against a reference quartz thermometer (Hewlett Packard Model 2801 A) in a water bath before the investigation. Urine flow rate was measured using a urometer. Temperatures and urine flow rate were recorded every 30 min. Agreement between the methods of measurement was assessed as described by Bland and Altman. RESULTS: 124 measuring points could be analyzed. Bladder temperature had a bias (B) of -0.06 degree C compared to oesophageal temperature. Limits of agreement (LOA; +/- 2 s) were +/- 0.68 degree C. In upper abdominal surgery (B: 0.02 degree C; LOA: +/- 0.42 degree C) a higher precision of oesophageal temperature estimation could be demonstrated compared to lower abdominal surgery (B: -0.14 degree C; LOA: +/- 0.82 degree C). Lower urine flow rates generally increased the limits of agreement. Regarding lower abdominal surgery the bias additionally increased to -0.22 degree C. CONCLUSION: Urinary bladder temperature recording is a clinically acceptable method to measure core temperature during abdominal surgery. The accuracy during lower abdominal surgery is decreased compared to upper abdominal surgery, especially in case of a urine flow rate below 250 ml/h.

Abdomen↗
PubMed2000

[Prenatal ultrasonography in Switzerland--a repersentative national survey] .

BACKGROUND: The cost-effectiveness ratio of routine ultrasound during pregnancy has been debated for years. However, there is a lack of population based data concerning both costs and benefit. AIM: Population based survey of ultrasound examinations (US) during pregnancy in Switzerland with respect to quantity, indications and results; estimation of total costs, the proportion paid by health insurance and the costs for routine US. METHOD: During a representative week all certified physicians and obstetrical out-patient departments in Switzerland were asked to participate in an anonymous questionnaire based national survey on the use of ultrasound during pregnancy. RESULTS: With 62.9% of the physicians and 90.6% of the out-patient departments participating a total of 6455 questionnaires were returned. On average, 4.6 US were done per pregnancy or about 520,000 scans per year. At a mean price of $ 50 per scan total costs equalied $ 26 million a year. $ 19.5 million were covered by health insurance and the rest was not billed by the physicians. The indication for the scan was a medical problem in 48%, a routine scan in 36.9% of cases a first and a second trimester scan is paid for and in 15.1% reassurance of either the women or the physician. Abnormal results were found in 40.7% of medical indications, in 15% of routine scans and in 12.6% of reassurance cases. CONCLUSION: The considerable number of scans done for reasons of reassurance and not changed for does support our hypothesis that ultrasound during pregnancy has become a tool to routinely check the general state of the fetus comparable to the stethoscope of the general practitioner. One in seven US yielded a pathological result. Maximal cost savings for the health insurance amount to about 9 million a year. This amount has to be balanced by the health benefit, respectively if routine US were abolished.

Cost-Benefit Analysis↗
PubMed2002

Automated graphic assessment of respiratory activity is superior to pulse oximetry and visual assessment for the detection of early respiratory depression during therapeutic upper endoscopy.

BACKGROUND: Recommendations from the American Society of Anesthesiologists suggest that monitoring for apnea using the detection of exhaled carbon dioxide (capnography) is a useful adjunct in the assessment of ventilatory status of patients undergoing sedation and analgesia. There are no data on the utility of capnography in GI endoscopy, nor is the frequency of abnormal ventilatory activity during endoscopy known. The aims of this study were to determine the following: (1) the frequency of abnormal ventilatory activity during therapeutic upper endoscopy, (2) the sensitivity of observation and pulse oximetry in the detection of apnea or disordered respiration, and (3) whether capnography provides an improvement over accepted monitoring techniques. METHODS: Forty-nine patients undergoing therapeutic upper endoscopy were monitored with standard methods including pulse oximetry, automated blood pressure measurement, and visual assessment. In addition, graphic assessment of respiratory activity with sidestream capnography was performed in all patients. Endoscopy personnel were blinded to capnography data. Episodes of apnea or disordered respiration detected by capnography were documented and compared with the occurrence of hypoxemia, hypercapnea, hypotension, and the recognition of abnormal respiratory activity by endoscopy personnel. RESULTS: Comparison of simultaneous respiratory rate measurements obtained by capnography and by auscultation with a pretracheal stethoscope verified that capnography was an excellent indicator of respiratory rate when compared with the reference standard (auscultation) (r = 0.967, p < 0.001). Fifty-four episodes of apnea or disordered respiration occurred in 28 patients (mean duration 70.8 seconds). Only 50% of apnea or disordered respiration episodes were eventually detected by pulse oximetry. None were detected by visual assessment (p < 0.0010). CONCLUSIONS: Apnea/disordered respiration occurs commonly during therapeutic upper endoscopy and frequently precedes the development of hypoxemia. Potentially important abnormalities in respiratory activity are undetected with pulse oximetry and visual assessment.

Adult↗
PubMed2003

A cluster of nosocomial Klebsiella pneumoniae bloodstream infections in a neonatal intensive care department: Identification of transmission and intervention.

OBJECTIVE: We sought to determine the cause and mode of transmission of a cluster of bloodstream infections as a result of Klebsiella pneumoniae. DESIGN AND SETTING: We conducted a prospective cohort study in a neonatal intensive care department from May 1999 to December 2000. METHODS: We performed surveillance of nosocomial infections, and clinical and environmental investigations. RESULTS: During an 8-week period, 5 cases of K pneumoniae bloodstream infections were observed, at least 3 of them belonging to the same genotype. Before the second case developed any symptoms of infection, the same strain had also been found in the patient environment. Intervention measures were, therefore, immediately introduced. Further cases, however, occurred in the following weeks. Even after further intervention activities and the end of the outbreak, the same strain was discovered in environmental samples from a stethoscope and a nurse's hand. CONCLUSIONS: Even where there is acute awareness of the problem and a generally high infection control level in a department, it is difficult to change behavior in such a way that further nosocomial infections can be totally excluded.

Bacteremia↗
PubMedDate not supplied

The Medical Device and Laboratory Product Problem Reporting Program.

Health care technology, those objects and techniques used in health care practice, is so important and customary today, it is difficult to realize that not too long ago physicians had few beneficial devices, drugs, or procedures to offer patients. It was only in the nineteenth century that advances in diagnosis, marked by the invention of the stethoscope, and in therapy, denoted by the introduction of ether anesthesia, inaugurated the era of modern medicine. Over the century and a half that followed, we developed an extra-ordinary armory of diagnostic and therapeutic tools, which have significantly improved life expectancy and raised the quality of life for countless persons all over the world. These advances also have created ethical, economic, organizational, and political problems concerning their appropriate use and distribution.

Equipment Failure↗
PubMed2004

Safety and efficacy of misoprostol for induction of labour in a semi-urban hospital setting.

Most studies on the use of misoprostol for induction of labour have been carried out in well-endowed hospitals in developed countries with state-of-the-art monitoring equipment. There is need for more studies to be conducted in facilities with limited resources, if more patients are to benefit from the low cost and effectiveness of the drug. Following Ethical Committee approval, 152 women had labour induced in our maternity unit using intravaginal misoprostol. The patients were monitored clinically using the WHO model partograph with digital palpation of uterine contractions and intermittent auscultation of fetal heart with a pinard stethoscope. One hundred and thirty-five (88.8%) of the women had a vaginal delivery, while nine (5.9%) had a caesarean section for various obstetric indications. Eight cases of uterine hyperstimulation were noted but none of uterine rupture. We conclude that misoprostol can be used safely for induction of labour in less endowed hospital settings such as in developing countries, using basic clinical tools for monitoring.

Administration, Intravaginal↗