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PubMed1991

Magnetic resonance imaging and tomographic evaluation of occlusal appliance treatment for advanced internal derangement of the temporomandibular joint.

This study evaluates the positional relationship of the disc and mandibular condyle in patients with late opening clicks treated with appliance therapy. A total of 30 joints (18 patients) were studied. Twenty-seven of these 30 joints were treated with the appliance until the joints were silent to auscultation. The patients were then evaluated with axial corrected tomography and magnetic resonance imaging (MRI) in the centric occlusion position and with their bite appliance (Sved-type) in place. Comparisons were made between condyle position in centric occlusion and with the appliance in place. Magnetic resonance imaging was then used to evaluate disc positional changes. Each imaging procedure was made in the same sagittal plane. Only changes in condyle positioning could be identified. Evidence of disc repositioning with the appliance in place was seen in only three MRI examinations. The remaining 27 joints continued to exhibit disc displacement with various changes in disc morphology. It is concluded that the concept of "disc capture" is a clinical term only, and that such perceived clinical success should not lead to the assumption that an actual change in intra-articular anatomic relationships has occurred. Joint noises may decrease because joint space is increased, allowing smoother condylar translation beyond disc surface irregularities and positional abnormalities.

Cartilage, Articular↗
PubMed1992

Effects of tobacco smoking on the topographic EEG II.

1. Tobacco smokers are well aware of the long term hazards of tobacco smoking, yet they continue to smoke. Presumably people smoke because of short term gains due to nicotine. 2. The mechanism by which nicotine is a drug reinforcer still needs a great deal of study. The specific aim of the present study was to determine the effects of tobacco smoking on the topographic EEG of 12 hr deprived heavy tobacco smokers. 3. Seven normal adult tobacco smokers of mixed sex were recruited into the study and compared with six normal nonsmokers of similar age and sex. 4. A Grass Model 8-24D EEG and 16 different scalp monopolar electrodes were used to record the EEG using both ears as reference before and after smoking. EKG lead II was recorded on channel 17. Blood pressure was measured by auscultation. Exhaled CO was measured using a CO detector. Computer analysis of the EEG data was run of line on a Zenith 386/25 microcomputer using RHYTHM 7.1. The same system was used to store the EEG in digitized form. The maximum number of 4 sec artifact free epochs in a 3 min recording period with eyes open and then closed was used before and after low and high nicotine tobacco or sham smoking. 5. The hypothesis of this research was confirmed, i.e., that tobacco smoking of high nicotine cigarettes (about 2.0 mg/cigarette) would cause a shift in EEG alpha rhythm to higher frequencies in more diffuse midline cortical structures. In other studies an increase in alpha rhythm has been correlated with an awake relaxed behavioral state. 6. A heart rate increase was a more sensitive index of tobacco smoking than an increase in arterial blood pressure. Exhaled smoking CO levels correlated with the nicotine and tar content of the cigarette.

Adult↗
PubMed1994

Clinical significance of PQ segment depression in acute Q wave anterior wall myocardial infarction.

OBJECTIVES: This study was designed to evaluate the clinical significance of PQ segment depression and to examine the frequency of PQ segment depression in infarction-associated pericarditis. BACKGROUND: PQ segment deviation is almost as characteristic as the classic ST segment deviation and is detected in most patients with pericarditis. However, the incidence and clinical characteristics of PQ segment depression in acute myocardial infarction are not defined. METHODS: Three hundred four consecutive patients with acute Q wave anterior wall myocardial infarction were examined carefully by auscultation, electrocardiogram, echocardiogram and chest roentgenogram. The diagnosis of pericarditis was made on the basis of pericardial rub detected by more than two observers during the 1st 3 days after hospital admission. At least 0.5 mm of PQ segment depression from the TP segment observed for > 24 h in both limb and precordial leads was considered diagnostic of PQ segment depression. RESULTS: A pericardial rub was present in 65 patients (21%) and absent in 239 patients. PQ segment depression was detected in both limb and precordial leads in 30 patients (10%): 18 patients with pericardial rub and 12 patients without pericardial rub. On the basis of five clinical variables, multivariate analysis was performed to determine the important variables related to the occurrence of PQ segment depression. Pericardial rub was selected with left ventricular segments with advanced asynergy as a significant factor related to PQ segment depression. There were 31 in-hospital deaths, and a significantly higher hospital mortality rate was observed in patients with PQ segment depression (23% vs. 9%). CONCLUSIONS: Although PQ segment depression was observed in a minority of patients with infarction-associated pericarditis, it was one of the clinical signs of larger infarct size and increased hospital deaths.

Echocardiography, Doppler↗
PubMed1992

Simultaneous bilateral spontaneous pneumothorax: case report.

A 22-year-old previously healthy male was admitted to the emergency department for chest pain and dyspnea of 1-day's duration. He had a history of heavy smoking. The patient was cyanotic, agitated, and severely dyspneic. Lung auscultation revealed severe diffuse bronchospasm and equally diminished breath sounds on both sides. Nasotracheal intubation and mechanical ventilation were performed shortly after admission due to acute respiratory failure. Simultaneous bilateral spontaneous pneumothorax was diagnosed from the chest x-ray, and chest tube drainage was immediately performed bilaterally. Computerized tomography of the chest 1 month later showed diffuse emphysematous bullae of the lungs. The case presented here should increase physicians' awareness of this rare form of spontaneous pneumothorax and its diverse manifestations.

Adult↗
PubMedDate not supplied

Inhalation injury with burns: a lethal combination.

Inhalation injury is known to add significant morbidity and mortality to patients with burns. Estimating the severity of inhalation injury is difficult, as signs of respiratory failure may occur hours or even days after the injury. We have reviewed 86 consecutive patients who were admitted to our Burn/Trauma Center with burns and evidence suggestive of smoke inhalation. Of these patients, 88% required endotracheal intubation. There was a 62% mortality. Admission chest x-rays studies, PAO2, and auscultation of the patient's lungs were normal in 90% of the study group. These factors could not be used to predict respiratory failure or death. Patients with as little as 15% total body surface burns with mild smoke inhalation are at significant risk of respiratory failure and the need for ventilatory support.

Adolescent↗
PubMed1990

French influence on the development of medicine in Louisiana.

The paper presents a brief survey of the state of medicine in the 18th century with an emphasis upon developments in France. In the early nineteenth century the emergence of the Paris Clinical School made France pre-eminent in medicine. Its leaders emphasized localism, correlated symptoms with postmortem reports, and introduced clinical statistics. They also introduced the stethoscope and the techniques of auscultation and palpation and were the first to recognize that excessive bloodletting, purging and other depletory measures were harmful. The French population in Louisiana continued to look to France for educational and intellectual leadership well into the nineteenth century, and the findings of the Paris Clinical School had an immediate impact upon Louisiana medicine, leading to a clash between the French-speaking physicians who emphasized moderation and good nursing and the English-speaking practitioners who believed in drastic intervention.

Clinical Medicine↗
PubMed1995

[Role of anticholinergic agents in acute bronchiolitis in infants].

There is almost universal agreement that neither beta 2-agonists, theophyllin nor steroids, given either by inhalation or systemically, have any effect on lung function in acute bronchiolitis of infancy. As ipratropium bromide appears to be a more effective bronchodilator drug than beta 2-stimulants in the first year of life, a study was set up to investigate its possible role in bronchiolitis. Diagnostic requirements for inclusion in the study were tachypnoea, hyperinflation recession, and the presence of fine crepitations on auscultation with a chest X-ray which excluded either heart failure or gross pneumonia. Twenty-five infants were recruited in the preliminary study. A respiratory jacket and water filled oesophageal catheter (feeding tube) were used to measure the work of breathing per minute and per litre of expired gases. After baseline readings the infants received salbutamol (2.5 mg), ipratropium bromide (250 micrograms) or placebo in 2 ml volumes using a standard nebuliser. The salbutamol and water were associated with an increase in the work of breathing of 4% and 22% respectively. The ipratropium therapy led to a fall of 18% with a significant response in 6 of 15 infants studied. Following these encouraging results, a double blind study was set up assessing the effects of nebulised ipratropium bromide (250 micrograms) and nebulised saline given every 6 hours to 66 infants admitted to the ward with acute bronchiolitis. Response to therapy was determined using symptom scores and need for nebulised therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1994

Giant congenital coronary artery fistula to left superior vena cava and right atrium with compression of left pulmonary vein simulating cor triatriatum--diagnostic value of magnetic resonance imaging.

A 3-year-old girl with a continuous murmur on auscultation was found to have left coronary artery to right atrial fistula simulating cor triatriatum sinister on echocardiography. Coronary angiography of the patient was also insufficient to clarify the exact pathologic anatomy. Magnetic resonance imaging showed that the main drainage of the aneurysmal coronary artery was to the left superior vena cava, resulting in a diffuse arteriovenous fistula in the lower lobe of the left lung by compressing its pulmonary vein.

Child, Preschool↗
PubMed2005

Capillary refill time is an unreliable indicator of cardiovascular status in term neonates.

PURPOSE: Decisions regarding the need for volume replacement in neonates often are made in the immediate newborn period. Capillary refill time (CRT) is used as an indicator of circulatory status; however, recent data show that CRT varies considerably with age, ambient and skin temperature, anatomical site of measurement, and duration of pressure. The purpose of this study was to (1) examine the relationship between CRT and heart rate (HR) and blood pressure (BP) in term neonates, and (2) evaluate the differences among CRT values measured at 3 body sites and with varying duration of cutaneous pressure. DESIGN: This was a prospective, cross-sectional, correlational study. Subjects Forty-two appropriate-weight-for-gestational-age (AGA) neonates with birthweights, (M = 3407; SD = +/- 540 g), gestational ages (M = 39 weeks; SD = +/- 1 week), and sex (21 males, 21 females). Infants had no history of perinatal distress or maternal chorioamnionitis. METHODS: Each neonate was studied prospectively 1 to 4 hours after birth. The infants were clothed with only a diaper and evaluated on a radiant warmer bed set to achieve an axillary temperature of 36.5 degrees to 37.0 degrees C. Capillary refill time was measured with a digital stopwatch at 3 sites: volar surface of finger (F), plantar surface of heel (H), and lower sternum (St), using brief (1- to 2-second) and extended (3- to 4-second) pressure. Heart rate was auscultated and counted for 60 seconds, and BP was measured by oscillometry. Relationships among variables were assessed by Pearson correlation coefficient, analysis of variance, and multiple regression analysis. The Bonferroni correction for multiple comparisons was applied. MAIN OUTCOME MEASURES: Capillary refill time, blood pressure, and heart rate. PRINCIPAL RESULTS: There was no significant site variation for CRT for either brief (2.4 +/- 0.6 to 2.9 +/- 1.0 seconds) or extended (3.8 +/- 0.8 to 4.3 +/- 0.8 seconds) pressure. However, regardless of site, CRT was greater when extended versus brief pressure was used (P < 0.001). There were no significant correlations between HR and CRT. There was a moderate, direct relationship between BP and CRT observed in the following anatomic sites: (1) sternum/extended pressure and systolic BP (SBP), diastolic BP, and mean BP (r = 0.35, P = 0.02; r = 0.49, P = 0.001; and r = 0.43, P = 0.005, respectively); (2) sternum/brief pressure and SBP (r = 0.31, P = 0.05); and (3) finger/extended pressure and SBP (r = 0.30, P = 0.05). CONCLUSIONS: An unanticipated moderate, direct correlation between BP and CRT was observed; prolongation of CRT occurred with elevated blood pressure. This finding may have been secondary to increased circulating vasoactive substances in the newborn period; measurement of these substances was beyond the scope of this study. In addition, CRT was highly dependent on the duration of cutaneous pressure, regardless of the site. These 2 findings indicate that CRT may be an unreliable indicator of cardiovascular status in the term neonate during the first 4 hours after birth.

Analysis of Variance↗
PubMed2005

The vexatious vital: neither clinical measurements by nurses nor an electronic monitor provides accurate measurements of respiratory rate in triage.

STUDY OBJECTIVE: Of all the vital signs, only respiratory rate is still measured clinically in most US triage systems. Previous studies have demonstrated the inaccuracy, poor interobserver agreement, and low variability of routine measurements of respiratory rate. We assess the variability and accuracy of triage nurses' measurements of respiratory rate against a criterion standard. Also, we assess electronic measurement of respiratory rate against the same criterion standard. METHODS: Consecutive patients presenting to an urban teaching emergency department (ED) were enrolled in this prospective study. Electronic measurement of respiratory rate was recorded throughout the triage encounter when nurses were recording measurements of respiratory rate. Electronic respiratory rate was measured using transthoracic impedance plethysmography. Immediately after each triage evaluation, criterion standard measurements of respiratory rate were made by research assistants using the World Health Organization recommendation of auscultation or observation for 60 seconds. RESULTS: We enrolled 159 patients. Variability was low for triage nurses' measurements of respiratory rate (SD 3.3) and electronic measurement of respiratory rate (SD 4.1) compared with criterion standard measurements of respiratory rate (SD 4.8; P <.05). Triage nurses' measurements of respiratory rate and electronic measurement of respiratory rate showed low sensitivity in detecting bradypnea and tachypnea. In a Bland-Altman analysis, triage nurses' measurements of respiratory rate and electronic measurement of respiratory rate showed poor agreement with criterion standard measurements of respiratory rate. Subgroup analysis of patients presenting with cardiac and respiratory symptoms yielded similar results. CONCLUSION: Neither triage nurses nor an electronic monitor provides accurate measurements of respiratory rate in the ED. Emergency physicians should search for new electronic modalities for measuring respiratory rate to bring respiratory rate into line with other vital signs. Emergency physicians should also consider new clinical strategies for measuring respiratory rate.

Adolescent↗
PubMed2005

A pilot study to derive clinical variables for selective chest radiography in blunt trauma patients.

STUDY OBJECTIVE: The goal of this pilot study was to determine whether clinical criteria can identify blunt trauma patients with significant acute intrathoracic injury on chest radiograph. METHODS: From January 2003 to May 2004, adult blunt trauma patients who received chest radiographs were prospectively enrolled at 2 urban trauma centers. Exclusion criteria were age less than 15 years, penetrating trauma, trauma more than 72 hours before presentation, isolated head trauma, and Glasgow Coma Scale score less than 14. Before chest radiograph viewing, providers recorded the following data: mechanism of injury, vital signs including oxygen saturation, patient symptoms, intoxication, distracting injuries, and the presence or finding of visible chest wall injury, chest palpation tenderness, pain on lateral chest compression, crepitus, and abnormal chest auscultation. Significant acute intrathoracic injury was defined as pneumothorax, hemothorax, aortic injury, 2 or more rib fractures, sternal fracture, or pulmonary contusion by blinded radiologist chest radiograph interpretation. RESULTS: Of the 507 enrolled patients, 15 patients were excluded because chest radiograph was not performed. Significant acute intrathoracic injury was confirmed in 31 of 492 (6.3%) patients. Palpation tenderness and chest pain had the highest sensitivity (90%) as individual criteria for significant acute intrathoracic injury, and hypoxia had the highest specificity (97%). The combination of palpation tenderness and hypoxia identified all significant acute intrathoracic injury with the following screening performance with 95% confidence intervals (CIs): sensitivity 100% (95% CI 91% to 100%); specificity 50% (95% CI 45% to 54%); positive predictive value 12% (95% CI 9% to 17%); and negative predictive value 100% (95% CI 99% to 100%). CONCLUSION: In this small sample, the combination of palpation tenderness and hypoxia identified all blunt trauma patients with significant acute intrathoracic injury while potentially eliminating the need for 46% of chest radiographs.

Adult↗
PubMed2005

What is the best approach to diagnosing large-vessel vasculitis?

Temporal arteritis, including large-vessel giant cell arteritis, and Takayasu's arteritis are the two primary large-vessel vasculitides. Patients with temporal arteritis often present with headache, swollen temporal arteries, impairment of vision or symptoms of polymyalgia rheumatica. Clinical examination includes palpation of the temporal arteries and radial pulses, auscultation of the subclavian and axillary region, and fundoscopy. The presence of jaw claudication, diplopia and temporal artery abnormalities correlates with a high probability of positive histology. Duplex ultrasonography of the temporal arteries delineates a characteristic hypoechoic, oedematous wall swelling, stenoses and occlusions. It detects the same pathologies in the axillary arteries and other arteries in large-vessel giant cell arteritis. Angiography, magnetic resonance imaging, magnetic resonance angiography, electron beam computed tomography, computed tomography angiography and positron emission tomography show characteristic changes in the aorta and its primary branches in large-vessel giant cell arteritis and Takayasu's arteritis. Takayasu's arteritis often begins with diffuse symptoms such as low-grade fever, arthralgia, fatigue and weight loss. Clinical examination is important to detect bruits, pulse reduction and blood pressure differences. Profound experience exists with angiography. Other imaging methods are interesting alternatives as they are less invasive and may depict the inflammatory wall swelling.

Giant Cell Arteritis↗
PubMed2005

Evaluation of infections in non-small cell lung cancer patients treated with radiotherapy.

PURPOSE: We aim to determine infections occurring in patients with non-small cell lung cancer during radiotherapy (RT). METHODS AND MATERIALS: A total of 181 patients had been treated with thoracic radiotherapy between October 1995 and December 1999. Radiotherapy was given using 1.8-3Gray (Gy) fraction daily, five fractions a week for a total dose of 59.4Gy (30-70.2Gy). A complete history was collected retrospectively for each patient. All microbiological examinations were performed according to the routine procedures of the hospital laboratory. Numeric and categoric variables were employed such as sex, age, performance status, histology, stage, chemotherapy, usage of corticosteroids, neutropenia, surgery, hospitalization, associated diseases, smoking during treatment, package per year of cigarette smoking, dose of radiotherapy, and response rates. RESULTS: Infections developed in 84 patients (46%, 84/181) during thoracic radiotherapy. A 101 episodes of infections developed in these patients. Most patients suffered from sputum production (65%), cough (59%), auscultation findings (31%) and fever (31%). Gram-negative bacteria were the most frequently isolated pathogens in the cultures of specimens (70%, 16/23 samples). Neoadjuvant chemotherapy (OR=4.81; 95% CI, 1.57-9.12; p=0.003) and neutropenia (OR=4.25; 95% CI, 1.44-6.89; p=0.009) were found as risk factors for influencing infection based on logistic regression analyses. Package per year of cigarette smoking was found statistically significantly higher in patients with infections than patients without infections (p=0.001). A slight increase in infections, which was of borderline statistical significance (p=0.07), was observed in patients age over 70. Ciprofloxacin and clarithromycin were the most frequently used agents in treatment. Median survival was 9 months in the patients with infection and 13 months in the 97 patients without infection. Overall survival seemed to be statistically significantly better in patients without infection than patients with infection (p=0.042) calculated using Kaplan-Meier method. Based on Cox regression analyses; overall survival was not correlated to presence of infection but associated with poor performance status (</=80) (OR=2.35; 95% CI, 0.85-8.93; p=0.03), and usage of corticosteroids (OR=2.68; 95% CI, 0.98-6.72; p=0.01). The dose of radiation therapy >5940 cGy (OR=2.06; 95% CI, 0.72-7.18; p=0.007) and the absence of response to treatment (OR=2.45; 95% CI, 0.89-14.23; p<0.001) were also found to be risk factors for survival. CONCLUSIONS: Infections are important causes of morbidity and mortality in lung cancer patients. The control of infection in these patients may improve the survival. Predisposing factors and treatment management approaches in non-small cell lung cancer should be defined carefully.

Adult↗
PubMed2006

The role of carbon dioxide detectors for confirmation of endotracheal tube position.

There is evidence that practitioners who are responsible for airway management at newborn resuscitations may place an endotracheal tube incorrectly with confidence. Moving on to the further stages of resuscitation, without managing the airway adequately, and commencing ventilation has the potential for significant harm to the baby. Because primary confirmation is fallible, there is a need for secondary confirmation of correct endotracheal tube placement and effective airway and breathing before moving on to cardiovascular support. Symmetric chest movement, auscultation, exhaled carbon dioxide (CO(2)), and an increase in heart rate have been suggested as providing secondary confirmation. Measurement of exhaled CO(2) is accepted widely as a standard of care in adult and pediatric intensive care and in anaesthetized patients.

Capnography↗
PubMed2004

Neonatal respiratory mechanics and development of bronchial hyperresponsiveness in preterm infants.

BACKGROUND: In preterm ventilated infants, irreversible damage to the airway mucosa in the neonatal period might be related to the development of bronchial hyperresponsiveness (BHR) in subsequent years. AIMS: To evaluate whether neonatal indicators of long-term respiratory morbidity, respiratory system compliance (Crs) and resistance (Rrs), were causally related to bronchial responsiveness at the age of 2 and whether these relationships were affected by other factors. STUDY DESIGN: Mean neonatal Crs and Rrs of the first 3 days of life were assessed using the single breath occlusion technique. Bronchial challenge tests were performed at 2 years of age. When wheezing occurred during chest auscultation or oxygen saturation decreased below 90%, the provocative concentration of methacholine was recorded. SUBJECTS: Forty-five preterm infants of <37 weeks gestation, being mechanically ventilated within 24 h after birth. RESULTS: Decreased neonatal Crs was related to BHR (beta per ml/kPa, 0.061; 95% confidence interval, 0.019 to 0.103; p=0.006). Correction was required for radiological gradation of respiratory distress syndrome, the maximal peak inspiratory pressure required during mechanical ventilation and postnatal corticosteroid therapy. Neonatal Rrs, gestational age and birth weight were not related to subsequent BHR development. CONCLUSION: In ventilated preterm infants, decreased neonatal Crs was related to the development of BHR at the age of 2.

Adult↗
PubMed2006

High prevalence of clinically silent severe mitral regurgitation in patients with heart failure: role for echocardiography.

Mitral regurgitation (MR) is common in patients with congestive heart failure (CHF) and has adverse effects on prognosis. In view of the altered hemodynamics in CHF, we examined the accuracy of auscultation for its detection in CHF with reduced systolic function. We examined 370 patients on stable heart failure therapy enrolled in our CHF clinic, if they had a physical examination by one of the two senior cardiologists and an echocardiogram within 2 weeks after the physical examination. The MR murmur was graded 0 to 6 on physical examination. MR was graded 0 to 4 on echocardiography using standard echocardiographic criteria. The left ventricular (LV) ejection fraction was 21 +/- 12% and age was 65 +/- 15 years. By echocardiography MR was present in 345 patients (94%), being 1+ in 162 (44%), 2+ in 80 (22%), 3+ in 54 (15%), and 4+ in 51 (14%). The frequency of an audible MR murmur by physical examination was 4% in 1+ MR, 11% in 2+ MR, 13% in 3+ MR, and 37% in 4+ MR. The audibility of MR murmur was not related to age, sex, body size, LV size, ejection fraction, or left atrial size. In conclusion, grade 3 or 4+ MR is present in one third of patients with CHF and reduced ejection fraction, and is inaudible in three quarters of them by physical examination. Echocardiography is needed for its detection. Audibility of MR murmur cannot be predicted by body size, LV size, or LV function in these patients.

Aged↗
PubMed2006

A case report of a round cystic tumor in the left ventricular outflow tract.

We report a case of a patient who was admitted to our hospital complaining of angina pectoris. On auscultation, a systolic ejection murmur was heard at the right upper sternal border. Transthoracic echocardiography displayed regional wall motion abnormalities and detected a mobile mass in the left ventricular outflow tract, causing mild obstruction during systole. The mass appeared as an unilocular cystic tumor. Coronary angiography showed a significant lesion in the left anterior descending artery. Surgical treatment was indicated for coronary artery disease and for the unpredictable behaviour of the neoplasm. The mass was identified as arising from the top of the anterior papillary muscle. Histopathological examination revealed that the tumor was a cavernous hemangioma. Cardiac hemangiomas are rare, benign vascular tumors of the heart. This is an unusual case of left ventricular hemangioma incidentally discovered, which raised an interesting differential diagnosis.

Aged↗
PubMed2004

The diagnosis of heart failure in primary care: value of symptoms and signs.

BACKGROUND: The value of symptoms and signs in the diagnosis of CHF has rarely been tested in large numbers of patients in the community. The aim of this study was to evaluate the importance of symptoms, signs, and past medical history in the diagnosis of CHF in primary care. METHODS: Data on a sample of Portuguese men and women attending 365 primary care centres for any condition other than the treatment of acute infection, metabolic conditions or pregnancy were collected. All subjects who scored three or more points in the sum of categories one and two of the Boston questionnaire (history and physical examination) and those being treated for heart failure with loop or thiazide diuretics were considered to have possible heart failure and referred for further assessment including a resting echocardiogram. The sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratio (LR) for the diagnosis of heart failure were calculated. RESULTS: A total of 5434 subjects were identified, of whom 1058 fulfilled the criteria for further assessment; 551 subjects had cardiac dysfunction at rest, of which 35.5% were in NYHA class I and 4.9% in class IV. Prior use of digoxin (LR 24.9) and/or diuretics (LR 10.6), a history of coronary artery disease (LR 7.1) or of pulmonary oedema (LR 54.2), were associated with a greater likelihood of having heart failure. Amongst current symptoms, a history of paroxysmal nocturnal dyspnoea (LR 35.5), orthopnea (LR 39.1) and breathlessness when walking on the flat (LR 25.8) were associated with a diagnosis of heart failure. However, these symptoms were not frequent amongst patients with heart failure within this population (sensitivity <36%). Jugular pressure > 6 cm with hepatic enlargement, and oedema of the lower limbs (LR 130.3), a ventricular gallop (LR 30.0), a heart rate above 110 bpm (LR 26.7), and rales at pulmonary auscultation (LR 23.3) were all associated with a diagnosis of heart failure, but were infrequent findings in patients with heart failure (sensitivity <10%). CONCLUSIONS: Symptoms and signs, and clinical history had limited value in diagnosing heart failure when used alone. The signs and symptoms that best predicted a diagnosis of heart failure were those associated with more severe disease. If investigation is limited to patients with more definite symptoms and signs of heart failure, fewer than 50% of cases will be identified and a large number of patients with mild symptoms will be missed.

Adult↗