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PubMed2004

Recognition of internal derangements.

One of the most common symptoms of temporomandibular disorders is an internal derangement (ID). The aim of this study was to test the inter-observer reliability of the recognition of IDs by means of auscultation, palpation or both. To that end, 120 women and 100 men were screened by two trained examiners for the presence of IDs. Anterior disc displacement was diagnosed in 14% of the cases and hypermobility in 12%. In 4% of the cases, the ID was classified as 'other'. The inter-rater reliability (Cohen's kappa) was moderate for the presence of an ID for all techniques, while for the classification into type, an almost perfect reliability was found for the combined technique. It was concluded that the type of ID can best be established with the combination of auscultation and palpation; for the establishment of an ID as such, any of the three techniques would suffice.

Adolescent↗
PubMed2005

Proc, Dr. Sam, Uncle Henry, and the "Little Green Book". Interview by Charles F. Wooley.

During his house staff training before World War II, Dr. W. Proctor Harvey encountered Dr. Samuel A. Levine at the Peter Bent Brigham Hospital in Boston. Following military service, Harvey returned to Boston and became Levine's first cardiology fellow. The book Clinical Auscultation of the Heart--the Little Green Book by Levine and Harvey in 1949 combined Levine's clinical wisdom with Harvey's objective phonocardiographic methods and brought an important objective dimension to the art of cardiac auscultation. Both Levine and Harvey shared experiences and friendship with Henry Christian, the first Physician-in-Chief when the new Brigham Hospital Opened in 1913. Christian, appointed Dean of the Harvard Medical School in 1908 at the age of 32, was referred to as the "Boy Dean." He held the Hersey Chair of Theory and Practice of Physic from 1908 until 1939, was one of the founding group of the American Society for Clinical Investigation, and a major force in academic medicine. Levine served as intern to Christian and then joined the Brigham medical staff in 1915. Proctor Harvey followed Henry Christian's path from their mutual hometown of Lyunchburg, VA to the Peter Bent Brigham Hospital. A series of illuminating and respectful professional interactions--initially between Christian and Levine, between Levine and Harvey in the early 1940s, and between Harvey and Christian in the 1950s--provide the background for the genesis of the Little Green Book and a remarkable example of academic heritage.

Cardiology↗
PubMed2004

Low intensity heart murmurs in boxer dogs: inter-observer variation and effects of stress testing.

Inter-observer variation in the detection and grading of low intensity heart murmurs in boxer dogs was investigated. Six veterinarians with different levels of experience examined 27 boxers by cardiac auscultation. The dogs were auscultated before and after exercise, and the results were compared with phonocardiographic and echocardiographic examinations performed at rest and during two different stress tests. A subvalvular aortic ridge was identified in six dogs on two-dimensional echocardiography. Using dogs with low intensity murmurs or dogs free of heart murmurs, inter-observer agreement was positively correlated to the level of experience at rest (weighted kappa [kappa] 0.14 to 0.75), while the agreement was poor after exercise (weighted kappa 0.01 to 0.36). The presence of a subvalvular aortic ridge was associated with higher aortic flow velocities (P<0.002) and higher auscultatory murmur grading (P<0.001). There was an increase in murmur duration during one kind of stress test (P<0.001) and in aortic flow velocity during the other (P=0.001).

Animals↗
PubMed2002

Heart murmurs recorded by a sensor based electronic stethoscope and e-mailed for remote assessment.

BACKGROUND: Heart murmurs are common in children, and they are often referred to a specialist for examination. A clinically innocent murmur does not need further investigation. The referral area of the University Hospital is large and sparsely populated. A new service for remote auscultation (telemedicine) of heart murmurs in children was established where heart sounds and short texts were sent as an attachment to e-mails. AIM: To assess the clinical quality of this method. METHODS: Heart sounds from 47 patients with no murmur (n = 7), with innocent murmurs (n = 20), or with pathological murmurs (n = 20) were recorded using a sensor based stethoscope and e-mailed to a remote computer. The sounds were repeated, giving 100 cases that were randomly distributed on a compact disc. Four cardiologists assessed and categorised the cases as having "no murmur", "innocent murmur", or "pathological murmur", recorded the assessment time per case, their degree of certainty, and whether they recommended referral. RESULTS: On average, 2.1 minutes were spent on each case. The mean sensitivity and specificity were 89.7% and 98.2% respectively, and the inter-observer and intra-observer variabilities were low (kappa 0.81 and 0.87), respectively. A total of 93.4% of cases with a pathological murmur and 12.6% of cases with an innocent murmur were recommended for referral. CONCLUSION: Telemedical referral of patients with heart murmurs for remote assessment by a cardiologist is safe and saves time. Skilled auscultation is adequate to detect patients with innocent murmurs.

Adolescent↗
PubMed1994

Athletic heart syndrome in dogs competing in a long-distance sled race.

The cardiac effects of endurance training were evaluated by cardiac auscultation and electrocardiographic examination of 48 heavily trained sled dogs (3,000-5,000 km of training), 18 lightly trained sled dogs (300-800 km of training), 19 untrained sled dogs, and 14 mongrel dogs. A grade I-II/VI early- to midsystolic cardiac murmur was auscultated with increasing frequency as training level increased. The QRS duration (66.1 +/- 7.4 ms) and QT interval (236 +/- 20 ms) were significantly (P < 0.05) longer in heavily trained sled dogs than in mongrel dogs (QRS, 60.6 +/- 4.6; QT, 219 +/- 11 ms). A long QT interval (> 250 ms) was observed in 8 (16.7%) heavily trained dogs but not in the other groups. A significant rightward shift in the mean electrical axis of ventricular depolarization in the frontal plane was observed in heavily trained sled dogs. The auscultatory and electrocardiographic findings in heavily trained sled dogs were remarkably similar to those reported in elite human endurance athletes, suggesting that endurance-trained sled dogs provide a naturally occurring model for the athletic heart syndrome.

Animals↗
PubMed1984

Crackles in the early detection of asbestosis.

We studied 386 workers exposed to asbestos to assess the value of chest auscultation by a trained technician in detecting asbestosis as defined by previously reported clinical, physiologic, and roentgenologic criteria. The presence and degree of crackles were assessed at preselected basilar lung sites by a technician whose performance was validated by comparison with computer-generated time-expanded waveforms of tape recordings of lung sounds. Asbestosis was present in only 2.8% of the total population, but it was present in 8.6% of those with over 25 yr or more of employment. The technician correctly identified all the workers in whom the diagnosis was most certain, that is, those with all criteria positive. The overall true positive rate was 55%. The majority (94.8%) of those with no abnormal criteria were correctly classified. Auscultation by an objectively validated technician can be a useful noninvasive method for screening industrial populations exposed to asbestos.

Allied Health Personnel↗
PubMedDate not supplied

Comparison of four bedside indicators used to predict duodenal feeding tube placement with radiography.

The validity of four indicators to predict successful duodenal feeding tube placement was evaluated in a prospective trial. Data were collected on each indicator at prepyloric (< or = 65 cm) and postpyloric (> or = 75 cm) feeding tube lengths. Feeding tubes were placed in 106 patients. Eighteen feeding tubes were located in the stomach, and 88 were in the duodenum. Auscultation (progression of loudest sound locations from the left to the right abdomen) had a positive predictive value of 85% (negative predictive value, 31%). The vacuum effect (a change from 40 mL of aspirated air to < or = 10 mL after 60 mL of air instillation) had a positive predictive value of 86% (negative predictive value, 45%) and was significantly correlated with duodenal placement (p = .02). Aspirate was present at prepyloric and postpyloric lengths in 35 cases. Ten of these 35 cases had the defined change in pH from < or = 4.0 to > or = 6.0 (positive predictive value, 100%; negative predictive value, 28%). The positive predictive value of color (a change to yellow) was also 100% (n = 11); the negative predictive value was 29%. The low negative predictive values of the indicators suggest that the absence of defined changes is of no assistance in discriminating between stomach and duodenal placement. A positive auscultation or vacuum effect test is not conclusive for duodenal placement. A positive pH or color change test may obviate the need for a confirmatory radiograph.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1976

Pulmonary congestion in chronic heart disease. Radiologic, clinical and hemodynamic relationships.

Pulmonary congestion in chronic heart disease was evaluated by lung auscultation and roentgen examination of the chest and compared with pressure recording of the pulmonary circulation in 49 cases. Whereas auscultation appeared not to be correlated to the pressures, the radiologic findings proved to be a reliable measure of increased pressures. The radiologic assessment was based on isolated flow shift to the upper lobes of the lungs, indicating slight pulmonary venous hypertension, and flow shift in association with blurring of the lower lobe vessels, indicating pulmonary interstitial oedema. In distinction to the results from acute cardiac failure interlobular septa were often demonstrated in association with pulmonary interstitial oedema, and pulmonary alveolar oedema rarely demonstrated in spite of marked pulmonary venous hypertension.

Adolescent↗
PubMed1995

The measurement of methacholine responsiveness in 5 year old children: three methods compared.

The aim of this study was to compare the feasibility of three techniques for measuring the response to bronchial challenge in young children: a direct airway measurement, the forced oscillation technique (FOT) for determining respiratory system resistance at 6 and 8 Hz (Rrs6 and Rrs8), and two indirect methods, the change in transcutaneous oxygen tension (PtcO2) and the detection of wheeze on auscultation of the chest. Thirty children aged 5 yrs, with a history of wheeze, and six asymptomatic controls, took part in a bronchial challenge test using methacholine administered by Wright nebulizer by the tidal-breathing method. The provocative concentration which produced a 35% increase in Rrs6 (PC35Rrs6) and a 15% decreases in PtcO2 (PC15PtcO2) were determined by interpolation, and the chest was ausculated after each dose of methacholine. The FOT was found to be unreliable in this age group: in seven children, the data were technically unsatisfactory in the presence of induced bronchoconstriction, whilst in three children, changes in Rrs were inconsistent after challenge. The use of Rrs8 did not improve the detection of positive responses. PC15PtcO2 was measurable in 29 of 30 children, and in 18 of these PC35Rrs6 was also measurable. In no subject did a significant, sustained increase in Rrs occur during challenge in the absence of a significant change in PtcO2. Wheeze was audible in only 4 of 25 (16%) of the positive and in no negative challenges. With this protocol, we found the FOT to be unreliable and the auscultation method valueless and potentially dangerous, since marked falls in PtcO2 of up to 33% sometimes occurred in the absence of wheeze.(ABSTRACT TRUNCATED AT 250 WORDS)

Airway Resistance↗
PubMed1999

Methacholine challenge in preschool children: methacholine-induced wheeze versus transcutaneous oximetry.

Tracheal/chest auscultation for wheeze and transcutaneous oximetry have both been suggested as measures of outcome in bronchial provocation tests in young children. This study aimed to compare the sensitivity and safety of these two techniques as end-points for methacholine challenge in children aged <4 yrs. Seventy-two methacholine challenges were performed in 39 children aged <4 yrs with recurrent wheeze. Arterial oxygen saturation (Sa,O2) and transcutaneous oxygen pressure tcPO2 continuously, and the test was terminated when wheeze was heard or at Sa,O2 <91%. tcPO2 was not used as an end-point. Wheeze or desaturation occurred at < or =8 mg x mL(-1) methacholine in every test. One child had transient clinical cyanosis, but no other ill-effects were seen. Fifty-six tests (78%) were terminated for wheeze, seven (10%) for fall in Sa,O2 and nine (12%) showed simultaneous responses in both parameters. Twenty-eight tests (39%) contained a fall in tcPO2 >3 kPa but six of these also showed a significant rise. Fifty-three tests (75%) contained a fall in tcPO2 >15%, but 20 of these also showed a significant rise. Tracheal/chest auscultation with Sa,O2 monitoring is a sensitive and relatively safe end-point for bronchial challenges in preschool children. The erratic pattern of transcutaneous oxygen pressure response in some children casts doubt on its reliability as a proxy measure of bronchial obstruction.

Auscultation↗
PubMed2002

A relative value method for measuring and evaluating cardiac reserve.

BACKGROUND: Although a very close relationship between the amplitude of the first heart sound (S1) and the cardiac contractility have been proven by previous studies, the absolute value of S1 can not be applied for evaluating cardiac contractility. However, we were able to devise some indicators with relative values for evaluating cardiac function. METHODS: Tests were carried out on a varied group of volunteers. Four indicators were devised: (1) the increase of the amplitude of the first heart sound after accomplishing different exercise workloads, with respect to the amplitude of the first heart sound (S1)recorded at rest was defined as cardiac contractility change trend (CCCT). When the subjects completed the entire designed exercise workload (7000 J), the resulting CCCT was defined as CCCT(1); when only 1/4 of the designed exercise workload was completed, the result was defined as CCCT(1/4). (2) The ratio of S1 amplitude to S2 amplitude (S1/S2). (3) The ratio of S1 amplitude at tricuspid valve auscultation area to that at mitral auscultation area T1/M1 (4) the ratio of diastolic to systolic duration (D/S). Data were expressed as mean +/- SD. RESULTS: CCCT(1/4) was 6.36 +/- 3.01 (n = 67), CCCT(1) was 10.36 +/- 4.2 (n = 33), S1/S2 was 1.89 +/- 0.94 (n = 140), T1/M1 was 1.44 +/- 0.99 (n = 144), and D/S was 1.68 +/- 0.27 (n = 172). CONCLUSIONS: Using indicators CCCT(1/4) and CCCT(1) may be beneficial for evaluating cardiac contractility and cardiac reserve mobilization level, S1/S2 for considering the factor for hypotension, T1/M1 for evaluating the right heart load, and D/S for evaluating diastolic cardiac blood perfusion time.

Adolescent↗
PubMed2004

A comparison of faculty-led small group learning in combination with computer-based instruction versus computer-based instruction alone on identifying simulated pulmonary sounds.

BACKGROUND: Computer-based learning has gained widespread acceptance in medical curricula, but can it replace faculty-led teaching. PURPOSE: To investigate the effectiveness of independent computer-based learning of pulmonary auscultation alone and in combination with faculty-led teaching. METHODS: The first method involved independent computer-based instruction (CBI; Group 1) of 113 second-year medical students. The second method involved a combination of faculty-led instruction and independent CBI (Group 2) of 79 second-year medical students. A pretest-posttest method of assessment was used. RESULTS: The pretest showed recognition rates of 48% for Group 1 and 46% for Group 2, whereas the posttest showed recognition rates of 81% for Group 1 and 88% for Group 2. The posttest clinical correlation scores were identical with both groups scoring 93 percent. CONCLUSIONS: The study demonstrates that student learning of pulmonary auscultation is similar whether a computer-based independent instructional approach is used alone or in combination with faculty-led sessions.

Auscultation↗
PubMed1979

Bedside evaluation of large motor units in childhood spinal muscular atrophy.

One hundred patients with motor unit disease were examined to determine the diagnostc reliability of several clinical signs of large motor units. These signs were high-intensity, low-pitched rumbling on skeletal muscle auscultation, voluntary contraction fasciculations, contraction fasciculation trembling, and palpable contraction fasciculations. Among 22 cases of spinal muscular atrophy, contration fasciculation trembling was noted in 86 percent, abnormal muscle auscultation in 68 percent, palpable contraction fasciculations in 64 percent, and voluntary contraction fasciculations in 50 percent.

Adolescent↗
PubMed1985

Clinical significance of asymptomatic neck bruits.

The value of neck bruits as indicators of underlying carotid artery disease was assessed by correlating the results of carotid Doppler examination with auscultation in 336 patients with asymptomatic bruits. Also, the separate findings of auscultation by two physicians were compared for agreement in the quality and location of the bruits. Levels of agreement between the physicians in the clinical examination were acceptable for the presence and site of the neck bruits, but were unacceptable for the intensity, pitch, and duration. Unilateral bruits in the upper neck indicated underlying internal carotid artery (ICA) stenosis detectable by carotid Doppler (greater than 35% stenosis) in 61%, whereas only 11% of patients with bruits localized to the supraclavicular area had ICA stenosis. "Silent" contralateral ICA stenosis was detected by Doppler in 28% of patients with unilateral cervical bruits. Bilateral cervical bruits were the most powerful predictors (76%) of underlying ICA stenosis detectable by Doppler. Neck bruits are valuable indicators of underlying carotid artery disease, but Doppler ultrasound examination adds significantly to clinical accuracy.

Auscultation↗
PubMed1991

Frequency spectra of normal breath sounds in childhood.

Clinicians who auscultate the chest of normal children note that the frequency content of their breath sounds appears to vary with age. Because these changes have not been systematically documented before, we recorded and analyzed inspiratory breath sounds in 35 children (0 to 13 years) and five adults (34 to 43 years). Our objective was to determine if the frequency content of normal breath sounds differed with age. Using a Fast Fourier Transform program, we calculated an average amplitude frequency spectrum from the inspiratory portion of the breath sounds of each subject (n = 10 breaths), and we compared the shape of the AFS and the values of selected frequency parameters. We found that the shape of the AFS of the youngest children differed most from the AFS of adults. Three of four selected frequency parameters (F25, F50, F95) differed significantly between children and adults (p less than 0.05), and one parameter (F75) did not (p = 0.11). The F25, F50, and F75 parameters of children (but not F95) were correlated (p less than 0.001) with increasing height and age. These results suggest that differences in the frequency content of the normal breath sounds of children and adults contribute to the differences that clinicians detect during clinical auscultation.

Adult↗
PubMed1985

Direct and indirect blood pressure during exercise.

In 27 subjects, we compared rest and exercise blood pressure (BP) measurements determined directly by catheterization of the radial artery with simultaneous values obtained indirectly by auscultation of the brachial artery. As work increased, the systolic BP increased, whereas the diastolic BP did not change. Considering all comparisons, direct BP was greater than indirect BP by a mean of 29.0 mm Hg for systolic BP and 12.3 mm Hg for diastolic BP. As exercise level increased, the difference between direct and indirect systolic BP decreased whereas the difference between direct and indirect diastolic BP did not change. Both methods have advantages for assessment of BP response to exercise: normality of BP response is best assessed by auscultation, whereas beat-by-beat trends in BP are more accurately defined by the direct method.

Adolescent↗
PubMed1995

Digital signal processing of the phonocardiogram: review of the most recent advancements.

The objective of the present paper is to provide a detailed review of the most recent developments in instrumentation and signal processing of digital phonocardiography and heart auscultation. After a short introduction, the paper presents a brief history of heart auscultation and phonocardiography, which is followed by a summary of the basic theories and controversies regarding the genesis of the heart sounds. The application of spectral analysis and the potential of new time-frequency representations and cardiac acoustic mapping to resolve the controversies and better understand the genesis and transmission of heart sounds and murmurs within the heart-thorax acoustic system are reviewed. The most recent developments in the application of linear predictive coding, spectral analysis, time-frequency representation techniques, and pattern recognition for the detection and follow-up of native and prosthetic valve degeneration and dysfunction are also presented in detail. New areas of research and clinical applications and areas of potential future developments are then highlighted. The final section is a discussion about a multidegree of freedom theory on the origin of the heart sounds and murmurs, which is completed by the authors' conclusion.

Coronary Disease↗
PubMed2005

Heart murmur and anaemia in the pediatric population.

Innocent heart murmurs are hearth murmurs that occur in patients with a normal heart structure. They do not represent a disease of the heart and vascular system, and should not be treated as such. Iron-deficiency anaemia often causes, along with other symptoms, systolic heart murmurs and tachycardia. It appears in children of all ages representing a most common haematological paediatric disease. To establish the influence of iron-deficiency anaemia on genesis of innocent murmurs and to compare auscultatory and phono-electrocardiographic findings in patients with anaemia and heart murmurs before and after iron therapy. The study includes 120 patients with innocent heart murmurs that have been auscultated at cardio-rheumatic outpatient department of Pediatric Clinic of the Clinical Center of the University of Sarajevo, during the period from 01/01/2004 to 31/12/2004. Further diagnostic procedure, i.e. laboratory tests, diagnosed iron-deficiency anaemia in 30/120 patients. These patients have been followed in this study. 22/30 patients had systolic murmur I/II intensity of Levin scale; 8/30 patients had II/VI systolic murmurs of intensity by Levin. The highest number of examinees had 0-1 years of age, and in this group the number of boys was higher than the number of girls (M: F = 12:4). During the auscultatory and phono-ECG examinations of murmurs, 6 patients had haemoglobin values less than 95 g/l, which corresponds to an average and severe type of anaemia. 24 patients had haemoglobin values between 95 and 110 g/l, which corresponds to benign type of anaemia. The most numerous were patients aged between 0 - 1 year (3 patients with hemoglobin value Hb < 95 g/l, 13 patients with hemoglobin value Hb 95-110 g/l). All patients were treated with iron medicaments. After three months, clinical and laboratory re-evaluation was performed and it has demonstrated that after iron therapy 24 patients had level of a haemoglobin Hb >110 g/l and 6 patients had haemoglobin levels between 95 and 110 g/l. By auscultatory and phono-ECG examinations, murmurs of a level of intensity I/II was registered in only one child, while in the other 29 patients there were not any registered heart murmurs. Diagnosis of anaemia in the paediatric population group delays definitive diagnosis of heart murmurs. Innocent murmurs in children with sideropenic anaemia occur as its consequence. After adequately conducted iron therapy, i.e. cured anaemia, heart murmurs were not auscultated.

Adolescent↗