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PubMed2001

Measurement of blood pressure at home: survey among pediatric nephrologists.

Recently, an international consensus paper was published for standardization of home self-blood pressure (BP) measurement in adults. However, few data exist regarding home BP measurement in children, although it is recommended for all pediatric patients on renal replacement therapy in Germany. Therefore, a survey was performed among German-speaking pediatric nephrologists (members of the Arbeitsgemeinschaft Pädiatrische Nephrologie) in order to study their opinions about home blood pressure measurements. Approximately 75% of German pediatric nephrology centers responded to the survey. More than 70% of the interviewees prescribed a blood pressure device for all children with renal diseases and hypertension or on renal replacement therapy. For children with antihypertensive medication, 2.8 daily measurements were recommended at mean and 2.2 measurements for children without therapy. Auscultation of Korotkoff sounds and oscillometric BP measurements were used in the same percentage for home BP recordings. The upper cut of level for home blood pressure values was rated by the pediatric nephrologists and compared to reference values of casual blood pressure. There was good agreement for upper systolic BP, but as many as 40 to 50% of the interviewees accepted upper diastolic BP values higher than the 97th percentile for casual BP. Home BP measurement was judged to be more important than office BP measurement by 64% of the nephrologists and less important than 24 h ambulatory blood pressure monitoring by 67%. The results of the survey showed wide discrepancies for standards of home BP measurement in children and adolescents, especially for the recommendations for upper diastolic BP. Before home blood pressure measurements can be recommended unrestrictedly in children and adolescents, we stress the need for standardization of blood pressure devices and measurement. Prospective studies in children are needed to demonstrate that these standards facilitate better prediction of cardiovascular outcome using home BP measurements compared to office BP recordings in children.

Blood Pressure↗
PubMed2003

Post-traumatic arteriovenous fistula presented with hypertrophic palmaris digitalis II.

A 19-year-old female was admitted to our department because of a hypertrophic palmaris digitalis II of the left hand displaying color changes. A thrill was easily palpated over the medial part of the finger. A review of her history revealed that this hypertrophy occurred after a blunt trauma to the left hand. Angiography showed arteriovenous fistulas between the digital branches of the radial and ulnar arteries and cephalic vein at the palmaris digitalis II of the left hand. These arteriovenous connections were closed with simple ligation under regional anesthesia. Post-operatively she had no sign of ischemia, and no thrill was palpated or auscultated.

Adult↗
PubMed2003

Aetiology and clinical presentation of mild community-acquired bacterial pneumonia.

A prospective study was initiated to analyse the bacterial aetiology and clinical picture of mild community-acquired pneumonia in Slovenia using the previously described Pneumonia Severity Index. Radiographically confirmed cases of pneumonia in patients treated with oral antibiotics in seven study centres were included. An aetiological diagnosis was attempted using culture of blood and sputum, urinary antigen testing for Streptococcus pneumoniae and Legionella pneumophila, and antibody testing for Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila in paired serum samples. One hundred thirteen patients were evaluable for clinical presentation and 109 for aetiological diagnosis. At least one pathogen was detected in 62.4% patients. The most common causative agents were Mycoplasma pneumoniae in 24.8%, Chlamydia pneumoniae in 21.1%, and Streptococcus pneumoniae in 13.8% of patients. Dual infection was detected in 8.3% of patients. Most patients suffered from cough, fatigue, and fever. Patients with atypical aetiology of pneumonia differed from those with typical bacterial pneumonia or pneumonia of unknown aetiology in age, presence of dyspnea, and bronchial breathing on lung auscultation. Patients with pneumococcal, chlamydial, and mycoplasmal infections differed in age, risk class, presence of dyspnea, bronchial breathing, and proteinuria. There was an overlap of other clinical symptoms, underlying conditions, and laboratory and radiographic findings among the groups of patients classified by aetiology. Since patients with mild community-acquired pneumonia exhibit similar clinical characteristics and, moreover, since a substantial proportion of cases are attributable to atypical bacteria, broad-spectrum antibiotic treatment seems to be recommended.

Adult↗
PubMed2006

Current diagnosis and treatment of temporal arteritis.

Corticosteroid treatment should start directly after suspected diagnosis. The diagnosis should be confirmed within the next 5 days by histology or ultrasound. Clinical assessment includes auscultation of the axillary arteries in the search for large-vessel giant cell arteritis. Angiography, magnetic resonance angiography, positron emission tomography, or ultrasound can confirm the diagnosis of large-vessel giant cell arteritis. The initial prednisolone dose is 40 to 70 mg/d. It should be reduced in weekly steps of 5 to 10 mg until 20 mg/d, and by 2.5 mg until 10 mg/d. Dose reduction is 1 mg/mo below 10 mg/d, depending on symptoms and erythrocyte sedimentation rate or C-reactive protein. Patients with ophthalmologic complications receive three to four daily infusions of 250 mg of methylprednisolone for 3 days. Low-dose aspirin reduces the risk of ophthalmologic and cardiovascular complications. The benefit of methotrexate as a corticosteroid-sparing agent is controversial. Corticosteroid treatment requires monitoring of glucose, blood and eye pressure, and adequate prevention of osteoporosis.

Journal Article↗
PubMed2001

Hospitalization decision for ambulatory patients with community-acquired pneumonia: a prospective study with general practitioners in France.

BACKGROUND: We designed a prospective study in the Puy-de-Dĵme region of France to identify factors associated with a hospitalization decision by general practitioners (GPs) for patients with community-acquired pneumonia (CAP). PATIENTS AND METHODS: 95 voluntary GPs were recruited to report over the period (February 1993 to March 1994) patients diagnosed with CAP defined as acute onset of fever associated with focal pulmonary crackles and/or radiological changes consistent with a pulmonary infection in patients over 3 years of age, living in the community. RESULTS: 37 of the 175 CAP patients (21.4%) were hospitalized. Univariate analysis showed that the hospitalization decision was related to age > 65 years, retirement, history of cardiovascular disease, other extrapulmonary chronic disease, chest auscultation findings, tachypnea at rest and altered mental status. Multivariate analysis identified four variables associated with hospitalization: living alone at home (OR = 3.75), history of cardiovascular disease (OR = 2.54), other chronic medical conditions excluding pulmonary diseases (OR = 4.28) and tachypnea at rest (OR = 3.33). The hospitalization decision by GPs for patients with CAP takes into account social conditions, co-morbid conditions of the patients and the seventy of CAP.

Adolescent↗
PubMed1991

Factors associated with atrial fibrillation in Q wave anterior myocardial infarction.

To elucidate the role of inflammatory and hemodynamic factors in the genesis of atrial fibrillation in acute myocardial infarction, 228 patients with a first Q wave anterior myocardial infarction were studied. Forty-nine patients had pericarditis (detection of pericardial rub by careful auscultation), and 36 patients had echocardiographically demonstrated hydropericardium (presence of pericardial effusion without pericardial rub). During the first 3 days after admission, transient episodes of atrial fibrillation were observed in 10 patients (20%) with pericarditis (group 1), 15 patients (42%) with hydropericardium (group 2), and 20 patients (14%) without pericarditis and hydropericardium (group 3). Although there was no significant difference in the incidence of atrial fibrillation between groups 1 and 3, patients in group 2 had a significantly higher incidence of atrial fibrillation than those in groups 1 and 3. Pulmonary capillary wedge pressure and the number of advanced asynergic segments were found to be the important factors discriminating the three groups by multivariate analysis. Therefore atrial fibrillation after acute Q wave anterior infarction was not related to the inflammatory infiltration involving the atria but to the increase in atrial pressure resulting from hemodynamic change caused by more extensive myocardial damage.

Atrial Fibrillation↗
PubMed1992

Prolonged QT interval in neonates: benign, transient, or prolonged risk of sudden death.

To determine the factors relating to prognosis, the records of 15 neonates with persistent prolongation of the QT interval on the electrocardiogram after the fourth day of life were reviewed. Patients were admitted for symptoms (syncope, cardiac failure, or seizures), abnormal auscultation with an irregular heart rate or bradycardia, or because of a family history of a long QT syndrome. All infants had a long QTc, ranging from 0.46 to more than 0.70 second. Eight patients who had a QTc over 0.60 second developed severe ventricular arrhythmias (torsades de pointes, ventricular tachycardia) or second-degree AV block. Twelve of 15 were treated with beta-blocking agents, combined with ventricular pacing in five cases. Four infants died in the first month of life; they all had a very long QT interval and had experienced ventricular arrhythmias and AV block. Six children are still being treated with beta-blocking agents for the long QT syndrome and are doing well. In five infants, electrocardiographic abnormalities were transient and the QT interval returned to normal within 1 year. Therefore (1) prolongation of the QT interval in neonates may be transient or may represent an early form of the long QT syndrome and (2) the length of the QT interval may provide data on prognosis: those with a QTc less than 0.50 second returned to normal; those with a QTc greater than 0.60 second were associated with severe arrhythmias and four of eight infants died.

Adrenergic beta-Antagonists↗
PubMed1994

International experience with secundum atrial septal defect occlusion by the buttoned device.

Several devices are available for transcatheter occlusion of atrial septal defect. This report describes the international experience with the buttoned device. During a 4.5-year period ending in February 1993, 180 transcatheter atrial septal defect occlusions were performed with the buttoned device. Patient age varied between 0.6 and 76 years and stretched atrial defect diameter between 5 and 25 mm. The defects were closed with 25 to 50 mm devices delivered through 8F (148 patients) or 9F (32 patients) sheaths. Twelve patients were adults whose defects were closed to prevent recurrence of cerebrovascular accidents caused by presumed paradoxic embolism. In the remaining patients the atrial defect was closed to treat the left-to-right shunt. The atrial septal defects were effectively occluded as demonstrated by (1) decrease in pulmonary-to-systemic flow ratio from 2.1 +/- 0.6 (mean +/- SD) to 1.05 +/- 0.1 (p < 0.01) by oximetry; (2) normalized S2 and disappearance of the diastolic murmur by auscultation; and (3) improvement in right ventricular volume overloading by echocardiogram. However, trivial to small shunts could be detected by color Doppler studies in 76 (45%) of 168 patients in whom such data are available. Complications included unbuttoning in 13 and whole-device embolization in 1. All patients remained stable, and retrieval of the device and surgical closure of the atrial septal defect were accomplished in 10 patients. Transcatheter retrieval was used in the remaining 4 patients. The incidence of unbuttoning, a major complication of the procedure, appeared to decrease with the increasing experience of the investigators and with device modification (third-generation). The follow-up duration varied between 1 month and 4 years. Six patients required surgery during the follow-up period. In the remaining patients (n = 160), clinical examination did not reveal signs of atrial shunts. Color Doppler studies revealed either complete disappearance of the previously demonstrated shunts or further diminution of their size. The results indicate that transcatheter occlusion of the atrial septal defects with buttoned devices is feasible, relatively safe, and effective, and it appears to be a viable alternative to surgery for some patients with secundum atrial septal defect. Complications are infrequent and should improve with experience.

Cardiac Catheterization↗
PubMed1995

Anatomic explanation of mobile systolic clicks: implications for the clinical and echocardiographic diagnosis of mitral valve prolapse.

An echocardiogram (echo) is often ordered for suspected mitral valve prolapse (MVP). Using echo as the gold standard, we conducted a meticulous physical examination on 61 patients with this referral diagnosis. Ninety percent of patients with negative physical examination and echo results for MVP had physical examination findings likely to have been misinterpreted as MVP by the referring physician. Redundant portions of the mitral valve apparatus were found in 57% of patients with MVP on our physical examination but not on echo. A carefully performed physical examination (including dynamic auscultation) can exclude MVP. Not all mobile systolic clicks are associated with anatomic echo prolapse; they can be generated by redundant chordae tendineae and, in the absence of echo prolapse, probably by redundant leaflets. Patients with mobile systolic clicks should have an echo to determine the portion of the spectrum of echo prolapse present and to determine risk stratification and management.

Adult↗
PubMed1979

Right ventricular infarction. Clinical diagnosis and differentiation from cardiac tamponade and pericardial constriction.

Twelve patients with a clinical diagnosis of right ventricular infarction are described. All had acute inferior wall myocardial infarction associated with the bedside findings of jugular venous distension, clear lungs on auscultation, and arterial hypotension. Hemodynamically, there was elevation of right-sided filling pressures not explained by normal or minimally elevated pulmonary wedge pressures. Four patients had an incorrect diagnosis of acute cardiac tamponade. However, a review of the data showed that the hemodynamic features of right ventricular infarction more closely resemble those of pericardial constriction, a point that may be helpful in distinguishing right ventricular infarction from cardiac tamponade. Invasive and noninvasive techniques that exclude the presence of pericardial fluid and suggest enlargement and abnormal contractility of the right ventricle were helpful in establishing the diagnosis of right ventricular infarction in several patients.

Aged↗
PubMed1983

Noninvasive diagnosis of persistent fetal circulation versus congenital cardiovascular defects.

Congenital cardiovascular anomalies associated with right-left atrial or ductal shunts must be excluded before a diagnosis of persistent fetal circulation (PFC) can be made. Despite the advent of 2-dimensional echocardiography (2-D echo), this differentiation can be difficult and may require cardiac catheterization with selective angiography. Fifteen consecutive cases were analyzed in which difficulty was encountered with this differential diagnosis, and experience with the use of cardiac auscultation, the 12-lead electrocardiogram (ECG), arterial blood gas determinations and 2-D echo, both alone and with injection of venous contrast material, is reviewed. Electrocardiographic abnormalities of ventricular axis, hypertrophy or dominance (p = 0.002) and suspicion of cardiovascular disease on 2-D echo (p = 0.011) were the most useful findings in differentiating patients with PFC from those with congenital cardiovascular abnormalities. The ECG was the most sensitive test (100% sensitivity, 90% specificity), while 2-D echo was the most specific (100% specificity, 75% sensitivity). Evidence of right-left shunting at atrial or ductal levels or both did not differentiate between the groups; both groups had evidence of such shunts. A decision tree was developed to facilitate this differential diagnosis, which uses the ECG and 2-D echo. If the ECG reveals no abnormalities of ventricular axis, dominance or hypertrophy, the 2-D echo shows no structural abnormalities, and total anomalous pulmonary venous return and coarctation/interruption of the aorta are specifically excluded, a congenital cardiovascular anomaly is effectively eliminated. We suggest that this approach can optimize the management of the cyanotic newborn with suspected PFC by eliminating the risks of cardiac catheterization and angiography without missing the diagnosis of a major structural cardiovascular anomaly.

Diagnosis, Differential↗
PubMed1987

Usefulness of electromagnetic flowmetry in intraoperative evaluation of aortic regurgitation associated with ventricular septal defect.

In 38 patients with aortic regurgitation (AR) associated with ventricular septal defect (VSD), indications for aortic valvuloplasty (AVP) or aortic valve replacement (AVR) were investigated by assessing AR ratio, which was measured by electromagnetic flowmetry of the ascending aorta during the operation. Residual AR was evaluated by auscultation postoperatively. Patients were assigned to group A if they underwent VSD closure alone and to group B if they underwent AVP in addition to VSD closure; patients who had no postoperative AR were assigned to group I and those with persistence of AR to group II. Thus, the patients were separated into 4 subgroups; A-I (9 patients), A-II (5 patients), B-I (20 patients) and B-II (4 patients). In subgroup A-I, mean AR ratio decreased from 9% to 7% postoperatively, in A-II from 19% to 16% (p less than 0.1), in B-I from 36% to 9% (p less than 0.01) and in B-II from 44% to 20% (p less than 0.05). An AR ratio of more than 25% should be regarded as an absolute indication for AVP or AVR. If the AR ratio is between 20 and 25%, the indication of AVP is determined by inspection of the aortic valve. A good correlation was found between AR ratio and the AR rate determined by the aortic angiographic findings (Sellers classification): grade I AR corresponded to an AR ratio of 5 to 15%, grade II to 20 to 35%, grade III to 25 to 50% and grade IV to 45% or higher (r = 0.87, p less than 0.01).

Aortic Valve↗
PubMed1988

Effect of mitral regurgitation on diastolic filling with left ventricular hypertrophy.

Earlier studies have suggested that mitral regurgitation (MR) augments early left ventricular (LV) diastolic filling. To determine whether MR affects early diastolic filling in patients with abnormal diastolic filling, transmitral pulsed-wave Doppler recordings were used to study 32 normal subjects, 21 patients with LV hypertrophy, 23 with LV hypertrophy and MR and 15 patients with MR. Patients with MR had increased peak early filling velocities (MR 108 +/- 27 cm/s, normal 80 +/- 16 cm/s, p less than 0.01), peak atrial filling velocities (MR 72 +/- 18 cm/s, normal 55 +/- 12 cm/s, p less than 0.05) and increased deceleration rates (MR 5.0 +/- 1.9 m/s2, normal 3.5 +/- 1.2 m/s2, p less than 0.05). Patients with LV hypertrophy had reduced peak early filling velocities (69 +/- 14 cm/s, p less than 0.05) and increased peak atrial filling velocities (83 +/- 16 cm/s, p less than 0.001). There was also an increase in the atrial filling fraction and reduction in the rapid filling fraction as compared with normal patients. Patients with LV hypertrophy and MR had increased peak early filling velocities (98 +/- 26 cm/s, p less than 0.01 vs normal, p less than 0.001 vs LV hypertrophy patients), increased atrial filling velocities (84 +/- 27 cm/s, p less than 0.001 vs normal), increased deceleration rates (4.4 +/- 2.4 m/s2, p less than 0.05 vs normal) and a normal distribution of diastolic filling. Within the LV hypertrophy and MR group, diastolic filling parameters were similar when patients were subgrouped on the basis of auscultability of MR. MR augments early diastolic filling and may tend to normalize diastolic filling patterns in LV hypertrophy patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiomegaly↗
PubMed1990

Comparison of direct and indirect measures of systemic arterial pressure during weightlifting in coronary artery disease.

Based on auscultation measurements after exercise, circuit weight training in cardiac patients has been reported to provoke minimal increases in systolic pressure. Direct (brachial artery catheter) and indirect (sphygmomanometry) measures of blood pressure were compared at rest, during lifting with the legs (approximately the fourth, ninth and fourteenth repetition) and during 2 minutes of recovery after lifting with the arms and legs. Subjects performed 15 repetitions of single-arm curl, single-arm military press and single- and double-leg press exercises at 40 and 60% of the maximum load that could be lifted once on a multistation weightlifting apparatus. Indirect measures of systolic pressure at rest were 13% less than those recorded directly (130 +/- 7 vs 149 +/- 8 torr; p less than 0.01); diastolic pressures were similar using either method. This pattern was maintained during lifting with the legs at both intensities, and after exercise with both the legs and the arms. The mean systolic pressure recorded indirectly immediately after exercise was 63 torr (31%) and 76 torr (34%) less than the average peak intraarterial value recorded during leg and arm exercises, respectively. The highest intraarterial pressures were generated during the final repetitions of the set; immediately after the last repetition, both systolic and diastolic pressures rapidly decreased. It is concluded that indirect estimates of systolic pressure are significantly less than true arterial values at rest, and during and after lifting. Moreover, indirect measurements after lifting do not allow accurate conclusions to be drawn about the arterial pressures generated during lifting because of the rapid decrease in pressure that occurs after exercise.

Blood Pressure↗
PubMed1990

Prognostic significance of mitral regurgitation in acute myocardial infarction. The MILIS Study Group.

To define the frequency, natural history and clinical correlates of the murmur of mitral regurgitation (MR) detected after myocardial infarction, clinical data from 849 patients with documented acute myocardial infarction were analyzed. A murmur suggestive of MR was present on admission in 76 patients (9%). Patients with MR on admission were older and more apt to be female and nonwhite. They also had a significantly greater frequency of prior infarction and signs and symptoms of congestive heart failure. There was no difference in the location (anterior or inferior) of infarction. Patients with MR on admission had a 36% mortality compared to 16% for those who developed MR later in the hospitalization and 15% for those without MR by auscultation (p less than 0.001). Correction for differences in baseline variables indicated that the presence of MR on admission did not contribute independently to mortality. Thus, the murmur of MR derives its prognostic significance from integration of multiple clinical, radiographic and electrocardiographic characteristics.

Female↗
PubMed1990

Validity of arm ergometer blood pressures immediately after exercise.

It is not possible to assess blood pressure (BP) by the standard cuff method during exercise primarily involving the arms. Consequently, such measurements are often taken immediately after (within 15 seconds) exercise. To assess the validity of this practice, 18 healthy men (mean age 32 years) who completed 3 progressive 3-minute workloads were studied during arm-crank ergometry. Ankle systolic BP was measured at the dorsalis pedis artery at seated rest, 15 seconds before completion of each exercise stage and immediately after each workload, using a Doppler stethoscope; simultaneous postexercise brachial systolic BPs were determined by auscultation. Brachial systolic BP during armcrank ergometry was estimated by the formula: (resting brachial systolic BP) + (exercise ankle systolic BP - resting ankle systolic BP). Brachial systolic BPs, obtained immediately after arm-crank ergometry, were significantly lower than those estimated during exercise (p less than 0.001), with corresponding mean values of 141 versus 153, 144 versus 173 and 151 versus 182 mm Hg at 150, 300, and 450 kg.m.min-1, respectively. The difference between measured (postexercise) and estimated pressures increased with progressive workloads. These findings indicate that systolic BPs taken by the standard cuff method immediately after arm-crank ergometry are likely to underestimate "true" physiologic responses.

Adult↗
PubMed1977

Mitral valve prolapse due to coronary artery disease.

Controversy exists concerning the etiologic role of coronary artery disease in the prolapsing mitral valve leaflet syndrome. A 35 year old man with progressive coronary artery disease is described. Auscultation before and after his first myocardial infarction revealed only a fourth heart sound; subsequently left ventricular cineangiography demonstrated normal anatomy and function of the mitral valve, despite extensive wall motion abnormalities. Six months later he experienced another myocardial infarction after which the typical mid-systolic click, late systolic murmur of mitral valve prolapse developed. A second left ventricular cineangiogram at this time revealed mid-systolic mitral valve prolapse and mitral regurgitation. This patient's course indicates that myocardial damage from coronary artery disease can cause mitral valve prolapse in patients with preexisting redundant mitral valve tissue.

Adult↗
PubMed1978

"Mitral stenosis" secondary to combined "massive" mitral anular calcific deposits and small, hypertrophied left ventricles. Hemodynamic documentation in four patients.

Certain observations are described in four elderly women with massive mitral anular calcific deposits, small thick-walled left ventricles and diastolic gradients between pulmonary artery wedge position (or left atrium) and left ventricle. All four patients had some degree of obstruction to left ventricular outflow. Examination at necropsy (two patients) or at operation (one patient) disclosed only focal fibrous thickening of the mitral leaflets without commissural or chordal fusion. By auscultation, none had mitral opening snaps, only two had loud first heart sounds and only one had a mitral diastolic rumble. Hemodynamic documentation of a diastolic gradient between pulmonary artery wedge position (or left atrium) and left ventricle in the presence of massive mitral anular calcific deposits and in the absence of diffuse disease of the mitral leaflets has not been demonstrated previously. The diastolic gradients are considered to result from the combination of the large mitral anular calcific deposits and the small, thick-walled, noncompliant left ventricles.

Aged↗