The Impact of Evolving Hand‐carried Echocardiographic Technology on Outpatient Physical Examination Accuracy in Pediatric Cardiology

Background. Cardiac auscultory skills are declining. Hand‐carried ultrasound (HCU) has been proposed as a method to enhance diagnostic accuracy of the physical examination (PE). However, features of HCU devices are varied. Objective. The aim of this study was to compare the diagnostic accuracies of an experienced pediatric cardiac PE alone vs. the PE combined with the assistance of an HCU device when using 2 HCU devices with different capabilities. The results were compared with conventional echo as the reference standard. Methods. All outpatients seen by a single pediatric cardiologist underwent physical examination and HCU. Two HCU devices were compared. The first HCU device (HCU‐1) had limited options with only 2‐dimensional echo, limited Doppler, and a single transducer frequency (2.5 MHz). The second HCU device (HCU‐2) was a unit with greater transducer choices and a wider variety of applications. A single echocardiologist performed the PEs & HCUs. Conventional echoes were performed by a pediatric sonographer and interpreted by a second pediatric echocardiologist. Examination accuracies centered on 3 broad areas including: cardiac shunts, valvular insufficiency, and valvular anatomy. The accuracy of the PE alone was compared with the accuracy of the combined PE & HCU‐1 vs. PE & HCU‐2. Results. Thirty patients total (3 months?19 years, 4–82 kg) were evaluated. Eighteen were examined with HCU‐1 and 12 were examined with HCU‐2. The accuracy of the combined PE & HCU‐1 did not improve accuracy over the PE alone. However, the accuracy of the combined PE & HCU‐2 was greater than the PE alone. Conclusions. Use of a limited HCU device does not improve diagnostic accuracy over an experienced PE alone and may actually worsen diagnostic accuracy in some cases. However, the improvements in newer HCU devices may enhance diagnostic accuracy over the PE alone, even for experienced physicians.     

Impact of hand-carried cardiac ultrasound on diagnosis and management during cardiac consultation rounds.

AIM: To evaluate the impact of hand-carried cardiac ultrasound (HCU) on the diagnosis and management of patients during cardiac consultation rounds. METHODS AND RESULTS: One hundred and fifty patients hospitalized in non-cardiac units were included after the consulting cardiologist felt that an echocardiographic examination was indicated as part of his work-up. They were randomly allocated to echocardiography with an HCU device (SonoHeart, SonoSite, Inc.) (75 patients) or with a full-featured standard echo (FE) system (75 patients). The consulting cardiologist noted whether a definitive diagnosis was made or further study was necessary. Diagnosis and change in management were noted. In the HCU patient group there were 103 clinical questions. Seventy-two percent of the referral questions required no comprehensive echocardiographic evaluation. For questions of left ventricular function, valve abnormalities and pericardial effusion this was 98%. In 48% there was an immediate change in clinical management. In the FE patient group there were 94 clinical questions. In 32% the FE examination led to change in clinical management. CONCLUSION: HCU echocardiography provides clinically worthwhile assessment of left ventricular function, valve abnormalities and pericardial effusion in 98% of the cases. A direct assessment of cardiac function and anatomy at the bedside by an experienced cardiologist results in a significant immediate change in clinical management during consultation.     

Accuracy and reliability of physical signs in the diagnosis of pleural effusion

Although pleural effusion is a common disorder among patients presenting with respiratory symptoms, there is limited evidence on the accuracy and reliability of symptoms and signs for the diagnosis of pleural effusion. In our study, conducted at a rural hospital in India, two physicians, blind to history and chest radiograph findings, and to each other's results, independently evaluated 278 patients (196 men), aged 12 and older, admitted with respiratory symptoms. We did a blind and independent comparison of physical signs (asymmetric chest expansion, vocal fremitus, percussion note, breath sounds, crackles, vocal resonance and auscultatory percussion) with the reference standard (chest radiograph). We measured diagnostic accuracy by computing sensitivity, specificity, and likelihood ratios (LRs), and inter-observer reliability by using kappa (kappa) statistic. We performed multivariate analysis to identify the clinical signs that independently predict pleural effusion. The prevalence of pleural effusion was 21% (57/278). The LRs of positive signs ranged from 1.48 to 8.14 and their 95% confidence intervals (CIs) excluded 1. Except for pleural rub, the LRs for negative signs ranged between 0.13 and 0.71. The interobserver agreement was excellent for chest expansion, vocal fremitus, percussion and breath sounds (kappa 0.84-0.89) and good for vocal resonance, crackles and auscultatory percussion (kappa 0.68-0.78). The independent predictors of pleural effusion were asymmetric chest expansion (odds ratio [OR] 5.22, 95% CI 2.06-13.23), and dull percussion note (OR 12.80, 95% CI 4.23-38.70). For the final multivariate model, the area under receiver operating characteristic curve (ROC curve) was 0.88. In conclusion, our data suggest that physical signs may be helpful to rule out but not rule in pleural effusion.     

Usefulness of noninvasive diagnostic tools for diagnosis of acute pulmonary embolism in patients with a normal chest radiograph

The value of bedside examination and noninvasive tests in the diagnosis of acute pulmonary embolism (PE) among patients with a normal chest radiograph was investigated. Normal chest radiographs were present in 20 of 260 patients (8%) with acute PE and in 113 of 642 (18%) with suspected acute PE, in whom the diagnosis was excluded. A partial pressure of oxygen in arterial blood less than or equal to 70 mm Hg in a dyspneic patient with a normal chest radiograph was more often seen among patients with PE (9 of 17, 53%) than among patients in whom PE was excluded (18 of 93, 19%; p less than 0.01). However, no combinations of blood gases, signs and symptoms were strictly diagnostic. High probability ventilation/perfusion scans among patients with a normal chest radiograph were indicative of PE in only 6 of 9 patients (67%). Among patients with low-probability ventilation/perfusion scans, 8 of 47 (17%) had PE. This study showed that the combination of dyspnea and hypoxia in a patient with a normal chest radiograph is a useful clue to the diagnosis of PE. Although intuition suggested that ventilation/perfusion scans would yield better results in patients with a normal chest radiograph, the ability to diagnose PE by ventilation/perfusion scans in this subset of patients was not enhanced, except by a reduction of the percentage of patients with intermediate probability scans.     

A comparison by medicine residents of physical examination versus hand-carried ultrasound for estimation of right atrial pressure

Physicians' ability to accurately estimate right atrial (RA) pressure from bedside evaluation of the jugular venous waveform is poor, particularly when performed by physicians in training. Conventional ultrasound measurement of the inferior vena cava (IVC) accurately predicts RA pressure, but the cost, lack of portability, and specialized training required to acquire and interpret the data render this modality impractical for routine clinical use. The objective of this study was to compare physical examination with hand-carried ultrasound (HCU) in the detection of elevated RA pressure (>10 mm Hg). After limited training (4 hours didactic and 20 studies), 4 internal medicine residents using an HCU device estimated RA pressure from images of the IVC in 40 consecutive patients <1 hour after right-sided cardiac catheterization. RA pressure was also estimated from examination of the jugular venous pulse (JVP) in 40 patients before right-sided cardiac catheterization. RA pressure was successfully estimated from HCU images of the IVC in 90% of patients, compared with 63% from JVP examination. The sensitivity for predicting RA pressure >10 mm Hg was 82% with HCU and 14% from JVP inspection. Specificities were similar between the techniques. Overall accuracies were 71% using HCU and 60% with JVP assessment. In conclusion, internal medicine residents with brief training in echocardiography can more frequently and more accurately predict elevated RA pressure using HCU measurements of the IVC than with physical examination of the JVP.     

Relation of plain chest radiographic findings to pulmonary arterial pressure and arterial blood oxygen levels in patients with acute pulmonary embolism.

Abnormalities of the plain chest radiograph of 123 patients with acute pulmonary embolism (PE) and no prior cardiac or pulmonary disease were related to the pulmonary arterial mean pressure, the partial pressure of oxygen in arterial blood, and the alveolar-arterial oxygen gradient. Patients with either a prominent central pulmonary artery or cardiomegaly had higher pulmonary arterial mean pressures than did patients with atelectasis, a pulmonary parenchymal abnormality or pleural effusion (p less than 0.001). These radiographic findings give clues to the severity of pulmonary hypertension in acute PE and suggest that pulmonary infarction or hemorrhage is associated with less severe PE.     

Itraconazole-induced hypokalemia in a patient with pulmonary aspergilloma]

An 80-year-old man was admitted to the hospital with a diagnosis of pulmonary aspergilloma. A new azole antifungal agent, D 0870, was administered to the patient for 7 days orally, and itraconazole (400 mg/day) was started on March 5, 1997. After 1 month of chemotherapy, facial and pretibial edema were observed and the patient's serum potassium concentration decreased to 2.5 mEq/l. A chest radiograph disclosed cardiomegaly with cardiac effusion and right pleural effusion on admission. The serum potassium concentration rose after the cessation of itraconazole therapy. The serum ITCZ concentration remained high for 2 weeks after admission. Although reports of hypopotassemia induced by ITCZ are rare, we concluded that blood concentrations should be monitored more carefully when treating pulmonary aspergilloma patients with high-dose regimens of ITCZ.     

Radial artery pulse pressure variation correlates with brachial artery peak velocity variation in ventilated subjects when measured by internal medicine residents using hand-carried ultrasound devices

BACKGROUND: Rapid prediction of the effect of volume expansion is crucial in unstable patients receiving mechanical ventilation. Both radial artery pulse pressure variation (DeltaPP) and change of aortic blood flow peak velocity are accurate predictors but may be impractical point-of-care tools. PURPOSES: We sought to determine whether respiratory changes in the brachial artery blood flow velocity (DeltaVpeak-BA) as measured by internal medicine residents using a hand-carried ultrasound (HCU) device could provide an accurate corollary to DeltaPP in patients receiving mechanical ventilation. METHODS: Thirty patients passively receiving volume-control ventilation with preexisting radial artery catheters were enrolled. The brachial artery Doppler signal was recorded and analyzed by blinded internal medicine residents using a HCU device. Simultaneous radial artery pulse wave and central venous pressure recordings (when available) were analyzed by a blinded critical care physician. RESULTS: A Doppler signal was obtained in all 30 subjects. The DeltaVpeak-BA correlated well with DeltaPP (r = 0.84) with excellent agreement (weighted kappa, 0.82) and limited intraobserver variability (2.8 +/- 2.8%) [mean +/- SD]. A DeltaVpeak-BA cutoff of 16% was highly predictive of DeltaPP > or = 13% (sensitivity, 91%; specificity, 95%). A poor correlation existed between the CVP and both DeltaVpeak-BA (r = - 0.21) and DeltaPP (r = - 0.16). CONCLUSIONS: The HCU Doppler assessment of the DeltaVpeak-BA as performed by internal medicine residents is a rapid, noninvasive bedside correlate to DeltaPP, and a DeltaVpeak-BA cutoff of 16% may prove useful as a point-of-care tool for the prediction of volume responsiveness in patients receiving mechanical ventilation.     

床边超声心动图检查在首诊心血管急危重症中的应用价值

目的:探讨床边超声心动图检查在首次诊断心血管急危重症疾病中的应用价值及操作体会。方法:回顾性分析我院2010-01-2010-12期间行急诊床边超声心动图检查共271例患者的资料。结果:床边超声心动图检查的阳性率为44.3%,其中有节段性室壁运动异常的急性冠状动脉综合征94例(包括室壁瘤破裂1例),瓣膜性疾病6例,心包积液5例,主动脉夹层3例,感染性心内膜炎赘生物2例,先天性心脏病3例,心房占位性病变4例,其他3例。因床边超声心动图检查首次确诊疾病,修正临床治疗,甚至挽救患者生命的有20例。结论:对症状不典型、初诊为急性冠状动脉综合征的主动脉夹层,及时进行床边超声心动图检查可起到鉴别诊断、改变治疗方案的作用;对表现为胸闷或气促的心包大量积液患者可明确诊断,指导心包穿刺引流;对高度怀疑的急性肺栓塞,床边超声心动图检查可现场动态观察临床抢救是否有效。     

Acute myocardial infarction and cardiac perforation on non-gated CT

A 79-year-old man was referred to emergency department for vagueabdominal pain. In the past, the patient had cardiac arrhythmiasnecessitating a pacemaker placement. On admission, the patienthad a normal ausculation and the abdomen examination was unremarkable.Postero-anterior chest radiograph revealed normal cardiac sizeand a small left pleural effusion.     

Free-wall rupture during the acute phase of myocardial infarction. Apropos of 2 cases surgically treated with success

The authors report two cases of cardiac rupture during acute myocardial infarction successfully treated surgically. In the first case, rupture occurred 7 days after hospital admission for anteroseptal myocardial infarction. The patient developed sudden cardiogenic shock with signs of venous hypertension without left ventricular failure. The second patient was admitted for syncopal chest pain with transient hypotension which regressed after volume repletion and pressor amine therapy. On admission, the patient had signs of cardiac tamponade. The ECG showed recent inferolaterobasal myocardial infarction. In both cases the diagnosis was made by 2D echocardiography which showed voluminous circumferential pericardial effusions probably due to haemorrage, with an image very suggestive of a blood clot in the effusion of the second patient. The two patients underwent emergency cardiac surgery and both survived with a 4 and 1.5 month follow-up respectively. These two cases confirm the value of 2D echocardiography as an emergency bedside procedure for the diagnosis of cardiac rupture, especially when images of intrapericardial thrombosis are observed, as in our second patient. In addition, the first case raises once again the question of the role of late thrombolysis as a predisposing factor of cardiac rupture at a time when this technique is proposed up to 24 hours after the onset of symptoms.     

Usefulness of a hand-carried cardiac ultrasound device for bedside examination of pericardial effusion in patients after cardiac surgery

To identify the incidence of pericardial effusion in patients after cardiac surgery using a hand-carried cardiac ultrasound device, 200 patients were assessed on postoperative day 3. If a pericardial effusion was found, patients were monitored for 3 consecutive days with a hand-carried cardiac ultrasound device. Within 72 hours after surgery, 43 patients (21.5%) had developed an effusion, of whom 2 patients had cardiac tamponade and 41 patients (21%) had a small pericardial effusion. No difference was found in the incidence of effusion based on the type of cardiac surgery. Of patients with a small pericardial effusion on day 3 after surgery, an additional 2 of 41 (5%) developed cardiac tamponade.     

Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease

The history, physical examination, chest radiograph, electrocardiogram and blood gases were evaluated in patients with suspected acute pulmonary embolism (PE) and no history or evidence of pre-existing cardiac or pulmonary disease. The investigation focused upon patients with no previous cardiac or pulmonary disease in order to evaluate the clinical characteristics that were due only to PE. Acute PE was present in 117 patients and PE was excluded in 248 patients. Among the patients with PE, dyspnea or tachypnea (greater than or equal to 20/min) was present in 105 of 117 (90 percent). Dyspnea, hemoptysis, or pleuritic pain was present in 107 of 117 (91 percent). The partial pressure of oxygen in arterial blood on room air was less than 80 mm Hg in 65 of 88 (74 percent). The alveolar-arterial oxygen gradient was greater than 20 mm Hg in 76 of 88 (86 percent). The chest radiograph was abnormal in 98 of 117 (84 percent). Atelectasis and/or pulmonary parenchymal abnormalities were most common, 79 of 117 (68 percent). Nonspecific ST segment or T wave change was the most common electrocardiographic abnormality, in 44 of 89 (49 percent). Dyspnea, tachypnea, or signs of deep venous thrombosis was present in 107 of 117 (91 percent). Dyspnea or tachypnea or pleuritic pain was present in 113 of 117 (97 percent). Dyspnea or tachypnea or pleuritic pain was present in 113 of 117 (97 percent). Dyspnea or tachypnea or pleuritic pain or atelectasis or a parenchymal abnormality on the chest radiograph was present in 115 of 117 (98 percent). In conclusion, among the patients with pulmonary embolism that were identified, only a small percentage did not have these important manifestations or combinations of manifestations. Clinical evaluation, though nonspecific, is of considerable value in the selection of patients in whom there is a need for further diagnostic studies.     

Transesophageal echocardiography using cypress-miniaturized echocardiogram unit: initial clinical experience

Transesophageal echocardiography (TEE) was introduced clinically in the United States in 1987. Recent technologic advances have resulted in the creation of a small portable hand-carried ultrasound (HCU) device that can be easily carried throughout the hospital with greater flexibility for cardiac imaging. These HCU devices have harmonic, color, and spectral Doppler (continuous/pulsed wave). Siemens Medical Solutions USA, Inc. has incorporated a TEE connector, which connects to its Cypress (highly miniaturized echocardiogram unit) and allows the performance of a TEE with this unit, which is mildly heavier than a typical HCU. We describe our initial clinical experience with this unit. The image quality is comparable to routine TEEs, with the advantages of shorter duration, portability, affordable cost, avoiding the use of high-end machine from the echo lab, availability of non-HCU units for other studies, and preventing the need for an echo technician to be involved in the procedure.     

Two cases of prostate cancer found primarily from lung metastatic lesions]

We report two cases of prostate cancer found primarily from a metastatic lesion appearing in a chest radiograph. Patient 1 was admitted to our hospital because his chest radiograph and chest CT showed pleural effusion on the left. Thoracocentesis and pleural biopsy were unremarkable, so he was observed as both an outpatient and an inpatient. His general condition worsened, and after the third admission, he died. His autopsy revealed prostate cancer and positive immunohistochemical reactions for PSA and PSAP in both lungs, and prostate specimens demonstrated that prostate cancer had metastasized to the lung. Patient 2 was referred for evaluation of a bilateral multiple nodular shadow in a chest radiograph, and prostate cancer was discovered. Immunohistochemical reactions for PSA and PSAP were positive in both specimens of TBLB and prostate biopsy, confirming that the multiple lung tumors were metastases from prostate cancer.     

Rapid assessment of left ventricular systolic function in a pacemaker clinic using a hand-carried ultrasound device

Objective Pacemaker recipients with left ventricular (LV) dysfunction are potential candidates for upgrades to implantable defibrillators or cardiac resynchronization devices. This study sought to determine if a hand-carried ultrasound (HCU) device could be used for rapid, inexpensive identification of LV dysfunction in a busy pacemaker clinic.Materials and methods Eighty patients undergoing routine pacemaker check were enrolled. Patients underwent HCU imaging in the sitting position during device interrogation, by an internist who had 20 h of didactic training and 20 practice examinations. LV dysfunction was defined as ejection fraction (EF) <40%. Patients also underwent echocardiography limited to EF assessment by a sonographer using a full-feature platform.Results The mean age was 75 ± 13 years; 49% were female. Coronary artery disease was present in 29%; 82% were NYHA class I or II. At the time of HCU imaging, 48% of patients were receiving RV pacing. HCU images were interpretable in 91% (73/80) and required 3.7 ± 0.9 min to complete. Based on the full-feature echo, LV dysfunction prevalence was 17/80 (21%); 25% of these patients were NYHA class I. The sensitivity of the HCU exam was 75%, specificity was 91%, negative predictive value was 93%, positive predictive value was 71%, and accuracy was 88%.Conclusions HCU screening in a pacemaker clinic by a non-cardiologist can rapidly and accurately identify pacemaker recipients with at least moderate LV dysfunction who might be candidates for device upgrades. Ventricular dyssynchrony associated with RV pacing does not limit HCU identification of LV dysfunction.     

Hand-carried ultrasound improves the bedside cardiovascular examination

OBJECTIVES: We assessed the clinical utility of hand-carried cardiac ultrasound (HCU) devices to assist physicians in the diagnosis of cardiovascular disease. MATERIALS AND METHODS: We reviewed 42 articles published from 1978 to 2004. RESULTS: The capability and simplicity of the HCU device assist physicians in the diagnosis of cardiovascular disease at the initial patients contact. HCU is particularly useful in the setting of emergency or critical care, community screening, or in remote areas with limited access to health care. CONCLUSION: The inherent limitations of the physical examination as well as the reduced focus and training in physical diagnosis of current and recent medical school graduates has set the stage for the HCU device to modify traditional medical practices by complementing the physical examination with real-time cardiovascular imaging.     

Correlates of Early Hospital Readmission or Death in Patients With Congestive Heart Failure

Among patients with heart failure who survive an admission to the hospital, those who are readmitted or die soon after discharge may warrant special attention. Therefore, we prospectively followed 257 patients admitted nonelectively to an urban university hospital, with a complaint of shortness of breath or fatigue and evidence of congestive heart failure on admission chest radiograph, who were discharged alive. Through survey of patients and families, review of the hospital computer system, and a search of the National Death Index, we recorded death and hospital readmission. Within 60 days of discharge, 13 patients (5%) died and 82 (32%) died or were readmitted to the hospital. Using Cox proportional-hazards modeling, the multivariable correlates of readmission or death were single marital status (adjusted hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.3 to 3.3), Charlson Comorbidity Index score (HR 1.3 per point to maximum 4 points, 95% CI 1.1 to 1.6), admission systolic blood pressure of ≤100 mm Hg (HR 2.8, 95% CI 1.6 to 5.0), and absence of new ST-T-wave changes on the initial electrocardiogram (HR 1.9, 95% CI 1.1 to 3.3). Self-reported patient compliance and clinical instability at discharge were not correlates. Almost all patients stratified by these factors had at least a 25% risk of readmission or death. Our independent correlates of readmission or death support the importance of both medical and social factors in the pathway to clinical decline. However, we could not reliably identify a truly low-risk group. Interventions to decrease early readmission or death among patients with heart failure should target both medical management and the adequacy of social support, and probably need to be applied to all admitted patients.

To determine correlates of early readmission or death, we prospectively followed 257 patients admitted to an urban university hospital with a complaint of shortness of breath or fatigue and evidence of congestive heart failure on admission chest radiograph. Single marital status, increasing comorbidity, relative hypotension, and absence of new ST-T-wave changes on initial electrocardiogram were the correlates, but we could not reliably identify a truly low-risk group.     

Multiple myeloma presenting initially with pleural effusion and a unique paraspinal tumor in the thorax

We herein report an extremely rare case of a patient with IgD-lambda positive multiple myeloma presenting with myelomatous pleural effusion and ascites. A 58-year-old man visited our hospital with dyspnea as his initial symptom. His chest radiograph findings on admission revealed a left pleural effusion, and later, bilateral involvement. Computed tomography (CT) of the chest showed a paraspinal tumor with extension from the upper mediastinum to the abdomen. The cytological examination demonstrated myeloma cells in the pleural effusion and ascites, and histologically, in the pleura, an abdominal subcutaneous tumor and bone was observed. The pleural effusion was an exudate and slightly bloody. The ADA was 70 IU/L. Pleural effusion accompanying myeloma or primary pleural myeloma is very rare and, furthermore, the extremely rare findings of both myeloma cells in the ascites (although the ascites was mainly caused by liver cirrhosis) and a high ADA activity in the pleural fluid were also observed in this case.     

Sustained improvement in left ventricular function and mortality by intracoronary streptokinase administration during evolving myocardial infarction

One hundred eighty-eight patients with acute myocardial infarction were studied prospectively from August 1980 to September 1982. One hundred thirty-six of these patients were entered into a intracoronary streptokinase study after informed consent was obtained. The remaining 52 patients, who either met exclusion criteria for the study or refused to participate, served as a control group and were treated as those in the study group except that they did not undergo emergency cardiac catheterization. Left ventricular function was determined in both groups by gated radionuclide ejection fraction (EF) on admission to the hospital, at discharge, and 6 months after discharge. With successful reperfusion up to 18 hr after onset of chest pain, mean left ventricular function in the study group improved (EF 39 +/- 13% on admission and 46 +/- 12% at discharge; p less than .001). Mean EF in control patients and those not achieving reperfusion did not change from admission to discharge. Mean EF at 6 month follow-up was not significantly different than at discharge in the study group or the control group. Total cardiac mortality in the control group was 19% compared with 10% in the study group (p = .06, NS). When patients admitted in pulmonary edema or shock (Killip class III or IV) were excluded from both groups, total cardiac mortality in the study group was significantly lower (4%) compared with in the control group (12.5%, p less than .05. The administration of intracoronary streptokinase during evolving myocardial infarction up to 18 hr after onset of chest pain may result in decreased mortality and sustained improvement in left ventricular function.