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PubMed1984

Infarction-associated pericarditis. Rarity of diagnostic electrocardiogram.

To examine how often pericarditis is associated with myocardial infarction and how often it is diagnosable by electrocardiographic changes, we determined the frequency of diagnostic (Stage I) ST-segment changes in 423 consecutive patients admitted to the coronary-care unit. Careful auscultation and electrocardiography were performed at least once daily in all patients and at least twice daily in those presenting with new chest pain of any description or a pericardial rub. Thirty-one patients had pericardial rubs, usually detected within the first four days after admission. Only 1 of the 31 had diagnostic electrocardiographic changes. The 31 patients with pericarditis differed significantly from the 392 patients without pericarditis in several respects: male predominance; Killip Classes II, III, and IV; and Q-wave infarcts. However, differences in the location of the infarct and in mortality were not statistically significant. We conclude that during acute infarction-associated pericarditis the pericardial rub is the most frequent clinical sign, and ST-segment changes diagnostic of pericarditis are rare. Our findings are consistent with the confinement of pericardial involvement to the infarct zone.

Electrocardiography↗
PubMed1987

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

We describe an outbreak of acute rheumatic fever that occurred in the intermountain area centered in Salt Lake City, Utah. Seventy-four children meeting the modified Jones criteria for the diagnosis of acute rheumatic fever were evaluated by the staff at Primary Children's Medical Center, Salt Lake City, from January 1985 through June 1986. This represents an eightfold increase over the average annual incidence at this hospital during the past decade. Carditis, a dominant feature of the outbreak, was confirmed by auscultation in 53 of the patients (72 percent). An additional 14 patients were found to have mitral regurgitation by Doppler ultrasound examination, raising the total incidence of carditis to 91 percent. The children were predominantly from white (96 percent) middle-class families with above-average incomes and with ready access to medical care. There was no apparent increase in the incidence of streptococcal disease or other explanation for the marked increase in acute rheumatic fever. However, mucoid M type 18 and M type 3 group A streptococcal strains were isolated from several siblings of the patients and from schoolchildren (chosen at random) in the area. We conclude that acute rheumatic fever remains an important health problem in the United States.

Acute Disease↗
PubMed1993

Clinical outcomes and costs of transcatheter as compared with surgical closure of patent ductus arteriosus. The Patient Ductus Arteriosus Closure Comparative Study Group.

BACKGROUND: Transcatheter implantation of the Rashkind PDA occluder is an alternative to conventional surgical closure of isolated patent ductus arteriosus. Neither the clinical outcomes nor the costs of these procedures have been formally compared. METHODS: We performed a retrospective cohort study to evaluate the clinical outcomes within a seven-month period for comparable patients with patent ductus arteriosus who underwent either placement of an occluder or surgical closure. The patients were treated between 1982 and 1987 at 14 major North American centers where patent ductus arteriosus was closed predominantly by a surgical procedure or by the occluder technique. To estimate inpatient and follow-up costs, we multiplied the observed use of resources by 1989 unit costs based on hospital-accounting and physician-reimbursement data. RESULTS: On the basis of cardiac auscultation at follow-up, the initial procedure resulted in closure of the ductus arteriosus in 77.3 percent of 185 patients in whom the occluder was implanted (95 percent confidence interval, 70.6 to 83.1 percent) and 99.8 percent of 446 surgical patients (95 percent confidence interval, 98.8 to 100.0 percent). Second procedures increased the percentage of successful closures to 87.6 percent (95 percent confidence interval, 81.9 to 92.0 percent) and 100.0 percent (95 percent confidence interval, 99.3 to 100.0 percent) for patients in the occluder and surgical groups, respectively. There were no deaths. Major complications occurred in 2.7 percent of the patients in whom the occluder was implanted (95 percent confidence interval, 0.9 to 6.2 percent) and 0.2 percent of the patients who underwent surgery (95 percent confidence interval, 0.0 to 1.2 percent); moderate complications in 16.8 percent (95 percent confidence interval, 11.7 to 22.9 percent) and 15.0 percent (95 percent confidence interval, 11.8 to 18.7 percent), respectively; and minor complications in 11.4 percent (95 percent confidence interval, 7.2 to 16.8 percent) and 24.9 percent (95 percent confidence interval, 20.9 to 29.2 percent). Including the cost of follow-up care, the mean estimated cost per case treated surgically was $8,838 (in 1989 U.S. dollars), as compared with $11,466 per case treated with the occluder technique. Sensitivity analyses based on our data identified no plausible situations in which the costs of surgery and of implantation of the occluder would be equal. CONCLUSIONS: The more effective and less costly surgical procedure was superior to transcatheter placement of the occluder for closure of isolated patent ductus arteriosus. Consequently, our results do not support the wide-spread dissemination of the occluder procedure for the management of this common congenital lesion.

Cardiac Catheterization↗
PubMed2001

Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.

STUDY OBJECTIVE: To determine the incidence of unrecognized, misplaced endotracheal tubes inserted by paramedics in a large urban, decentralized emergency medical services (EMS) system. METHODS: We conducted a prospective, observational study of patients intubated in the field by paramedics before emergency department arrival. During an 8-month period, emergency physicians assessed tube position at ED arrival using a combination of auscultation, end-tidal carbon dioxide (ETCO(2)) monitoring, and direct laryngoscopy. RESULTS: A total of 108 intubated patients were studied. On arrival in the ED, 25% (27/108) of patients were found to have improperly placed endotracheal tubes. Of the misplaced tubes, 67% (18/27) were found to be in the esophagus, whereas in 33% (9/27), the tip of the tube was found to be in the hypopharynx, above the vocal cords. Of the patients with misplaced tubes noted in the hypopharynx, 33% (3/9) died while in the ED. For the patients found to have tubes in the hypopharynx, 56% (5/9) had evidence of ETCO(2) on ED arrival. For the patients found to have esophageal tube placement on ED arrival, 56% (10/18) died in the ED. Esophageal intubation was associated with an absence of expired CO(2) (17/18, 94%) on ED arrival. The single patient in this subset with a recordable ETCO(2) had been nasotracheally intubated with the tip of the endotracheal tube noted in the esophagus while spontaneous respirations were present. On patient arrival to the ED, 63% (68/108) of the patients had direct laryngoscopy in addition to ETCO(2) determination. All patients had ETCO(2) evaluation performed on arrival. All patients in whom an absence of ETCO(2) was demonstrated on patient arrival underwent direct laryngoscopy. In cases in which direct laryngoscopy was not performed, the attending physician documented the ETCO(2) in conjunction with the presence of bilateral breath sounds. CONCLUSION: The incidence of out-of-hospital, unrecognized, misplaced endotracheal tubes in our community is excessively high and may be reflective of the incidence occurring in other communities. Data from other communities are needed to clarify the scope of this alarming issue.

Allied Health Personnel↗
PubMed2002

Determinants and assessment of regurgitation after mitral valve repair.

OBJECTIVES: The ability to detect residual regurgitation is important in the management of patients after mitral valve repair. We performed a study of 264 patients to determine the risk factors and to compare the accuracy of clinical assessment with that of echocardiography. METHODS: Operative details and valve pathologic data were obtained from individual patient case notes. Clinical assessment consisted of history, examination, and electrocardiography. The presence of regurgitation was ranked in 7 grades, from none to severe. Transthoracic echocardiography was performed blinded to and independently of clinical assessment on the same visit and was graded similarly. Univariate analyses of demographic, etiologic, and operative variables were performed. Significant factors were entered into a multivariate logistic regression model. Sensitivities and specificities were calculated for each diagnostic modality, and the kappa statistic was used to express agreement. RESULTS: Mean (+/- SE) freedoms from regurgitation at 1 and 5 years were 91.5% +/- 1.7% and 47.5% +/- 3.2%. Factors independently associated with postoperative regurgitation were poor ventricular function (P =.04), increased age (P =.01), and chordal procedures (P =.006). When assessing the presence of regurgitation, auscultation conferred a specificity of 78%, a sensitivity of 77%, and a kappa of 0.43 relative to echocardiography. Electrocardiographic criteria for left ventricular hypertrophy were superior, with a complete specificity of 100% but a low sensitivity of 15%. Agreement within 7 grades of severity was moderate, with a weighted kappa value of 0.42. CONCLUSIONS: The hazard function for regurgitation after mitral repair increases steadily after the third year, with ventricular function, age and chordal procedures as independent risks. Clinical assessment and electrocardiography are excellent in identifying regurgitation, but their agreement is less when grading severity.

Aged↗
PubMedDate not supplied

Cardiopulmonary function and morphologic changes in beagle dogs after multiple lung lavages.

This study evaluated the long-term biomedical risks risks of multiple, massive saline lung lavage using dogs. Risks were assessed using clinical examinations of cardiopulmonary function, thoracic radiographs, auscultation of the chest, body temperature, and hematologic values. Thirty-six dogs given 10 lavages over a 49-day period had no gross lesions at time of necropsy 7 days after the last lavage. Six dogs, followed with clinical examinations after each of 10 lung lavages, had no detectable effects from the lavage except for elevated body temperature and bronchial breathing at 24 hr after some procedures. No gross lesions were found at sacrifice 28 days after the last lavage. The only histologic lesions found were those also found in unlavaged control dogs. Six dogs that were lavaged 10 or more times had normal pulmonary function values for 4 yr after the last lung lavage. No chronic sequelae were found in healthy beagle dogs given 10 or more lung lavages suggesting a minimal long-term risk associated with these procedures.

Animals↗
PubMed1978

Case report: Recurrent postictal pulmonary edema.

A 32-year-old man with a long history of grand mal seizures but otherwise good health had recurrent episodes of postictal pulmonary edema when he failed to take anticonvulsant medication regularly. This case illustrates most of the features observed in other reported cases of postictal pulmonary edema. Symptoms include dyspnea and cough with production of various quantities of mucoid fluid that may be copious and frankly hemorrhagic. Blood pressure is normal, and temperature may be normal also but is frequently elevated to 100 or 101 F. No cardiac irregularities are heard on auscultation, and the ECG is often normal, but a wide range of abnormalities may be seen. Considerable arterial hypoxemia may occur, and leukocytosis (11,000 to 14,000 cells per cubic millimeter) is common. Rales and rhonchi are audible, and chest films often show bilateral upper and middle lobe infiltrates. The patient is usually clinically improved within 24 hours and the pulmonary edema completely cleared in three to five days.

Adult↗
PubMed1980

Mitral valve prolapse: etiology, diagnosis, and management.

Mitral valve prolapse is a common cardiac anomaly in which diagnosis is generally made by auscultation. In a typical case, a midsystolic click followed by a late systolic murmur is heard, although this pattern can vary. Selected pharmacologic agents (vasopressors and vasodilators) may be useful in diagnosis, and echocardiography can be helpful in cases without auscultatory signs. In the majority of cases, mitral valve prolapse is benign and no specific treatment is needed except reassurance and perhaps endocarditis prophylaxis. Patients with chest pain and symptomatic arrhythmias may benefit from propranolol, those with ventricular tachycardia should receive antiarrhythmic therapy, and those with abnormal resting ECGs or frequent ventricular premature beats should be further tested because of increased risk of sudden death or possibility of associated ischemic heart disease.

Echocardiography↗
PubMed1984

Bedside evaluation in cardiac emergencies. Criteria for rapid diagnosis.

Because timely diagnosis and treatment are essential in cardiac emergencies, every physician who provides primary critical care should master the art of cardiovascular examination. In particular, this requires patience and skill at auscultation, as subtle differences in murmurs, for example, often differentiate two conditions. With a tentative diagnosis, the physician can then choose only the necessary confirmatory tests.

Acute Disease↗
PubMed1990

Mitral valve prolapse. When is it serious?

Mitral valve prolapse can best be diagnosed with careful clinical evaluation, including dynamic auscultation. Treatment consists of reassurance, pharmacotherapy for troublesome symptoms, and careful monitoring for signs of complications. Most complications can be either prevented or treated.

Humans↗
PubMed2001

Pulmonary imaging and function in the common cold.

The common cold is generally considered to be an upper respiratory tract infection. We studied the lower respiratory tract in 76 otherwise healthy young adults with the common cold. Viral infection was diagnosed in 56 (74%) of the 76 subjects. Rhinovirus was detected in 42 (55%) subjects. Chest radiography (CR) and high-resolution computerized tomography (HRCT) were carried out in 40 subjects on day 7, and pulmonary function testing with bronchodilator challenge was carried out in 36 patients on days 7 and 21 of the study. Clinical examinations were carried out on days 1, 7 and 21. The subjects recorded their symptoms on a diary card for 20 d. The mean duration of cough was 8.4 (SD 6.5) d and that of sputum production 5.9 (SD 6.4) d. No abnormal findings were detected in the lungs on auscultation. CR and HRCT showed no pulmonary changes associated with the common cold. No clinically remarkable increases were seen in peak expiratory flow, forced expiration volume in 1 s or forced vital capacity after bronchodilator challenge on either days 7 or 21. All patients made a clinical recovery without antimicrobial therapy within 21 d. We conclude that the common cold in young otherwise healthy adults is an upper respiratory tract infection and that clinically important abnormalities in the lower respiratory tract are rare.

Adult↗
PubMed2004

Safety and efficacy of misoprostol for induction of labour in a semi-urban hospital setting.

Most studies on the use of misoprostol for induction of labour have been carried out in well-endowed hospitals in developed countries with state-of-the-art monitoring equipment. There is need for more studies to be conducted in facilities with limited resources, if more patients are to benefit from the low cost and effectiveness of the drug. Following Ethical Committee approval, 152 women had labour induced in our maternity unit using intravaginal misoprostol. The patients were monitored clinically using the WHO model partograph with digital palpation of uterine contractions and intermittent auscultation of fetal heart with a pinard stethoscope. One hundred and thirty-five (88.8%) of the women had a vaginal delivery, while nine (5.9%) had a caesarean section for various obstetric indications. Eight cases of uterine hyperstimulation were noted but none of uterine rupture. We conclude that misoprostol can be used safely for induction of labour in less endowed hospital settings such as in developing countries, using basic clinical tools for monitoring.

Administration, Intravaginal↗
PubMed1998

What is the normal heart rate of a term fetus?

There is controversy about the value of continuous versus intermittent auscultation of the fetal heart during labour, but there is no agreement on what constitutes normal heart rate of a term fetus. There are variations between the definitions adopted by different countries, and even within a single country. We propose 110-160 beats per minute for clinical use.

Journal Article↗
PubMed1998

Atrial fibrillation associated with central nervous symptoms and colic in a horse: a case of equine cardiomyopathy.

A 18-year-old Dutch Warmblood mare was referred for colic. Upon arrival, lethargy, blindness, head pressing, ataxia, and circling were the main clinical signs. On rectal examination a hard mass and oedema around the cranial mesenteric artery were palpated. Plasma liver enzyme activities and the ammonia level were elevated. Atrial fibrillation with a pulse frequency of 36-52 beats per minute was noticed. On both sides a holosystolic murmer with the maximum intensity on the right side could be auscultated. Postmortem examination revealed eccentric hypertrophy of the right atrium and a pale spotted myocardium, most prominently of the right ventricle, with secondary venous congestion of the azygos and mesenteric veins. The liver changes were indicative of chronic congestion. Despite the normal pulse rate, it appeared that congestive heart failure due to cardiomyopathy, was responsible for the presenting symptoms of this patient.

Animals↗
PubMed1990

Physiologic responses of paraplegics and quadriplegics to passive and active leg cycle ergometry.

The purposes of this study were three-fold: (a) to determine acute physiologic responses of spinal cord injured (SCI) subjects to peak levels of leg cycle ergometry utilizing functional neuromuscular stimulation (FNS) of paralyzed leg muscles, (b) to determine the relative contributions of passive and active components of FNS cycling to the peak physiologic responses, and (c) to compare these physiologic responses between persons who have quadriplegia and those who have paraplegia. Thirty SCI subjects (17 quadriplegics and 13 paraplegics) performed a discontinuous graded FNS exercise test from rest to fatigue on an ERGYS 1 ergometer. Steady-state physiologic responses were determined by open-circuit spirometry, impedance cardiography with ECG, and auscultation. In the combined statistics of both groups, it was noted that peak FNS cycling significantly increased (from rest levels) mean oxygen uptake by 255%, arteriovenous O2 difference VO2 and VE, Q and a-vO2 and VCO by 69%, and stroke volume by 45%, while total peripheral vascular resistance decreased by 43%. Mean peak power output for paraplegics (15 W) was significantly higher than for quadriplegics (9 W), eliciting higher peak levels of pulmonary ventilation and sympathetically mediated hemodynamic responses such as cardiac output, heart rate, and systolic and diastolic arterial blood pressure. Passive cycling without FNS produced no statistically significant increases in physiologic responses above the resting level in either group.

Adult↗
PubMed2000

Asthma in adult patients presenting with symptoms of acute bronchitis in general practice.

OBJECTIVES: To investigate the association between asthma and acute bronchitis in adults and to ascertain criteria to help general practitioners (GPs) differentiate between acute bronchitis and asthma. DESIGN: Descriptive study. SETTING: Primary health care centre in The Netherlands. PATIENTS: 192 patients, aged 18-75 years, not known to have asthma or other pulmonary diseases, attending their GP with cough persisting for at least 2 weeks. METHODS: Patients were considered to have asthma or chronic obstructive pulmonary disease on the basis of a questionnaire on respiratory symptoms, spirometry and methacholine challenge testing. They were classified as having acute bronchitis if, according to international guidelines, coughing was more frequent than normal for at least 2 weeks, but no more than 4 weeks. Furthermore, either expectoration of purulent sputum for a maximum of 2 weeks and/or rhonchi as assessed by auscultation had to be present. By means of logistic regression symptoms, signs and peak expiratory flow measurements were sought to predict which patients with acute bronchitis actually had asthma. RESULTS: Of the 80 (41.7%) subjects with symptoms of acute bronchitis, 29 (36.9%) were patients with asthma. Within the acute bronchitis group, female sex and symptoms of current reported wheeze, reported episodes of attacks of dyspnoea over the last year and symptoms elicited by allergens were of help in identifying patients who actually had asthma. CONCLUSIONS: A considerable proportion of the patients presenting with acute bronchitis are actually patients with asthma. The absence or presence of a few symptoms and female sex may help to differentiate between these disorders.

Adult↗
PubMed2003

Symptoms and signs of community-acquired pneumonia in children.

OBJECTIVE: The aim of this investigation was to identify the clinical symptoms and signs of pneumonia in hospitalised patients with confirmed aetiologic diagnosis and to study whether it is possible to differentiate viral from bacterial pneumonia by these means. DESIGN: A 3-year prospective study. SETTING: Turku University Hospital, Turku, Finland. PATIENTS: 254 children with radiologically confirmed community-acquired pneumonia. MAIN OUTCOME MEASURES: Data on symptoms and signs were collected from the hospital records of patient files. A standardised case record form was used. RESULTS: Eleven percent of the patients presented the illness without any respiratory symptoms. Patients with viral pneumonia versus those with bacterial pneumonia were younger (means 2.8 vs 4.1 years) and more often had acute otitis media (41% vs 18%), dyspnea (48% vs 25%) and rhonchi on auscultation (47% vs 26%). Thoracic pain, headache and decreased breathing sounds were more common in patients with bacterial pneumonia. CONCLUSIONS: Although the clinical findings in viral pneumonia showed some differences from those in bacterial pneumonia, they were largely overlapping. This similarity and the frequent occurrence of mixed infections make it impossible to differentiate between viral and bacterial pneumonia simply by clinical symptoms and signs.

Child, Preschool↗
PubMedDate not supplied

Digital envelope detector for blood pressure measurement using an oscillometric method.

Blood pressure measurement in the finger artery offers some advantages compared with that in the brachial artery. However, volume oscillometric signals obtained from finger artery measurement are often influenced by motion artefact due to respiration, speaking, involuntary or voluntary movement, etc. In this paper, we developed a digital envelope detector to detect the maximum oscillation criterion in blood pressure measurement for the first time. The digital envelope detector is robust to noise signals generated by motion artefact and filters out the carrier frequency efficiently. To verify the feasibility of our method, we measured blood pressure for eight subjects using our developed system. The results were compared with the auscultation method. In the case of using a digital envelope detector, we could reduce the mean difference error and standard deviation by 30-40%. Our proposed digital envelope detector is a useful tool to improve the accuracy of blood pressure measurement in finger artery.

Adult↗