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PubMed1976

Direct monitoring of arterial pressure in the newborn and infant: a difficult procedure made easy.

Accurate continuous measurement of arterial blood pressure, especially during and following operation, is indispensable for optimal management of the seriously ill newborn or infant. Conventional indirect techniques (flush technique, auscultation, Doppler monitoring device) for assessing the circulatory status in this age group are not reliable, and a direct method would be preferable. Arterial cannulation in such patients has been discouraged by the technical problems related to former techniques.

Blood Pressure Determination↗
PubMed1996

An evaluation of the use of cisapride in horses with chronic grass sickness (equine dysautonomia)

A clinical trial was carried out to determine the effect of cisapride on rate of passage of digesta and clinical parameters in horses with chronic grass sickness. Sixteen horses were given intramuscular cisapride (0.1 mg kg-1 three times daily) (group I), and 15 received oral cisapride (0.8 mg kg-1 three times daily) (group O). A liquid-phase marker (cobalt-EDTA) and a solid-phase marker (polystyrene pellets) were given by stomach tube at the beginning of each of three consecutive 7 day periods, i.e., before, during and after cisapride therapy. Seven horses in each group completed the rate of passage trial; the remainder provided clinical data only. The rate of passage was found to be significantly faster after cisapride therapy than before. Comparison with data from 20 normal animals showed a trend towards normal rates of passage after therapy. In cases that died during the trial, the caecum and large colon were the main sites of pellet retention. Dry matter intake was significantly higher after therapy than before in group O and dry matter output was higher after treatment than before in both groups. Gut auscultation score increased in both groups in the periods during and after cisapride administration but heart rate was unaffected. Diarrhoea and colic occurred in each group but its occurrence was not associated with cisapride therapy. The results suggest that by increasing gut motility, cisapride is of benefit in the management of selected cases of chronic grass sickness.

Animals↗
PubMed1995

Symptoms and signs in pulmonary medicine: old observations and new interpretations.

Andre Gide wrote, "Everything has been said before, but since nobody listens we have to keep going back and beginning all over again." To a certain extent, that statement applies to the importance of accurate and systematic history taking and physical examination in clinical practice. Although we are trained in habits of comprehension and accuracy in history taking and examination of patients, periodic reminders are required to develop a diagnostic framework based on observation (inspection), palpation, percussion, and auscultation. This monograph reemphasizes the method to be pursued in the treatment of a patient with pulmonary symptoms. It consists of three parts: (1) questioning the patient about his or her medical history; (2) performing the physical examination of the respiratory system; and (3) examining the extrapulmonary signs and symptoms. Once a strong clinical framework has been constructed, its further development and refinement depend on the clinician's experience, power of observation, and systematic reading of the medical literature. Good physicians must continue to learn throughout their careers; this is the most essential element of a physician's development. Be patient, however; as Cowper said, "Knowledge, to become wisdom, needs experience."

Eye Diseases↗
PubMed1986

The electrocardiogram often fails to identify pericarditis after percutaneous transluminal coronary angioplasty.

Acute pericarditis was recognized in six of 1,316 patients undergoing percutaneous transluminal coronary angioplasty (PTCA) between September, 1980 and December, 1984. "Atypical" chest pain different from the patients' usual exertional angina pectoris accompanied by a low grade fever and a pericardial friction rub on cardiac auscultation was considered diagnostic. Cardiac enzymes (CK-MB) were mildly elevated in three of six patients. None had perfusion defects on thallium-201 perfusion images. Serial ECG's showed minor ST-T abnormalities in five of six, while only one had the "classical" generalized ST elevation commonly expected with acute pericarditis. No patient had occlusion of the vessel undergoing PTCA nor compromise of any branch vessels in the region of the stenosis. All patients had significant dissection at the site of PTCA which may cause a regional, localized acute pericarditis not recognized by standard 12-lead ECG records.

Acute Disease↗
PubMed1996

Optimal elective management of patent ductus arteriosus in the older child.

Open surgical ligation has proven to be a safe and effective method to bring about closure of the patent ductus arteriosus (PDA). Recent studies have suggested that percutaneous transcatheter and video-assisted thorascopic closure may be better and more cost-effective techniques for PDA closure. The authors reviewed their experience with open thoracotomy for the elective ligation of PDA in 42 children over a 3-year period. The male:female ratio was 1.6:1; the age of the patients (mean +/- SD) was 2.8 +/- 2.3 years and their weight was 14 +/- 7 kg. In all cases the diagnosis was confirmed preoperatively by echocardiography. Open ligation of the PDA was performed through a limited left posterolateral thoracotomy with exposure, by an extrapleural approach. Closure was established with two silk ligatures or a silk ligature and clip, and drainage of the extrapleural space was not used. The operating time was 85 +/- 12 minutes. The total duration of hospitalization was 3.1 +/- 0.8 days. There were no deaths. Successful closure was confirmed by auscultation in 39 children and by subsequent echocardiography in three patients. No surgical complications occurred, and no transfusions were required. Minor respiratory symptoms occurred in two patients postoperatively. Transient systemic hypertension was seen in two patients, and one wound infection occurred.

Age Factors↗
PubMed1994

Persistence of acute rheumatic fever in the intermountain area of the United States.

We report our 8-year experience with the resurgence of acute rheumatic fever during the years 1985 through 1992. The records of 274 confirmed cases referred to Primary Children's Medical Center were reviewed. The clinical features including the presence of the Jones criteria, demographic data, preceding streptococcal infection, and the use of echocardiographic studies were tabulated and assessed. Patients came predominantly (84%) from middle-class families with access to medical care. Only 46 patients (17%) sought medical attention for a preceding sore throat. Carditis evident by auscultation was the dominant major manifestation in 68% of the cases. Echocardiography demonstrated mitral regurgitation that was not audible in 15 (47%) of 32 patients who had only polyarthritis at onset and in 30 (57%) of the 53 who had pure chorea. The incidence of acute rheumatic fever has been declining since the peak of the outbreak in 1985 but is continuing in the intermountain area at rates comparable to those of the 1960s.

Acute Disease↗
PubMed1997

Rapid estimation of insertional length of endotracheal intubation in newborn infants.

OBJECTIVE: To create a simple and accurate method of predicting the correct insertional length of endotracheal intubation during resuscitation of neonates. STUDY DESIGN: Phase I of the study enrolled infants that required either orotracheal or nasotracheal intubations. The endotracheal tube position was confirmed by auscultation and radiographic images. Three regression equations were then created using nasal-tragus length, sternal length, and birth weight on insertional length. In phase II of the study, the modified regression equations of nasotracheal and sternal length were used to predict endotracheal tube insertional length in 50 infants (40 orotracheal and 10 nasotracheal). RESULTS: Nasal-tragus length and sternal length are good parameters to estimate insertional length for endotracheal intubation (p < 0.005 for both the parameters). The modified prediction equation for insertional length of the endotracheal tube for the orotracheal route is NTL or STL + 1. For the nasotracheal route the equation is NTL or STL + 2. CONCLUSION: During resuscitation of the neonate when vital parameters are difficult to obtain, the insertional length of endotracheal intubation can be quickly and accurately predicted by nasal-tragus length or sternal length.

Birth Weight↗
PubMedDate not supplied

The prevalence of mitral valve prolapse in children with anxiety disorders.

Studies in adults have suggested a comorbidity of mitral valve prolapse and anxiety disorders, especially panic disorder. The nature of the association between these disorders is yet unclear. In the last years, case studies have appeared, reporting on the comorbidity of anxiety disorders and mitral valve prolapse in children. The present study evaluated the prevalence of mitral valve prolapse in children with anxiety disorders as compared to normal controls. The study group consisted of 52 children, 6-18 years old, with a diagnosis of panic disorder (9.6%), separation anxiety disorder (65.4%) and/or overanxious disorder (61.5%). Fifty-one normal age- and gender-matched healthy children served as controls. All participants were evaluated for the presence of mitral valve prolapse by cardiac auscultation and echocardiography. None of the 52 children with anxiety disorder and one of the 51 control children (1.96%) had mitral valve prolapse. There appears to be no association between childhood anxiety disorders and mitral valve prolapse. Whether children with panic disorder proper show a greater prevalence of mitral valve prolapse remains an open question. Implications to the association of mitral valve prolapse and panic disorder are discussed.

Adolescent↗
PubMed1995

Video-assisted thoracoscopic surgery for congenital heart disease.

Video-assisted endoscopic techniques have reduced operative trauma in adult thoracic and general surgery, but applications in children with congenital heart disease have been limited. We report the development of video-assisted thoracic surgery procedures for neonates and infants with cardiovascular disease. Endoscopic instruments and techniques for pediatric cardiovascular procedures were designed and tested in the animal laboratory. Forty-eight operations were subsequently performed in 46 pediatric patients ranging in age from 2 hours to 14 years (median 9 months), weighing from 575 grams to 54 kg (median 8.5 kg). Clinical applications included seven different surgical procedures: patent ductus arteriosus interruption in infants (n = 26) and premature neonates (n = 5), vascular ring division (n = 8), pericardial drainage and resection (n = 3), arterial and venous collateral interruption (n = 2), thoracic duct ligation (n = 2), epicardial pacemaker lead insertion (n = 1), and diagnostic thoracoscopy (n = 1). There was no operative mortality. Technical success, defined as a video-assisted procedure completed without incising chest wall muscle or spreading the ribs, was achieved in 39 of 48 procedures (82%), with thoracotomy required to complete nine procedures. Most patients (22/25, 88%) undergoing elective ductus ligation were extubated in the operating room and discharged from the hospital within 48 hours of the operation. Eight of the last 10 patients having ductus ligation were discharged on the first postoperative day. Residual ductal flow was assessed by (1) transesophageal echocardiography in the operating room (incidence: 0/25, 0%, 70% CL 0% to 7.3%); (2) discharge auscultation (incidence: 1/30, 3%, 70% CL 0.5% to 10.8%); and (3) follow-up Doppler echocardiography (incidence: 3/25, 12%, 70% CL 5.4% to 22.6%). Video-assisted thoracoscopic techniques can be safely applied to pediatric patients with patent ductus arteriosus and vascular rings and may become an effective addition to the staged management of more complex forms of congenital heart disease.

Adolescent↗
PubMed1996

Perioperative microbiologic monitoring of tracheal aspirates as a predictor of pulmonary complications after cardiac operations.

The value of preoperative and early postoperative microbiologic testing of tracheal aspirates as a prognostic indicator of the development of pneumonia was evaluated in a prospective study of 213 cardiac surgical patients. Tracheal aspirates were obtained immediately after intubation and after the patient's arrival at the intensive care unit. Diagnosis of pneumonia was accepted if at least three of the following criteria were fulfilled: leukocytosis > 15,000 cells/mm3, body temperature >38.5 degrees C, positive results of auscultation, positive results of radiography (new infiltrates that seemed to be consistent with pneumonia), and increased core-reactive protein for more than 2 days after operation. Potentially pathogenic microorganisms were found in 54 (25.4%) of the preoperative tracheal aspirates and in 27 (12.7%) of the early postoperative tracheal aspirates. Positive microbiologic findings correlated with pneumonia in the postoperative course in 24.1% (p < 0.001) if the preoperative culture results were positive, in 48.2% (p < 0.001) if the postoperative culture results were positive, and in 44.0% (p < 0.001) if both were positive. The risk of pneumonia was increased in male patients (p < 0.05) and in patients with chronic obstructive pulmonary disease (p < 0.05). Demographic variables, smoking, acute pulmonary symptoms, temperature, leukocyte count at the day of the operation, and data on the operation and the extracorporeal circulation were not significantly related to pneumonia in the early postoperative course. The risk of development of postoperative pneumonia is significantly higher among patients with colonization of the lower respiratory tract. Positive culture results in routine microbiologic monitoring of tracheal aspirates are predictive of pulmonary complications after cardiac operations.

Adult↗
PubMed1992

Arteriovenous malformation of scrotum: a case report.

Arteriovenous malformations of the scrotum are rare. We report a case of arteriovenous malformation involving the scrotal vessels. The patient presented with painful scrotal swelling, which was mainly in the skin and the Dartos layers. Vascular lesions of the scrotum are rare. By far the most common condition is varicocele. Our patient was examined by 2 other urologists before us and no one made the diagnosis of arteriovenous malformation on clinical examination. Diagnosis was made by auscultation with the Doppler stethoscope. We suggest that the possibility of a scrotal arteriovenous malformation and hemangiomas should be entertained in patients with unilateral scrotal swelling.

Arteriovenous Malformations↗
PubMed1977

The use of the Doppler stethoscope in the evaluation of varicoceles.

Twenty-eight clinically detectable varicoceles of various sizes were examined with a Doppler ultrasonic stethoscope. Retrograde blood flow through the left internal spermatic vein was confirmed in all cases irrespective of size of the vascular abnormality. The Doppler stethoscope also was used to evaluate 13 patients suspected of having varicoceles but with inconclusive physical examinations. Retrograde flow through the internal spermatic vein could likewise be auscultated in 5 of these patients. Finally, the Doppler stethoscope was used to determine the adequacy of internal spermatic vein ligation in 5 postoperative patients whose seminal dysfunction persisted despite what appeared to be a surgically effective correction of aberrant gonadal venous flow.

Epididymis↗
PubMed1975

Arteriovenous fistula of the renal vessels: Surgical management.

The fifth case of arteriovenous fistula following nephrectomy for tuberculosis is presented. It is important to consider an arteriovenous communication in cases of unexplained congestive heart failure, particularly when blood pressure findings suggest arteriovenous shunting. The importance of the history of nephrectomy and findings of a loud bruit upon auscultation of the abdomen is evident. Diagnosis is established by selective renal angiography. The preferred treatment is complete excision of the fistulous communication.

Arteriovenous Fistula↗
PubMed1990

Acute myocardial infarction: initial manifestations, management, and prognosis.

In patients with suspected acute myocardial infarction (AMI), obtaining a thorough history is important for identifying both the cause of chest pain and any concurrent conditions that may complicate the management. Physical examination--including cardiac auscultation and determining the status of the peripheral vasculature--is important as a guide to immediate management and as a baseline for future comparison. The differential diagnosis of AMI is extensive, and various laboratory tests, such as electrocardiography, cardiac enzymes, radionuclide techniques, echocardiography, and cardiac catheterization, can aid in the diagnosis. The routine management of patients with AMI can include medical therapy with antithrombotic agents, nitrates, beta-adrenergic blockers, or calcium channel blocking agents. The major differences between Q-wave and non-Q-wave infarction are discussed. Some factors that affect early and late prognosis in patients with AMI are age of the patient, residual left ventricular function, residual myocardial ischemia, and substrates for sustained ventricular arrhythmias. Although much of the current enthusiasm in management of AMI is related to revascularization strategies, other important aspects of diagnosis and treatment should not be overlooked.

Humans↗
PubMed1994

Ensuring the accuracy of digital sphygmomanometers for home use.

OBJECTIVE: To describe the techniques for assessing the accuracy of digital sphygmomanometers. DESIGN: The necessary equipment and the recommended procedures for determining the accuracy of digital units by comparison with a mercury sphygmomanometer were reviewed. RESULTS: Evaluation of the accuracy of digital sphygmomanometers is a simple two-phase process: (1) comparison of the pressure sensors against a mercury column and (2) assessment of the ability to detect Korotkoff sounds. The only equipment needed is a mercury column, a Y tubing, a "dummy" arm, two male-female adapters, and a stethoscope. The two short ends of the Y tubing are used to connect the mercury sphygmomanometer and the digital unit, and the long end of the Y tubing is attached to the cuff of the digital unit. The inflation mechanism of the digital unit (manual or automatic) influences the approach used for comparing the two units. For both manually and automatically inflatable digital units, the digital display should be within +/- 4 mm Hg of the mercury level; likewise, a properly functioning digital unit should detect Korotkoff sounds (both systolic and diastolic readings) within +/- 4 mm Hg of the auscultated blood pressure measurements. If the digital sphygmomanometer is judged to be accurate, 6-month reevaluations are suggested. CONCLUSION: With use of minimal equipment, digital sphygmomanometers (except the new finger blood pressure monitors) can easily be assessed for accuracy by comparing the pressure sensors against a mercury unit and testing the sensitivity for detecting Korotkoff sounds. Self-monitoring of the blood pressure is helpful in assessing blood pressure changes over time and in evaluating antihypertensive therapy.

Blood Pressure Monitors↗
PubMed1988

Cardiopulmonary metastatic lesions of osteosarcoma and associated cerebral infarction.

Osteogenic sarcoma frequently disseminates by hematogenous routes. A 32-year-old patient underwent evaluation for an acute cerebral infarction. Cardiac auscultation disclosed an abnormal diastolic sound. Echocardiographic examination revealed a large left atrial mass, which was found at thoracotomy to be metastatic osteogenic sarcoma. Cerebral computed tomographic scans at the time of initial examination and 3 months later demonstrated new cerebral lesions consistent with metastatic growths. The abrupt cerebral infarction, other clinical findings, and results of diagnostic studies strongly suggested that the acute cerebrovascular event was the result of metastatic cerebral embolization from the tumor material found in the thorax. Cerebral infarction is an unusual and catastrophic complication of thoracic metastatic lesions of osteogenic sarcoma.

Adult↗
PubMed2001

[Cardiac abnormalities in children with neuromuscular diseases].

BACKGROUND: To evaluate cardiac abnormalities in children with different neuromuscular diseases (NMD) PATIENTS AND METHOD: In 40 patients with NMD, cardiac abnormalities were evaluated by cardiac auscultation, chest X-ray, electrocardiography (ECG), ambulatory Holter ECG and Doppler echography. RESULTS: Sinus tachycardia, high R/S complex, deep Q waves, repolarization disorders, electrical conduction abnormalities, auricular and ventricular extrasystoles, Wolff-Parkinson-White syndrome, mitral valve prolapse and dilated cardiomyopathy were found. CONCLUSIONS: The association of cardiac abnormalities in children with NMD is frequent. Conventional ECG monitorization, Holter ECG and echocardiography allow their diagnosis and follow-up.

Child↗
PubMed2001

[Community acquired pneumonia in patients older than 60 years. Incidence of atypical agents and clinical-radiological progression].

BACKGROUND: Seventy five patients older than 60 years with a community acquired pneumonia followed up in an outpatient clinic, were prospectively studied in order to determine the incidence of atypical agents, clinical-radiological characteristics, progression and the differences with pneumonia in younger patients. METHOD: Clinical-radiological evaluation protocols were activated in the first visit and in two subsequent controls. Etiological diagnosis was made by means of serology (in the first visit and three weeks later). RESULTS: Initially, 85 patients older than 60 years were included of which 75 non hospitalized were fully followed up. Also, in the comparative study, 216 outpatient clinic patients 60 years old or younger were followed up during the same period. In the first group the frequency of atypical agents was 33.3%. The most frequently isolated bacteria was Coxiella burnetii (13.3%)followed by virus and Legionella pneumophila. No case of Mycoplasma pneumoniae was diagnosed. The most frequent radiological onset was alveolar infiltrate (85%). The comparative study between the two populations (older or younger than 60 years), found few clinical differences (dyspnea more frequent in older,feverish chill in younger) and auscultation (crackles more frequent in older). We did not find differences remaining clinical-radiological or laboratory data. Most patients presented a favourable clinical and radiological progression. Only 2 patients needed hospital admission (2.7%). CONCLUSIONS: In outpatient clinic patients older than 60 years with community acquired pneumonia a high number of atypical agents have been found. The clinical-radiological evolution was satisfactory for most of them. Age was not a decisive element in determining hospital admissions.

Adolescent↗