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PubMed1995

Acoustic properties of the normal chest.

Laënnec invented the stethoscope in 1816 and published a treatise on auscultation in 1819. We then had to wait until the 1950s to observe development of modern devices and methods of recording and signal-processing, which allowed objective studies of lung sounds in time and frequency fields. Tracheobronchial sounds generated by ventilation originate in the upper airways, the frequency content of these sounds has led to extensive research. Consolidated lungs act as more efficient sound conductors to the chest wall (bronchial breathing murmur). Tracheobronchial sounds contain higher frequency components compared to vesicular lung sounds. The origin of vesicular lung sounds has been becoming progressively clear for about 10 yrs. It is at least partly produced locally, deep, and probably intralobular. Clearly, further studies need to be performed in order to elucidate the true mechanisms involved in generating vesicular lung sounds, the redistribution of intrapulmonary gas or vibrations caused by the stretching of lung tissue. The devices developed are already useful for monitoring the state of patients in intensive care. Sooner or later, real time analysis and automated diagnosis will become available.

Auscultation↗
PubMed2005

Teaching appropriate interactions with pharmaceutical company representatives: the impact of an innovative workshop on student attitudes.

BACKGROUND: Pharmaceutical company representatives (PCRs) influence the prescribing habits and professional behaviour of physicians. However, the skills for interacting with PCRs are not taught in the traditional medical school curriculum. We examined whether an innovative, mandatory workshop for third year medical students had immediate effects on knowledge and attitudes regarding interactions with PCRs. METHODS: Surveys issued before and after the workshop intervention solicited opinions (five point Likert scales) from third year students (n = 75) about the degree of bias in PCR information, the influence of PCRs on prescribing habits, the acceptability of specific gifts, and the educational value of PCR information for both practicing physicians and students. Two faculty members and one PCR led the workshop, which highlighted typical physician-PCR interactions, the use of samples and gifts, the validity and legal boundaries of PCR information, and associated ethical issues. Role plays with the PCR demonstrated appropriate and inappropriate strategies for interacting with PCRs. RESULTS: The majority of third year students (56%, 42/75) had experienced more than three personal conversations with a PCR about a drug product since starting medical school. Five percent (4/75) claimed no previous personal experience with PCRs. Most students (57.3%, 43/75) were not aware of available guidelines regarding PCR interactions. Twenty-eight percent of students (21/75) thought that none of the named activities/gifts (lunch access, free stethoscope, textbooks, educational CD-ROMS, sporting events) should be restricted, while 24.0% (8/75) thought that students should be restricted only from sporting events. The perceived educational value of PCR information to both practicing physicians and students increased after the workshop intervention from 17.7% to 43.2% (chi square, p = .0001), and 22.1% to 40.5% (p = .0007), respectively. Student perceptions of the degree of bias of PCR information decreased from 84.1% to 72.9% (p = .065), but the perceived degree of influence on prescribing increased (44.2% to 62.1% (p = .02)). CONCLUSIONS: Students have exposure to PCRs early in their medical training. A single workshop intervention may influence student attitudes toward interactions with PCRs. Students were more likely to acknowledge the educational value of PCR interactions and their impact on prescribing after the workshop intervention.

Adult↗
PubMed2002

Clinical review: hemodynamic monitoring in the intensive care unit.

Since the beginning of modern anesthesia, in 1846, the anesthetist has relied on his natural senses to monitor the patient, aided more recently by simple technical devices such as the stethoscope. There has been a tremendous increase in the availability of monitoring devices in the past 30 years. Modern technology has provided a large number of sophisticated monitors and therapeutic instruments, particularly in the past decade. Most of these techniques have enhanced our understanding of the mechanism of the patients' decompensation and have helped to guide appropriate therapeutic interventions. As surgery and critical care medicine have developed rapidly, patient monitoring capability has become increasingly complex. The most important aspect in monitoring the critically ill patient is the detection of life-threatening derangements of vital functions. Aggressive marketing strategies have been promoted to monitor almost every aspect of the patient's status. However, these strategies are only telling us what is possible; they do not tell us whether they enhance patient safety, improve our therapy, or even improve patient outcome.

Blood Volume↗
PubMed2004

Pharmaceutical advertising in emergency departments.

OBJECTIVES: Promotion of prescription drugs represents a growing source of pharmaceutical marketing expenditures. This study was undertaken to identify the frequency of items containing pharmaceutical advertising in clinical emergency departments (EDs). METHODS: In this observational study, emergency physician on-site investigators quantified a variety of items containing pharmaceutical advertising present at specified representative times and days, in clinical EDs. RESULTS: Measurements were obtained by 65 on-site investigators, representing 22 states. Most EDs in this study were community EDs (87% community and 14% university or university affiliate), and most were in urban settings (50% urban, 38% suburban, and 13% rural). Investigators measured 42 items per ED (mean = 42; median = 31; interquartile range of 14-55) containing pharmaceutical advertising in the clinical area. The most commonly observed items included pens (mean 15 per ED; median 10), product brochures (mean 5; median 3), stethoscope labels (mean 4; median 2), drug samples (mean 3; median 0), books (mean 3.4), mugs (mean 2.4), and published literature (mean 3.1). EDs with a policy restricting pharmaceutical representatives in the ED had significantly fewer items containing pharmaceutical advertising (median 7.5; 95% CI = 0 to 27) than EDs without such a policy (median 35; 95% CI = 27 to 47, p = 0.005, nonparametric Wilcoxon two-sample test). There were no differences in quantities of pharmaceutical advertising for EDs in community compared with university settings (p = 0.5), rural compared with urban settings (p = 0.3), or annual ED volumes (p = 0.9). CONCLUSIONS: Numerous items containing pharmaceutical advertising are frequently observed in EDs. Policies restricting pharmaceutical representatives in the ED are associated with reduced pharmaceutical advertising.

Advertising↗
PubMed2004

A history of pediatric specialties: the development of pediatric cardiology.

Pediatric cardiology, as a discipline, arose from early descriptive studies of congenital cardiac defects. The development of the stethoscope allowed some clinical diagnoses to be made during life. Cardiology as a medical specialty was limited, mainly, to internists. When Robert Gross ligated a patent ductus in 1938, pediatric cardiology, as a discipline, was born. Physiologic studies, angiography, and the development of extracorporeal circulation allowed congenital cardiac lesions previously considered a curiosity to be diagnosed and treated successfully. The few pediatricians who were interested in cardiology taught themselves, and soon pediatric cardiology training programs developed. By 1961, pediatric cardiology became the first subspecialty board in pediatrics. The past 60 y has brought enormous progress. Cardiac ultrasound, color-flow Doppler, and magnetic resonance imaging have made diagnostic cardiac catheterization almost unnecessary. Instead, interventional cardiac catheterization rapidly developed and is already able to replace surgery in the treatment of a number of cardiac defects. The first 50 y of cardiology has been focused on patient care, education, and clinical research, but the last 10 y has added exciting, basic research discoveries, which are elucidating the cause of cardiac defects with hope for prevention in the future. As a discipline, pediatric cardiology has always required a team-pathologists, physiologists, cardiologists, surgeons, intensivists, interventionists, and anesthesiologists-all playing an important role in the treatment of children with cardiac problems. Today the geneticists, molecular biologists, and other basic scientists are joining the team to ensure an exciting future for pediatric cardiology and the children yet to be born.

Cardiology↗
PubMed1999

School-based telemedicine: using technology to bring health care to inner-city children.

In the USA, children in low-income, medically understaffed areas have difficulty accessing health care. A pilot telemedicine service was established in Kansas, linking four elementary schools with a local hospital at 128 kbit/s. PC-based videoconferencing systems, a stethoscope, an otoscope and fax machine were installed for each school's nurse. During the first three months of operation, 187 consultations were conducted by a hospital physician over the video-link. Ear, nose and throat problems were the most common reason for referral (29%), followed by dermatological problems (20%) and mandatory school physicals (20%). Prescriptions were issued in 67% of cases. Eighteen per cent of children required referrals for specialist care. The pilot service successfully enabled medically disadvantaged children to receive health care and prompted four additional schools to join the project.

Child↗
PubMedDate not supplied

Respiratory assessment.

The ability to carry out and document a full respiratory assessment is an essential skill for all nurses. The elements included are: an initial assessment, history taking, inspection, palpation, percussion, auscultation and further investigations. A prompt initial assessment allows immediate evaluation of severity of illness and appropriate treatment measures may warrant instigation at this point. Following this, a comprehensive patient history will be elicited. Clinical examination of the patient follows and involves inspection, palpation, percussion and auscultation. At this point, consideration must be given to preparation of a light, warm, quiet, private environment for examination and suitable patient positioning. Inspection is a comprehensive visual assessment, while palpation involves using touch to gather information. The next stages are percussion and auscultation. While percussion is striking the chest to determine the state of underlying tissues, auscultation entails listening to and interpreting sound transmission through the chest wall via a stethoscope. Finally, further investigations may be necessary to confirm or negate suspected diagnoses.

Auscultation↗
PubMed2006

Contamination and decontamination of Doppler probes.

INTRODUCTION: Nosocomial infection occurs in 2-9% of patients undergoing vascular surgery and can lead to death, amputation or require complex revision surgery. Neck ties, pagers, stethoscopes and Doppler probes have been shown to carry pathogens. We measured bacterial colonisation of Doppler probes on a vascular unit and audited the effect of staff education at reducing this contamination. MATERIALS AND METHODS: Bacteriological culture swabs were taken from hand-held Doppler probes on the vascular surgical ward and clinic. There was no protocol for cleaning the Doppler probes, so manufacturers were contacted for their recommendations. The results of cultures were presented to nursing and medical staff, who were then asked to clean the probes with alcohol wipes after each use. After an interval of 1 week, bacteriological cultures from the same Doppler probes was repeated. RESULTS: Fifty bacteriological cultures were performed from 10 Doppler probes over a 4-week period. Thirteen (26%) cultures were positive for diphtheroids, coliforms, coagulase-negative staphylococci and skin flora. After staff education, 42 further swabs were taken from the same probes; two positive cultures were obtained with scanty growth of skin flora (chi2 P < 0.05). CONCLUSIONS: Staff education and simple cleaning significantly reduces the contamination of hand-held Doppler probes and may help prevent nosocomial infection.

Ambulatory Care↗
PubMedDate not supplied

Identification of resident and attending physicians: do parents know who is caring for their hospitalized child?

OBJECTIVE: Correct identification of a physician or resident is an essential first step in developing a good relationship between physicians, patients, and their families. However, many parents are unfamiliar with the individuals responsible for their children's care. This study was conducted to determine how often parents/guardians of hospitalized children could identify the residents and attending physicians caring for their children and what factors they considered important in physician identification. METHODS: This was a cross-sectional study with a convenience sample of the parents/guardians of hospitalized pediatric patients admitted to a university teaching hospital over a 2-month period; we used a self-administered, confidential questionnaire. RESULTS: Subjects were 144 parents/guardians of hospitalized children (100% of subjects asked to participate, 19.3% of all hospitalized children); parents had the following characteristics: mean age, 30 years; 51% Caucasian, 43% African American; 82% female. Physician identification was 76% for attending physicians and 73% for residents. The factors rated as most important to parents were physician introduction (50%-76%), prior relationship (27%-13%), wearing of a white coat (2%-8%), wearing of a name tag (4%-10%), and wearing of a stethoscope (0%-2%). Physician introduction was ranked higher for first hospitalizations. Subsequent hospitalizations increased identification of attending physicians but not residents. CONCLUSIONS: This study indicates that up to a quarter of parents could not identify the physician responsible for their children's care during a hospitalization. Improving physician identification may enhance other aspects of physician-family communication.

Child↗
PubMed1991

Auscultated forced expiratory time as a clinical and epidemiologic test of airway obstruction.

OBJECTIVE: Seeking an inexpensive, readily available, clinical, screening, and field surveillance test of airway obstruction, we determined the validity of current dogma that forced expiratory time (FET) is a good clinical test of airway obstruction yet is of no epidemiologic use given excessive intrasubject variability. SUBJECTS AND METHODS: Two hundred twenty-nine white male plumbers and pipefitters were evaluated by spirometry, chest roentgenography, and a standardized respiratory questionnaire during a union-sponsored asbestos screening program. Subjects were classified as having large airway obstruction (LAO), small airway obstruction (SAO) alone, or no obstruction, on the basis of standard spirometric prediction equations. Two physicians, blinded to clinical and spirometric data, independently measured FET while auscultating the trachea with a stethoscope. The FET was defined as the time taken for an individual to forcefully exhale through an open mouth from total lung capacity until airflow became inaudible. Five such times were recorded for each subject. The mean of the three times having the narrowest range was deemed the FET for calculating test sensitivity and specificity. Based on previous literature, an FET greater than or equal to 6 s was considered abnormally prolonged. RESULTS: Two hundred five subjects completed both spirometry and FET testing; 67 had LAO, 5 SAO, and 133 no obstruction. A total of 83 percent had three FETs reproducible within a range of less than or equal to 1 s. The sensitivity and specificity of FET for LAO were 92 and 43 percent, respectively, while for SAO alone, 60 and 44 percent, respectively. Overall, FET misclassified 56 percent of nonobstructed subjects. Adjusting the normal-abnormal cutoff points for both FET and SAO minimally improved the performance of FET. CONCLUSION: Although FET is a simple, inexpensive, sensitive, and fairly reproducible clinical test of LAO, it cannot be recommended as a clinical or an epidemiologic tool because of its extremely low specificity.

Asbestosis↗
PubMed1995

About egophony.

Egophony is a change in timbre (Ee to A) but not pitch or volume. It is due to a decrease in the amplitude and an increase in the frequency [corrected] of the second formant, produced by solid (including compressed lung) interposed between the resonator and the stethoscope head. This explains certain difficulties in learning this valuable but currently neglected sign as well as in understanding certain physiologic false-positive occurrences.

Auscultation↗
PubMed1996

Characteristics and diagnostic significance of wheezes during exercise-induced airway obstruction in children with asthma.

The diagnostic significance of wheezes for childhood asthma has not been studied systematically (to our knowledge), even though alternative diagnostic methods are limited, especially with children too young for lung function testing. To fill this gap, tracheal sounds were continuously recorded of 70 school-aged children with and 30 without asthma during standardized physical exercise. Wheezes were digitally analyzed and compared with sound patterns previously recorded after histamine inhalation. Exercise-induced wheezes proved to be indistinguishable from sound patterns associated with histamine. The diagnostic sensitivity and specificity of any wheeze for a fall in FEV1 greater than 20% after exercise were, respectively, 86% and 99%. The sensitivity and specificity of any wheeze for a diagnosis of asthma were, respectively, 19% and 100%. Wheezes were often audible for a short time only, making traditional (stethoscopic) detection unlikely and thereby restricting clinical diagnostic significance. This suggests that the development of automated detection techniques may be warranted.

Adolescent↗
PubMed2004

Adenosine bronchial provocation with computerized wheeze detection in young infants with prolonged cough: correlation with long-term follow-up.

BACKGROUND: Chronic cough in babies is often associated with bronchial hyperreactivity (BHR). The objective documentation of BHR in babies is difficult, and acoustic methods have been described (provocative concentration of a substance causing wheeze) for conducting bronchial provocation tests (BPTs). We conducted a study to evaluate automatic computerized wheeze detection (CWD) in determining BHR in young infants with prolonged cough, and its correlation with the subsequent development of wheezing. METHODS: Infants aged < 24 months with prolonged cough (ie, > 2 months) underwent acoustic BPTs with the response determined by CWD and auscultation by a physician. Telephone interviews with parents were conducted after 1 month and yearly for the next 3 years. RESULTS: A total of 28 infants who were 4 to 24 months old with prolonged cough were included in the study. Twenty of these infants (71.4%) had BHR as determined by a positive acoustic BPT result. In 11 of these 20 tests, the CWD occurred earlier, and in 9 tests it occurred at the same step as auscultation by a physician. Rhonchi or whistles often preceded wheezes. Seventeen of the 20 patients with BHR completed 3 years of follow-up. Of these, 14 had recurrent episodes of wheezing and shortness of breath, and 3 were well. Six of the eight adenosine-negative patients completed 3 years of follow-up and had no symptoms of BHR. CONCLUSIONS: Acoustic BPT is a technically feasible test for the detection of BHR in young infants. CWD provides an earlier detection of wheeze than stethoscope auscultation. In our group of infants, a positive acoustic BPT result had high correlation with symptoms compatible with BHR over the next 3 years.

Acoustics↗
PubMed2005

Continuous murmur caused by a ventricular septal defect post-myocardial infarction: visual display with a handheld computer.

Ventricular septal defects do not typically result in a continuous murmur. The only previously reported case involved a congenital ventricular septal defect. We report a case of an acquired ventricular septal defect following a large anterior myocardial infarction resulting in a continuous murmur. The continUous nature was confirmed both with 2D echocardiography and a specially equipped stethoscope in conjunction with a handheld computer to provide a visual display of the murmur. A proposed mechanism for the continuous murmur was discussed.

Computers, Handheld↗
PubMed1988

The utility of a long-acting sympathomimetic agent, procaterol, for nocturnal asthma.

Patients with nocturnal asthma have their lowest pulmonary function and lowest serum epinephrine level at 4 to 6 AM. We studied a new long-acting beta-adrenergic agonist, procaterol, in ten patients with nocturnal asthma. The patients received 0.1 mg of procaterol one night and a placebo the other night in random order. Pulmonary function tests were performed every two hours from 10 PM to 8 AM. Pulmonary sounds were recorded using a modified stethoscope and were subsequently analyzed to estimate the proportion of time occupied by wheezing (est Tw/Ttot). The forced expiratory volume in one second (FEV1) while receiving the placebo and procaterol were similar at 10 PM (placebo, 1.35 +/- 0.18 L [mean +/- SE]; procaterol, 1.48 +/- 0.20 L); however, by 4 AM, the FEV1 had dropped significantly lower on the night with the placebo (1.01 +/- 0.14 L) than the night with procaterol (1.30 +/- 0.19 L; p less than 0.05). The est Tw/Ttot was similar at 12 AM for both nights, but at 4 AM, there was a significant increase in the est Tw/Ttot for the group with placebo but not the group with procaterol. The use of a long-acting beta-adrenergic sympathomimetic agent reversed the obstruction of the airways seen with nocturnal asthma.

Asthma↗
PubMed1990

Expiratory lung crackles in patients with fibrosing alveolitis.

Inspiratory lung crackles are a diagnostic feature of interstitial pulmonary fibrosis, but expiratory crackles are not well documented. In a phonopneumographic study of 13 patients with fibrosing alveolitis, expiratory crackles were audible with the stethoscope in 12. Phonopneumographic analysis of these 12 patients showed the crackles to be fine with the initial wave deflection of the expiratory and inspiratory crackles in opposite directions. They were few in number, occurred predominantly in mid- and late expiration, and were not affected by varying the volume history or by breath holding maneuvers. These observations support the theory that some crackles are produced by vibration of the walls of peripheral airways. In addition, this group of patients showed a significant correlation between the number of expiratory crackles and the reduction in predicted transfer factor, suggesting that expiratory crackles may be a clinical indicator of the severity of disease in fibrosing alveolitis.

Aged↗
PubMed1990

[Phonographic diagnostic aid in heart defects using neural networks].

New approaches to pattern recognition and modeling using neural networks also provide powerful tools for the analysis of heart sounds in the diagnosis of heart failure. This paper describes how a neutral network can be used to estimate the duration of systolic and diastolic heart phases as well as to suggest a suitable diagnosis. A neural network-based auscultation system is capable of documenting and analysing a heart sound signal by applying methods similar to those used by physicians in the subjective interpretation of stethoscopic signals.

Diagnosis, Computer-Assisted↗
PubMed2002

Detection of bronchial breathing caused by pneumonia.

The classic auscultation with stethoscope is the established clinical method for the detection of lung diseases. The interpretation of the sounds depends on the experience of the investigating physician. Therefore, a new computer-based method has been developed to classify breath sounds from digital lung sound recordings. Lung sounds of 11 patients with one-sided pneumonia and bronchial breathing were recorded on both the pneumonia side and on contralateral healthy side simultaneously using two microphones. The spectral power for the 300-600 Hz frequency band was computed for four respiratory cycles and normalized. For each breath, the ratio R between the time-segments (duration = 0.1 s) with the highest inspiratory and highest expiratory flow was calculated and averaged. We found significant differences in R between the pneumonia side (R = 1.4 +/- 1.3) and the healthy side (R = 0.5 +/- 0.5; p = 0.003 Wilcoxon-test) of lung. In 218 healthy volunteers we found R = 0.3 +/- 0.2 as a reference-value. The differences of ratio R (delta R) between the pneumonia side and the healthy side (delta R = 1.0 +/- 0.9) were significantly higher compared to follow-up studies after recovery (delta R = 0.0 +/- 0.1, p = 0.005 Wilcoxon-test). The computer based detection of bronchial breathing can be considered useful as part of a quantitative monitoring of patients at risk to develop pneumonia.

Auscultation↗