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PubMed1999

Differences in the valuation of birth outcomes among pregnant women, mothers, and obstetricians.

BACKGROUND: Decisions are usually based on the perceived merits of alternative approaches. This process can be quantified by combining the probabilities of expected outcomes with their desirability. We studied differences in the valuation of birth outcomes among pregnant women, mothers, and obstetricians, and assessed how these would affect a particular obstetric decision. METHODS: In a study conducted at Leiden Hospital, Leiden, The Netherlands, 12 obstetricians, 15 pregnant women, and 15 mothers participated in a standard reference gamble to determine the value of 12 different outcomes: 3 types of birth combined with 4 states of infant outcome. These were then applied to an obstetric decision tree based on the Dublin trial of intermittent auscultation versus electronic intrapartum fetal heart rate monitoring. RESULTS: Contrary to obstetricians, women valued permanent neurologic handicap significantly higher than neonatal death (p < 0.01). Women expressed no overriding preferences for the type of birth, whereas obstetricians were clearly antipathetic to cesarean section. Within-group consistency was significantly higher for pregnant women and mothers than for obstetricians (p < 0.0001). However, application of the measured values to the obstetric decision tree merely led to marginal changes in overall expected value of the decision alternatives. CONCLUSIONS: Values attached to birth processes and outcomes differ significantly between (expectant) mothers and doctors. These differences should be recognized and respected in obstetric decision making.

Attitude of Health Personnel↗
PubMed1984

[Cardiac arrhythmias and their clinical significance in mitral valve prolapse].

Among 160 patients with mitral-valve prolapse but no other illness there were 118 with cardiac arrhythmias. 30 had frequent or multifocal ventricular premature systoles, 21 had coupled ventricular extrasystoles, and seven had ventricular tachycardia. In six patients the prematurity index was under 1. Supraventricular premature systoles were registered in 56 patients, with seven each having paroxysmal atrial tachycardia and paroxysmal atrial flutter or fibrillation. Ventricular arrhythmias were significantly more frequent in late-systolic prolapse and with positive auscultation findings (systolic click or systolic murmur). Long-term ECG monitoring was more valuable than an exercise ECG. About half the patients with frequent arrhythmias had palpitations and rapid heart action. Coupled ventricular premature systoles and ventricular tachycardias, as well as R-on-T were relatively rare; our findings thus tend to suggest a relatively favourable prognosis for these arrhythmias.

Adolescent↗
PubMed1985

Continuous-wave Doppler in the intraoperative assessment of carotid endarterectomy.

A sterile 8.5 MHz continuous-wave Doppler probe was used intraoperatively to evaluate the technical result of 229 consecutive carotid endarterectomies. Primary areas of evaluation included the proximal point of plaque transection and the internal and external carotid arteries at and distal to the termination of the endarterectomy. Subjective interpretation was made of the Doppler audio signal. Signs associated with inadequate technical results were a high-frequency signal indicative of luminal narrowing with a reduction in frequency distal to the area of stenosis, absence of a Doppler signal indicating occlusion, and a weak monophasic flow signal indicating poor distal perfusion. Abnormal signals were identified in 10 internal carotid arteries (4.3%) which prompted intraoperative angiography in eight and immediate reopening of the artery in an additional two. Significant lesions were identified in seven arteries (70%). Twenty external carotid lesions (8.7%) were detected by Doppler and in 19 cases (95%) a significant stenosis or obstruction was found when the vessel was reopened. Auscultation of a continuous-wave Doppler signal with a sterile probe at operation appears to have a high positive predictive value in the identification of both internal and external carotid stenoses. It is rapid, safe, relatively inexpensive, and avoids the problems associated with routine intraoperative angiography.

Auscultation↗
PubMed1982

Evaluation of heart sounds and murmurs in children.

Auscultation is the core of pediatric cardiovascular evaluation and should be performed according to a routine. The four heart sounds should be sought in order at their usual locations, with particular attention to the second sound because of its important diagnostic role in congenital cyanotic heart disease. The next sounds to listen for are clicks, which can be systolic, pulmonary, aortic, or midsystolic. Finally, murmurs should be sought in systole and then diastole. Besides being identified as systolic, diastolic, or continuous, murmurs should be characterized according to their relationship with the first and second heart sounds, intensity, frequency, and maximum location and radiation.

Adolescent↗
PubMed1982

Differential diagnosis of heart murmurs in children.

When a heart murmur turns up on routine examination of an otherwise health child, a thorough cardiovascular evaluation should be carried out according to the guidelines presented in the first two articles in this series (June, page 235, and July, page 151). The information gained by inspection, palpation, and auscultation is then coordinated and analyzed to arrive at the most likely diagnosis, as described in this concluding presentation.

Aortic Coarctation↗
PubMed1985

Correlation of a disease scoring system with arterial PO2 values in respiratory syncytial virus infection in calves.

The mean arterial PO2 value measured in blood obtained by puncture of the brachial artery of 20 calves with acute clinical signs of a bovine respiratory syncytial virus (BRSV) infection was 8.4 +/- 1.9 kPa. The values differed significantly from arterial PO2 values of eleven healthy calves (mean 14.2 +/- 1.5 kPa). A disease scoring system is presented based on the type of respiration and the findings on auscultation. A high correlation (r = -0.87) was found between disease scores and arterial PO2 values. This indicates that the described disease scoring system can be a useful tool in the evaluation of the severity and course of BRSV infections in calves, and could be used for evaluating the efficacy of BRSV vaccines in the field. The course of disease was studied in 127 calves with clinical signs of serologically proven BRSV infection. Animals with mild respiratory signs during the acute phase of disease remained free of severe respiratory problems until the end of a 35-day examination period. Mean disease scores indicated that animals with severe signs in the acute phase often developed persistent respiratory problems.

Animals↗
PubMed1999

Cardiac involvement in Sydenham's chorea: clinical and Doppler echocardiographic findings.

Sydenham's chorea is often encountered in pure form, but it may also occur in association with carditis. Recently, it has been reported that silent, mild valvular regurgitation has been encountered in patients with rheumatic fever manifested by isolated polyarthritis and pure chorea. We studied 22 children with Sydenham's chorea to determine clinical and subclinical heart involvement at the time of the initial diagnosis. Ages of the patients ranged from 6-19 y (mean 13.14+/-3.0), and the female/male ratio was 3.4:1. All patients were evaluated by clinical and echocardiographic examination with respect to heart involvement. Carditis was detected in only 5 of 22 patients (23%) by auscultation. Clinical valvular involvement was determined: mitral regurgitation in three and combined mitral and aortic regurgitation in two. The frequency of valvular involvement increased significantly to 63% 2(14/22) after adding silent mitral regurgitation detected by colour Doppler echocardiography (chi2=7.50, p=0.0062). We found that clinically inaudible, but echocardiographically significant, mild valvular regurgitation was frequent in patients with pure chorea. It is concluded that colour Doppler echocardiography may be useful in detecting silent valvular regurgitation and in deciding the duration of prophylaxis.

Adolescent↗
PubMed1991

Correlation between Korotkoff's sounds and ultrasonics of the brachial artery in healthy and normotensive subjects.

The clinical measurement of blood pressure is generally obtained by auscultation for Korotkoff's sounds over the brachial artery using a sphygmomanometer and cuff. Real-time two dimensional ultrasound and Doppler techniques were used to study the brachial artery movements and blood flow patterns during these pressure measurements. Simultaneous recordings of Korotkoff's sounds were obtained. A strong correlation in time was demonstrated between Korotkoff's five phases, brachial artery wall movements and specific blood flow patterns. The evidence largely supports what to date has been speculation as to the origin of Korotkoff's sounds in that Korotkoff's phases 1 and 3 appear to be produced by vigorous arterial wall motion and phase 5 by cessation of this movement. Phase 2 is produced by blood flow disturbance. Furthermore, the lack of correlation between phase 4 and any specific vascular event may go some way to explaining why in clinical practice phase 5 readings are now preferred for diastolic pressure.

Adult↗
PubMed1999

Comparison of four methods for assessing airway sealing pressure with the laryngeal mask airway in adult patients.

We have compared four tests for assessing airway sealing pressure with the laryngeal mask airway (LMA) to test the hypothesis that airway sealing pressure and inter-observer reliability differ between tests. We studied 80 paralysed, anaesthetized adult patients. Four different airway sealing pressure tests were performed in random order on each patient by two observers blinded to each other's measurements: test 1 involved detection of an audible noise; test 2 was detection of end-tidal carbon dioxide in the oral cavity; test 3 was observation of the aneroid manometer dial as the pressure increased to note the airway pressure at which the dial reached stability; and test 4 was detection of an audible noise by neck auscultation. Mean airway sealing pressure ranged from 19.5 to 21.3 cm H2O and intra-class correlation coefficient was 0.95-0.99. Inter-observer reliability of all tests was classed as excellent. The manometric stability test had a higher mean airway sealing pressure (P < 0.0001) and better inter-observer reliability (P < 0.0001) compared with the three other tests. We conclude that for clinical purposes all four tests are excellent, but that the manometric stability test may be more appropriate for researchers comparing airway sealing pressures.

Adolescent↗
PubMed1987

Diagnosis and quantification of aortic regurgitation by pulsed Doppler echocardiography in patients with mitral valve disease.

UNLABELLED: To test the ability of pulsed Doppler echocardiography (PDE) to detect and quantify aortic regurgitation (AR), 55 consecutive patients (14-74 years) with aortic and mitral valve disease were examined clinically and by echocardiography before cardiac catheterisation. The severity of AR was determined angiographically (I-IV) and compared to the extent of the regurgitant jet in the left ventricle measured by PDE. In 13 of 55 patients (3 with mitral stenosis, 3 with mitral incompetence, 3 with combined mitral lesions, 3 with aortic stenosis, one with aortic and mitral stenosis) neither angiography nor PDE showed AR (specificity 100%). Apart from 3 patients with poor echo quality PDE correctly detected AR in 39 of 42 patients (sensitivity 93%). Clinical examination (62%), mode M.mode (62%) and both methods combined (81%) were significantly less sensitive than PDE, especially in mild AR (P less than 0.008). The PDE degree of AR closely correlated with angiography (corrected contingency coefficient 0.91). Differentiation between AR III and IV was not possible. Mitral valve disease did not affect quantification of AR (n = 20 patients). CONCLUSIONS: Pulsed Doppler echocardiography is better than auscultation and M-mode echocardiography in the diagnosis of aortic regurgitation, especially in grades I and II. PDE can reliably discriminate between three degrees of aortic regurgitation (I-III). Mitral valve disease does not affect quantification of aortic regurgitation by PDE.

Adolescent↗
PubMed1999

Endobronchial intubation causes an immediate increase in peak inflation pressure in pediatric patients.

UNLABELLED: Our purpose was to determine whether endobronchial intubation always causes an immediate increase in peak inflation pressure and, if so, the magnitude of the increase. Fourteen children scheduled for central line placement for prolonged antibiotic administration comprised the study group. After routine premedication and induction of anesthesia (halothane in oxygen), an endotracheal tube was inserted, and its position was verified by auscultation and fluoroscopy. Children were mechanically ventilated using a preset volume pressure-limited ventilator with a 5-L fresh gas flow. All children received a constant tidal volume using a similar circuit, similar tubing, and a similar compression volume. The lowest peak inflation pressure to deliver a tidal volume of 15 mL/kg was used. After adjusting the respiratory rate (end-tidal CO2 30 mm Hg) and anesthetic level (halothane end-tidal 1.2%), the peak inflation pressure at this endotracheal position was recorded. The endotracheal tube was advanced into a bronchus, the position was verified as above, and peak inflation pressure was recorded. The endobronchial tube was then pulled back into the trachea, and placement of the central line proceeded. The peak inflation pressure at the endobronchial position was significantly greater than the peak inflation pressure at the endotracheal position (P < 0.0001). The increase was instantaneous at the endobronchial position. Monitoring peak inflation pressure while inserting an endotracheal tube and during anesthesia can help to diagnose endobronchial intubation. IMPLICATIONS: Monitoring peak inflation pressure while inserting an endotracheal tube and during anesthesia can help to diagnose endobronchial intubation.

Anesthetics, Inhalation↗
PubMed2000

Radioisotope bone scanning in pulmonary alveolar microlithiasis.

A 30-year-old woman was examined for a history of exertional breathlessness, swelling of her feet, and a mild dry cough of 4 to 5 months' duration. Her symptoms developed during the last month of her pregnancy, with gradually increasing dyspnea, swelling of the feet, and reduced urinary output. There was no history of expectoration, hemoptysis, chest pain, or tuberculosis. General physical examination showed no evidence of clubbing of the nails or lymphadenopathy. Chest auscultation revealed a few end-inspiratory crepitations at both lung bases. Bronchial alveolar lavage showed calcium particles, whereas results of the transbronchial lung biopsy were consistent with alveolar microlithiasis.

Adult↗
PubMed1984

Biases in the measurement of arterial pressure.

We compared cuff to simultaneous direct intra-arterial pressure in 26 seriously ill patients, in order to: test the accuracy of oscillometric and auscultatory estimates of direct systolic pressure; test muffling and disappearance of sound as indices of direct diastolic pressure; gain insight into the timing of the different phases of Korotkoff sounds; and assess the local and general effects of cuff inflation on blood pressure. We found that conventional estimation of systolic blood pressure by auscultation of the first Korotkoff sound (K1) underestimates direct systolic pressure by an average of 16 to 17 mm Hg. Oscillometric pressure measurement provides a significantly better estimate than K1 but still underestimates by 7 to 8 mm Hg. These systolic cuff measurements are biased downward from direct values because of local cuff effect and cuff error. Diastolic cuff measurements deviate from direct values primarily because of a local cuff effect which produces an upward bias of 5 mm Hg at the point of sound muffling (K4), and 3 mm Hg at the point where sounds disappear (K5). We recommend oscillometric measurement of systolic pressure and K5 measurement of diastolic pressure as the best indirect estimates of blood pressure in critically ill patients.

Aged↗
PubMedDate not supplied

Should women be given a choice about fetal assessment in labor?

Continuous electronic fetal monitoring (EFM) in labor is one of the most commonly used interventions during intrapartum care. However, randomized controlled trials, observational studies, and meta-analyses about the use of continuous EFM on low-risk intrapartum patients have found no significant differences in infant outcomes between infants whose mothers had EFM or intermittent auscultation (IA) of the fetal heart rate. In addition, research shows a higher incidence of cesarean birth when EFM is used. Although evidence-based practice is supposed to be our goal, the evidence about the lack of efficacy of EFM has not been used in practice. In fact, EFM has become the standard of practice in this country. Considering these facts, should EFM continue to be the standard of practice for low-risk laboring women? Is informed consent indicated, giving women the choice between EFM and IA? Should IA be offered to all low-risk laboring women? Ethical decision-making models are used to examine those questions and to help nurses better delineate their advocacy role.

Auscultation↗
PubMed1996

Ambient noise interferes with auscultatory blood pressure measurement during exercise.

This study was designed to investigate whether the acoustical characteristics of the Korotkoff sounds (K-sounds) were altered during exercise and/or masked by the ambient noise. After signing informed consent, 11 subjects (8 females, 3 males; 27 +/- 2 yr; 166.2 +/- 3.2 cm; 62 +/- 5 kg; means +/- SD) underwent a cycle ergometer exercise test that increased in workload by 30 W every 3 min until volitional fatigue. Heart rate, auscultatory systolic (SBP) and diastolic blood pressure (DBP), and oxygen consumption were monitored 1 and 2 min into each work stage. The auscultatory K-sounds were recorded with a microphone mounted in a stethoscope tube for later frequency (Hz) and sound pressure level (dB SPL) analysis. Frequency and SPL of ambient noise (99 +/- 13 Hz and 64 +/- 1 db at maximum, respectively) increased during the exercise test to magnitudes similar to the SBP and DBP K-sounds (166 Hz, 66 db; and 128 Hz, 69 db, respectively). Additionally, the ambient noise was responsible for a significant damping of the frequency and SPL of the measured blood pressure K-sounds and a rise in the measured frequency of the SBP K-sounds. Furthermore, we observed "inaudible" K-sounds at lower frequencies than adjoining audible K-sounds (100 Hz vs 126 Hz), supporting the known underestimation of SBP by auscultation. The increase in ambient noise during exercise testing dampens and may mask the auscultatory K-sounds, thus making detection of the proper K-sounds during exercise difficult at best. Furthermore, the presence of inaudible K-sounds may further explain the published discrepancies between auscultatory and intraarterial blood pressure measurements during exercise.

Acoustics↗
PubMed1983

Signs and symptoms of stroke and impending stroke in a series of optometric patients.

A sample of 1000 consecutively attending patients aged 50 years or more yielded 126 (12.6%) subjects having completed stroke or presenting with signs or symptoms indicating risk of stroke. The findings included 82 patients who had experienced transient ischemic attacks, 61 with cervical bruit, 24 with retinal signs of vascular insufficiency, and 26 who had suffered a completed stroke. The high incidence of stroke and the common occurrence of prodromal signs and symptoms of impending stroke justifies the inclusion of cervical auscultation and an extended history taking in the optometric examination. It is suggested that these procedures should be carried out on diabetic or hypertensive patients and all patients aged 50 years or older. Patients identified as being at risk of stroke should be referred for medical management.

Aged↗
PubMed1995

Respiratory rate and signs in roentgenographically confirmed pneumonia among children in China.

A clinical study was conducted in three Chinese community hospitals to investigate the reliability of respiratory rate and various clinical signs in the diagnosis of pneumonia among 54 children less than 5 years of age. Anteroposterior chest film was used as the diagnostic standard. The cutoff criterion for rapid breathing was 50 breaths/minute for infants ages 2 to 11 months and 40/minute in children 1 to 5 years old. Rapid breathing was a better predictor of pneumonia than rales (positive predictive values of 74.5 and 66.9%). Nasal flaring, chest indrawing, stridor and cyanosis of the tongue had predictive values of > 86%, but these clinical signs were observed in only a small proportion of patients. We recommend that village health workers use rapid breathing for diagnosis of pneumonia, rather than auscultation which is difficult and has proved unreliable. Sensitivity, specificity and positive and negative predictive values are presented for seven signs and symptoms of pneumonia.

Auscultation↗
PubMed1982

Noninvasive studies of the carotid bifurcation.

The accuracy of the noninvasive carotid system studies done in our laboratory during an 18-month period were reviewed. The usefulness of these procedures was found to be limited when used as a "blind" screen for extracranial vascular disease. The overall correlation with angiography was good, with few false-negatives and an accuracy rate of 86%. A comparison with cervical auscultation showed high false-positive rates for both methods.

Angiography↗