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PubMed2002

A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma.

STUDY OBJECTIVE: We sought to determine the prevalence of thoracic injuries in children sustaining blunt torso trauma and to develop a clinical prediction rule to identify children with these injuries. METHODS: We prospectively enrolled pediatric patients (<16 years) who presented to the emergency department of a Level I trauma center with blunt torso trauma and underwent chest radiography. Clinical findings were recorded in a standardized fashion by the ED faculty physician. Thoracic injuries included the following: pulmonary contusion, hemothorax, pneumothorax, pneumomediastinum, tracheal-bronchial disruption, aortic injury, hemopericardium, pneumopericardium, cardiac contusion, rib fracture, sternal fracture, or any injury to the diaphragm. Multiple logistic regression and recursive partitioning analyses were performed to generate a clinical prediction rule for identifying children with these injuries. RESULTS: Nine hundred eighty-six patients with a mean age of 8.3+/-4.8 years were enrolled. Eighty (8.1%; 95% confidence interval [CI] 6.5% to 10.0%) patients sustained thoracic injuries. Multiple logistic regression and recursive partitioning analyses identified the following predictors of thoracic injuries: low systolic blood pressure (14% with injury versus 2% without injury; adjusted odds ratio [OR] 4.6), elevated age-adjusted respiratory rate (51% versus 16%; adjusted OR 2.9), abnormal results on examination of the thorax (68% versus 36%; adjusted OR 3.6), abnormal chest auscultation findings (14% versus 1%; adjusted OR 8.6), femur fracture (13% versus 5%; adjusted OR 2.2), and a Glasgow Coma Scale (GCS) score of less than 15 (61% versus 26%; adjusted OR 3.3). Seventy-eight (98%; 95% CI 91% to 100%) of the 80 patients with thoracic injuries had at least 1 of these predictive factors. Three hundred thirty-six (37%) children had none of these predictive factors, including 2 (0.6%; 95% CI 0.1% to 2.1%) with thoracic injuries. These 2 injuries, however, did not require any intervention. CONCLUSION: Predictors of thoracic injury in children sustaining blunt torso trauma include low systolic blood pressure, elevated respiratory rate, abnormal results on thoracic examination, abnormal chest auscultation findings, femur fracture, and a GCS score of less than 15. These predictors can be used to create a sensible clinical decision rule for the identification of children with thoracic injuries.

Accidental Falls↗
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↗
PubMedDate not supplied

Effectiveness of self-applied tourniquets in human volunteers.

BACKGROUND: Tourniquets are not commonly used in routine extremity trauma, but can be vital for hemorrhage control in austere conditions. OBJECTIVE: To determine the effectiveness in human volunteers of currently available self-applied tourniquets for extremity hemorrhage. METHODS: Seven tourniquets were tested on the thigh for elimination of detectable distal pulse by Doppler auscultation at the popliteal artery (experiment I, n = 18 subjects). The tourniquets that were effective in >or=80% of subjects in experiment I were tested for effectiveness on the upper arm by auscultation at the radial artery (experiment II, n = 12 subjects). RESULTS: Three of the seven tourniquets were effective in all subjects in experiment I; a fourth tourniquet was effective in 88%. Three of the four successful devices were also 100% effective in experiment II; the fourth was effective in 75%. Failure of tourniquets to eliminate distal Doppler pulse signal was due to inadequate mechanical advantage for tightening, device failure (breakage), or intolerable pinching or circumferential pain prior to pulse elimination. The Combat Application Tourniquet (North American Rescue Products, Inc.), the Emergency & Military Tourniquet (Delfi Medical Innovations, Inc.), and the Special Operations Forces Tactical Tourniquet (Tactical Medical Solutions, LLC) were all found to be 100% effective in elimination of distal arterial pulse in both the arm and the leg in all subjects. CONCLUSION: Some commercially available tourniquets do not reliably occlude arterial blood flow and may not be successful in preventing extremity exsanguination in a trauma patient. Potential purchasers of such devices should bear this in mind when selecting a device for clinical use.

Adult↗
PubMed1994

Accuracy and performance of the Terumo ES-H51, a new portable blood pressure monitor.

A high performance portable automatic sphygmomanometer, the Terumo ES-H51 (104 g, 58 x 22 x 92 mm), was newly developed for clinical use as a substitute for auscultation using a mercury sphygmomanometer. This device usually displays blood pressure (BP) values obtained by the Korotkoff sound method (K-method). However, when the device judges that BP values obtained by the K-method are inaccurate or unreliable, it substitutes automatically BP values obtained by the cuffoscillometric method (O-method). The accuracy and reliability of the device was tested by comparing it to the auscultation with the standard mercury sphygmomanometer. The mean difference between BP values obtained by the standard method and those obtained by the K-method were -0.7 +/- 2.9 mm Hg systole (mean +/- SD) and -0.3 +/- 2.6 mm Hg diastole, whereas the difference between the former and those obtained by the O-method were 0.3 +/- 5.7 mm Hg systole and 0.3 +/- 4.3 mm Hg diastole (n = 170). The agreement between the BP values obtained according to each of the two methods using the device and the standard method was within 5 mm Hg for 72% to 93% of both systolic and diastolic readings. Therefore, BP values measured by the ES-H51 are accurate. The ES-H51 is sufficiently small and light to be carried easily anywhere. The objective and reproducible BP information obtained by the present device would be useful in clinical practice.

Adult↗
PubMed1998

The importance of clinical symptoms and signs in the diagnosis of community-acquired pneumonia.

A sample of 153 children was drawn from a teaching hospital in Säo Paulo, Brazil. It comprised 51 pneumonia cases and equal number of non-respiratory and healthy controls matched by age and sex. Age ranged from 1 month to 7 years. They were all submitted to a standard protocol to investigate clinical symptoms and signs, and diagnosis of pneumonia was supported by X-ray images. Univariate data analysis contrasting pneumonia and non-pneumonia subjects suggested that the best pneumonia indicators would be chest auscultation, history of breathlessness, history of cough, chest in-drawing and fast respiratory rate, in descending order. A multivariate approach including also data from X-ray investigation was then tried with the application of multiple discriminant analysis to study the separation of pneumonia cases, non-respiratory patients and healthy children. It revealed that when many items of information are considered the performance of individual symptoms and signs change. The best predictors of pneumonia were then identified as chest in-drawing, chest auscultation, X-ray, history of breathlessness and toxaemia. Clinical symptoms taken all together contribute more than signs and equal X-ray in importance. Accordingly, it is concluded that any attention to X-ray should be secondary to clinical investigation, and it is suggested that the WHO's guidelines could profit with the inclusion of at least one clinical symptom, namely history of breathlessness which was found more useful than the WHO recommended breath count.

Analysis of Variance↗
PubMed2005

Incorporating simulation technology in a canadian internal medicine specialty examination: a descriptive report.

High-stakes assessment of clinical performance through the use of standardized patients (SPs) is limited by the SP's lack of real physical abnormalities. The authors report on the development and implementation of physical examination stations that combine simulation technology in the form of digitized cardiac auscultation videos with an SP assessment for the 2003 Royal College of Physicians and Surgeons of Canada's Comprehensive Objective Examination in Internal Medicine. The authors assessed candidates on both the traditional stations and the stations that combined the traditional SP examination with the digitized cardiac auscultation video. For the combined stations, candidates first completed a physical examination of the SP, watched and listened to a computer simulation, and then described their auscultatory findings. The candidates' mean scores for both types of stations were similar, as were the mean discrimination indices for both types of stations, suggesting that the combined stations were of a testing standard similar to the traditional stations. Combining an SP with simulation technology may be one approach to the assessment of clinical competence in high-stakes testing situations.

Clinical Competence↗
PubMed1998

Automated blood pressure measurement at rest and during exercise: evaluation of the motion tolerant CardioDyne NBP 2000.

PURPOSE: The purpose of this study was to validate the use of a motion tolerant blood pressure monitor (CardioDyne NBP 2000, Luxtec, Worcester, MA) ) against standard manual auscultation at rest and during exercise. METHODS: Nineteen subjects (men, N = 9; women, N = 10) participated in the study (mean: age 21+/-1.2 yr; height 172.5+/-8 cm; mass 69.4+/-14.5 kg). Standard Bruce protocol treadmill exercise tests with 12-lead ECG and metabolic measures were administered to the subjects, with blood pressure measures taken at rest before, during, and after the exercise tests. Blood pressure by manual auscultatory sphygmomanometry and the CardioDyne NBP 2000 was recorded simultaneously in the same arm. Manual auscultatory blood pressure measures obtained by one experimenter were used as the criterion measure, and the data of two NBP 2000 audio reviewers were averaged for each data point recorded. RESULTS: Systolic blood pressure (SBP) and diastolic blood pressure (DBP) via manual auscultation and the NBP 2000 "automatic" values were not significantly different and were highly correlated at rest and during exercise. Resting intraclass correlation SBP values were high (range 0.95 to 0.98), as were DBP intraclass correlation values (range 0.83 to 0.95). Exercise intraclass correlation SBP values ranged from 0.94 to 0.99, and DBP intraclass correlation values from 0.88 to 0.93. CONCLUSION: We conclude that the NBP 2000 is simple to use at rest and during exercise stress testing and provides accurate and verifiable information.

Adult↗
PubMed2001

Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases.

We analyzed a series of 112 consecutive cases of left atrial myxoma diagnosed in a single French hospital (72 women and 40 men; age range, 5-84 yr) over 40 years, from 1959 to 1998. Symptoms of mitral valve obstruction, the first arm of the classic triad of myxoma presentation, were present in 75 patients (67%), with mostly cardiac failure or malaise. Symptoms of embolism, the second frequent presentation in the classic triad, were observed in 33 cases (29%) with 1 or several locations, essentially cerebral emboli with stroke. Males are statistically at greater risk than females of developing embolic complications. The third arm of the classic triad consists of constitutional symptoms (34%) with fever, weight loss, or symptoms resembling connective tissue disease, due to cytokine (interleukin-6) secretion. Younger and male patients have more neurologic symptoms, and female patients have more systemic symptoms. Seventy-two patients (64%) had cardiac auscultation abnormalities, essentially pseudo-mitral valve disease (53.5%) and more rarely the suggestive tumor plop (15%). The most frequent electrocardiographic sign was left atrial hypertrophy (35%), whereas arrhythmias were uncommon. The greater number of myxoma patients (98) diagnosed preoperatively after 1977 reflects the introduction of echocardiography as a noninvasive diagnostic procedure. However, there was no significant reduction in the average time from onset of symptoms to operation between patients seen in the periods before and after 1977. The tumor diameter ranged from 1 to 15 cm with a weight of between 15 and 180 g (mean, 37 g). The myxoma surface was friable or villous in 35% of the cases, and smooth in the other 65% cases. Myxomas in patients presenting with embolism have a friable surface; those in patients with cardiac symptoms, pseudo-mitral auscultation signs, tumor plop, and electrocardiogram or radiologic signs of left atrium hypertrophy and dilatation are significantly the larger tumors. The long-term prognosis is excellent, and only 4 deaths occurred among our 112 cases over a median follow-up of 3 years. The recurrence rate is low (5%), but long-term follow-up and serial echocardiography are advisable especially for young patients.

Adolescent↗
PubMed2003

The anaesthesiologist in the intensive care unit.

PURPOSE OF REVIEW: This review focuses on recent knowledge in areas of anaesthesia expertise which are indispensable to intensive care unit management, including airway management, vascular access, regional analgesia and the treatment of status asthmaticus and status epilepticus. RECENT FINDINGS: Etomidate as the sole agent for intubation in the intensive care unit has a 90% success rate, while in a prehospital setting, the addition of succinylcholine to etomidate results in a 99% success rate. In determining successful intubation, capnography and laryngoscopic/fibreoptic visualization are superior to auscultation, while auscultation is as effective as the self-inflating bulb or transillumination with the lightwand. The dorsalis pedis artery is an effective alternative to radial artery cannulation, while arterial cannulation itself can result in major adverse effects if complications arise. Ultrasound guidance in the placement of central catheters results in an improved insertion success rate. Internal jugular and subclavian lines have similar risk of haemothorax or pneumothorax, while subclavian lines are associated with the lowest incidence of infection. Midazolam, thiopentone and propofol have all been found to be efficacious in terminating refractory status epilepticus, with thiopentone resulting in a lower incidence of breakthrough seizures or treatment failure but an increased incidence of hypotension. Inhalational anaesthesia using isoflurane or desflurane has also been found to be successful in refractory status epilepticus. In the management of status asthmaticus, limiting minute volume while tolerating hypercapnia and acidosis as well as the use of inhalational anesthesia have proven effective strategies in a number of refractory cases. SUMMARY: The anaesthesiologist's unique knowledge and skills are ideally suited to the practical management of patients in a critical care setting as well as in the treatment of the critical phases of many illnesses.

Journal Article↗
PubMed2003

Reduction of interference in oscillometric arterial blood pressure measurement using fuzzy logic.

In oscillometry, oscillation amplitudes (OAs) embedded in the cuff pressure are drastically affected by a variety of artifacts and cardiovascular diseases, leading to inaccurate arterial blood pressure (ABP) measurement. The purpose of this paper is to improve the accuracy in the arterial pressure measurement by reducing interference in the OAs using a recursive weighted regression algorithm (RWRA). This method includes a fuzzy logic discriminator (FLD) and a recursive regression algorithm. The FLD is used to reduce the effect of artifacts caused by measurement motion disturbance or cardiovascular diseases, and to determine the truthfulness of the oscillation pulse. According to the truth degree, the relationship between the cuff pressure and OA is reconstructed using the regression algorithm. Because the regression method must utilize inverse matrix operation, which will be difficult to implement in an automatic or ambulatory monitor, the recursive regression method is proposed to solve this problem. To test the performance of this RWRA, 47 subjects underwent the ABP measurement using both the auscultation and the oscillometry combined with the RWRA. It was found that the average difference between the pooled blood pressures measured by the auscultation and those by the oscillometry combined with the RWRA was found to be only 4.9 mmHg. Clinical results demonstrated that the proposed RWRA is more robust than the traditional curve fitting algorithm (TCFA). We conclude that the proposed RWRA can be applied to effectively improve the accuracy of the oscillometric blood pressure measurement.

Adolescent↗
PubMed1994

Cough variant asthma: a case study with antigen, histamine and methacholine inhalation challenge tests.

This paper presents a 7 year old girl with cough variant asthma, in which house dust challenge test provoked fine crackles on auscultation without any changes of lung function test. Pretreatment with DL-chlorpheniramine maleate for 7 days inhibited the appearance of fine crackles. On histamine inhalation test, fine crackles and rhonchi appeared on auscultation without bronchoconstriction (% fall of one-second forced expiratory volume < 10%). These data suggest that the cause of cough variant asthma is mainly an immunoglobulin E-mediated allergic reaction in the mucus secreting system.

Asthma↗
PubMed2004

Type I cerebral dural arteriovenous fistulas of the lateral sinus: clinical features in 24 patients.

To review the clinical and diagnostic characteristics of type I cerebral dural arteriovenous fistulas (CDAVF) of the lateral sinus medical records of 24 patients with Type I CDAVF were retrospectively reviewed. All patients were interviewed aiming at presenting symptoms, impact on daily functioning, diagnostic delay, relevant medical history and post-treatment status. Nineteen of 24 patients (79%) were women. The median age at the time of diagnosis was 56 years (range 32-69). Unilateral pulsatile tinnitus was the presenting symptom in all patients. A bruit could be heard at auscultation on the retroauricular skull in all patients. The median diagnostic delay was 17.9 months (range 1-120). Standardized magnetic resonance imaging (MRI) of the brain was normal in all patients. The diagnosis of CDAVF was confirmed on cerebral angiography. In conclusion, CDAVF type I of the lateral sinus occurs predominantly in middle aged women and presents with unilateral pulsatile tinnitus, which resulted in impairment of social and occupational functioning in the vast majority of patients. An audible bruit at retroauricular auscultation confirms the clinical diagnosis of a cerebral dural fistula. MRI is not helpful in the diagnosis and cerebral angiography is indicated to classify the dural fistula.

Adult↗
PubMed1994

Intermittent versus continuous electronic monitoring in labour: a randomised study.

OBJECTIVE: To compare the efficacy in detecting signs of fetal hypoxia in labour of intermittent (I-group) versus continuous (C-group) electronic fetal monitoring in women with low or moderate risk factors for fetal distress. DESIGN: A prospective, randomised study. SETTING: A tertiary referral centre. SUBJECTS: Four thousand and forty-four parturients at low risk for obstetric complications with a reactive fetal heart rate admission test at arrival in labour. During the study period (October 5 1989 to May 31 1991), 5647 women were delivered in the labour ward. Of these, 1178 women (20.9%) were excluded because of high risk factors in pregnancy or at admission for labour, including women undergoing elective caesarean section. Of the remaining 4469 women 4044 (90.5%) were randomised to either intermittent (n = 2015) or continuous monitoring (n = 2029) during the first stage of labour. METHODS: In the C-group the fetal heart rate was recorded continuously with electronic fetal monitoring during the first stage of labour. In the I-group the fetal heart rate was recorded with electronic fetal monitoring for 10 to 30 min every 2 to 2.5 h during the first stage of labour, and the fetal heart rate was auscultated every 15 to 30 min in between recording periods. If complications occurred, recording was changed to continuous. In the second stage of labour all the women were monitored continuously. Umbilical cord artery acid-base status was assessed at birth. MAIN OUTCOME MEASURES: Duration of electronic fetal monitoring, rates of abnormal fetal heart rate patterns, caesarean section for fetal distress, acidosis in umbilical cord arterial blood at birth, Apgar scores of less than 7 at 1 or 5 min, and referrals to the neonatal intensive care unit. RESULTS: There were no significant differences between the study groups in the incidence of ominous fetal heart rate recordings: 6.3% (I-group) versus 6.6% (C-group), or the interval from arrival to first detected abnormal fetal heart rate, although the number of suspicious fetal heart rate patterns was higher in the C-group (28.6%) than in the I-group (24.6%). In the I-group electronic fetal monitoring was performed for (median monitoring time) 38.8% of the first stage of labour as compared with 78.6% in the C-group. The incidence of caesarean section for fetal distress was similarly low in both groups: 1.2% versus 1.0%. There were no significant differences in the immediate neonatal outcome in terms of umbilical artery pH, Apgar scores, or admissions to the neonatal care unit. CONCLUSIONS: Intermittent use of electronic fetal monitoring at regular intervals (with stethoscopic auscultation in between) appears to be as safe as continuous electronic fetal monitoring in low risk labours.

Apgar Score↗
PubMed2003

Echocardiographic parameters in 14 healthy English Bull Terriers.

OBJECTIVE: To determine the range of various cardiac parameters using echocardiography in apparently normal, healthy English Bull Terriers. DESIGN: Fourteen English Bull Terriers were selected for study. Cardiac auscultation of the parents of these dogs was normal. Echocardiographic examination of one parent of each animal showed: no mitral or aortic valve abnormalities; no myocardial lesions; no two dimensional evidence of fixed or dynamic left ventricular outflow tract obstruction; and no systolic aortic or left ventricular outflow tract turbulence on colour flow Doppler examination. The 14 selected dogs did not have arrhythmias or murmurs, and on echocardiographic examination had similar findings to their parents. Systolic blood pressure was measured in all dogs and they had no clinical evidence of Bull Terrier polycystic kidney disease or Bull Terrier hereditary nephritis. PROCEDURE: All dogs were auscultated and subjected to a sequential global echocardiographic assessment of the heart, including two dimensional long and short axis, and colour flow Doppler interrogation of the mitral and aortic valves. Dimensional measurements, including those from the left atrium, aortic annulus and left ventricle, were taken from a right parasternal window, and derived values such as fractional shortening, stroke volume and left atrial to aortic annulus ratio were calculated. Peak systolic aortic velocity was measured from the left parasternal window using two dimensional-guided pulsed wave Doppler with angle correction. Systolic blood pressure was measured using a Doppler monitor. The absence of Bull Terrier polycystic kidney disease was determined using renal ultrasonography, and of Bull Terrier hereditary nephritis using urinary protein to creatinine ratio. RESULTS: These 14 dogs had greater left ventricular wall thickness and smaller aortic root diameters than those reported as normal for other breeds of comparable body size. Left atrial dimensions were also larger, however this may have been due to the "maximising" method of measurement. These apparently normal English Bull Terriers also had higher aortic velocities than those reported for other breeds, possibly due to a smaller aortic root diameter or other anatomic substrate of the left ventricular outflow tract, lower systemic vascular resistance, or breed-specific "normal" left ventricular hypertrophy. While these dogs were selected to be as close to normal as possible, the breed may have a particular anatomy that produces abnormal left ventricular echocardiographic parameters. CONCLUSION: These echocardiographic parameters may be used to diagnose left ventricular outflow tract obstruction and left ventricular hypertrophy, and inaccurate diagnoses may result if breed-specific values are not used.

Animals↗
PubMedDate not supplied

Heart sounds and murmurs: changes related to severity of chronic valvular disease in the Cavalier King Charles spaniel.

Auscultatory, phonocardiographic (PCG), radiographic, and echocardiographic evidence of chronic valvular disease (CVD) were studied in 79 Cavalier King Charles Spaniels with a mean age of 7.6 years (SD 2.6). Cardiac murmurs were present in 59 of the dogs and the intensity of the systolic cardiac murmur, assessed by auscultation (grade 1-6), was correlated (P < .001) to the severity of CVD (heart failure class) and to the echocardiographic dimensions of the heart (left atrial ratio, La/Ao-d, and left ventricular end diastolic diameter, LVEDD) (both P < .001). The heart sounds and duration of electromechanical systole (Q-S2) were investigated in all dogs using measurements obtained from PCG recordings. Normal regression equations describing the relation between heart rate and systolic intervals (Q-S1, Q-S2 and S1-S2) were established based on observations in 11 normal control Cavalier King Charles Spaniels. The total electromechanical systole (Q-S2), Q-S1, and S1-S2 intervals in the 59 dogs were related to the corresponding normal regression equation. A shortening of Q-S2 and S1-S2 intervals were found in dogs belonging to heart failure class I (Q-S2; P < .01 and S1-S2; P < .05), class II, and classes III and IV (both P < .001). The ratio of the amplitudes of the first (S1) and second heart sounds (S2) measured on the PCG recordings was found to be increased in dogs belonging to class I (P < .01), class II, and classes III and IV (both P < .001). The relationship between cardiac dimensions (LVEDD and La/Ao-d) and S1a/S2a ratio was described by quadratic regression and found to be significant for both parameters (LVEDD; P < .001, R2 = .54 and La/Ao-d; P < .001, R2 = .63). The presence of a third heart sound (S3) was detected, using PCG, in 21 of the 68 dogs. The proportion of dogs exhibiting S3 increased with heart failure class (and increasing cardiac dimensions) (P < .001). These findings were confirmed by observations in 13 Cavalier King Charles Spaniels with cardiac failure progressing from heart failure class I to class II (Mean LVEDD from 30.2 to 35.2 mm and mean La/Ao-d from 1.09 to 1.43). An increase in intensity of the heart murmur, assessed by auscultation, increase in the ratio of the amplitudes of S1 and S2, as well as a shortening in Q-S2 and S1-S2 intervals (all P < .01) were found in these dogs.(ABSTRACT TRUNCATED AT 400 WORDS)

Analysis of Variance↗
PubMed1984

Three cases of ruptured mitral valve chordae in the horse.

The paper describes clinical observations in three horses with ruptured mitral valve chordae. Horses with ruptured mitral valve chordae may have a history of sudden onset of acute distress with predominantly respiratory symptoms. On auscultation there will be a widespread pansystolic murmur with an extension of the area of cardiac auscultation. The third heart sound may be very pronounced and unduly prolonged, associated with high volume flow during early ventricular filling in diastole. However, these sounds are not specific for chordal rupture--they are typical of severe mitral regurgitation. The electrocardiogram may show predominantly backward spatial vectors during ventricular depolarisation. The condition gives rise to left ventricular volume overload and pulmonary hypertension would be expected in horses showing signs of cardiovascular disturbance or those recently affected. Care is necessary during post mortem examination to avoid cutting through the mitral valve before a proper assessment has been made of the chordal insertions.

Animals↗
PubMed1991

Clinical evaluation of poor performance in the racehorse: the results of 275 evaluations.

A clinical sports medicine evaluation was applied to 275 racehorses with a history of poor racing performance. The poor performance evaluation included a) general physical examination and basic laboratory screening; b) respiratory examination including auscultation, thoracic radiographs, ventilation-perfusion lung scintigraphy and upper airway endoscopy at rest and during maximal treadmill exercise c) examination of the musculoskeletal system including lameness examination, video gait analysis at high speed, post exercise serum chemistry to identify obvious as well as sub-clinical myopathies, high detail radiography and nuclear scintigraphy; d) cardiac examination including auscultation, electrocardiographic analysis during strenuous exercise and when indicated, echocardiography; and e) a standardised exercise stress test entailing the measurement of oxygen consumption, carbon dioxide production, venous blood lactate concentration and heart rate during sequentially increasing running speeds on the high speed treadmill. The choice of diagnostic methodologies utilised were tailored to each individual in order to determine most efficiently the abnormalities contributing to inadequate racing performance. The results of this clinical evaluation showed that 1) many of the diagnoses were subtle requiring the use of sophisticated diagnostic equipment including scintigraphy and dynamic evaluation of the horse exercising on the high speed treadmill and 2) 84 per cent of the horses were diagnosed as suffering from more than one problem leading to the supposition that inadequate athletic performance is often caused by a constellation of abnormalities requiring a comprehensive approach to diagnosing decreased athletic capability.

Animals↗
PubMed1990

Symptomatic carotid ischaemic events: safest and most cost effective way of selecting patients for angiography, before carotid endarterectomy.

OBJECTIVE: To determine the safest, least costly, and most effective way to select patients with symptomatic carotid ischaemic events for carotid angiography before carotid endarterectomy. DESIGN: Prospective cohort study. SETTING: University departments of clinical neurosciences and clinical neurology. PATIENTS: 485 Patients with carotid territory transient ischaemic attacks of the brain (n = 224) or eye (n = 162) or retinal infarction (n = 99) were referred to a single neurologist between 1976 and 1986. INTERVENTIONS: Clinical examination by auscultation over the precordium, supraclavicular fossae, and neck vessels (all patients). Cerebral angiography of patients suitable for carotid endarterectomy. MAIN OUTCOME MEASURES: Financial cost and number of disabling strokes after angiography. RESULTS: 296 Patients were investigated by cerebral angiography. Ischaemic symptoms had occurred in the distribution of 298 internal carotid arteries (symptomatic) that were imaged, two patients having bilateral symptoms. The presence or absence of a carotid bruit and the maximum percentage diameter stenosis of the origin of the symptomatic internal carotid artery were correlated. The prevalence of mild disease (diameter stenosis greater than or equal to 25%) of the symptomatic internal carotid artery was 57%, and if an ipsilateral carotid bruit was heard the probability of mild stenosis rose to 92%. The prevalence of moderate disease of the symptomatic internal carotid artery (stenosis greater than or equal to 50%) was 39%, and if a bruit was heard the probability doubled to 78%. The prevalence of severe internal carotid disease (stenosis greater than or equal to 75%) was 22%, and if a bruit was heard the probability was more than double, at 49%. The direct cost to both the NHS and the private health sector of investigating patients with symptomatic carotid ischaemia was estimated for several strategies of carotid artery imaging and expressed in terms of financial cost and number of strokes after angiography incurred in detecting all patients with diameter stenosis of the symptomatic internal carotid artery of greater than or equal to 25%, 50%, or 75%. To detect diameter stenosis of the internal carotid artery of greater than or equal to 25% it is most cost effective to proceed directly to cerebral angiography in patients with a carotid bruit over the symptomatic carotid bifurcation and to screen patients without a carotid bruit by duplex carotid ultrasonography; patients in whom duplex ultrasonography discloses stenosis of greater than or equal to 25% are then referred for cerebral angiography. To detect only more severe internal carotid disease (stenosis of greater than or equal to 50%) the same policy applies, unless the local duplex ultrasonographic service is particularly efficient and reliable, when it is probably most cost effective and safer to screen all patients by this method irrespective of the findings on cervical auscultation. To detect stenosis of 75% or greater it is most cost effective to screen all patients with duplex ultrasonography, whether a carotid bruit is present or not, because this approach reduces the number of angiograms required, is the least expensive, and results in the least number of strokes after angiography. CONCLUSIONS: Patients selection for cerebral angiography before carotid endarterectomy needs to be appropriate and cost effective. Sound clinical evaluation and duplex carotid ultrasound are required. The findings of this study should not be applied to other medical centres without first considering possible differences in the prevalence of carotid artery disease, the efficiency and reliability of duplex ultrasonography, the local complication rates of cerebral angiography, and the local costs of the imaging procedures.

Adult↗