Cardiovascular abnormalities in Marfan syndrome]

During the period February to December 1990, 52 adult patients were referred to our clinic for evaluation of the presence of the Marfan syndrome. In 24 out of 52 patients the Marfan syndrome was diagnosed. Cardiac abnormalities were found in all patients: mitral insufficiency because of mitral valve prolapse (83%), aortic dilatation (67%), aortic insufficiency (38%), tricuspid valve insufficiency with or without tricuspid valve prolapse (17%) and atrial septal defect (4%). In 3 patients an aneurysm of the ascending aorta was found. Early recognition of the Marfan syndrome is relevant for prevention of the life threatening complication of aortic dissection. In patients with valve abnormalities endocarditis prophylaxis is advised. A Marfan outpatient clinic offers optimal diagnostic possibilities.     

Is antibiotic prophylaxis for bacterial endocarditis cost-effective?

BACKGROUND: Antibiotic prophylaxis for bacterial endocarditis is recommended by the American Heart Association (AHA) before undergoing certain dental procedures. Whether such antibiotic prophylaxis is cost-effective is not clear. The authors' objective is to estimate the cost-effectiveness of predental antibiotic prophylaxis in patients with underlying heart disease. METHODS: The authors conducted a cost-effectiveness analysis using a Markov model to compare cost-effectiveness of 7 antibiotic regimens per AHA guidelines and a no prophylaxis strategy. The study population consisted of a hypothetical cohort of 10 million patients with either a high or moderate risk for developing endocarditis. RESULTS: Prophylaxis for patients with moderate or high risk for endocarditis cost $88,007/quality-adjusted life years saved if clarithromycin was used. Prophylaxis with amoxicillin and ampicillin resulted in a net loss of lives. All other regimens were less cost-effective than clarithromycin. For 10 million persons, clarithromycin prophylaxis prevented 119 endocarditis cases and saved 19 lives. CONCLUSION: Predental antibiotic prophylaxis is cost-effective only for persons with moderate or high risk of developing endocarditis. Contrary to current recommendations, our data demonstrate that amoxicillin and ampicillin are not cost-effective and should not be considered the agents of choice. Clarithromycin should be considered the drug of choice and cephalexin as an alternative drug of choice. The current published guidelines and recommendations should be revised.     

Medical evaluation for outpatient dental procedures

Family physicians are often consulted to evaluate medically a patient for various dental procedures. The majority of the referrals are for diseases of the cardiovascular system. General guidelines have been established at the University of Maryland Family Health Center for the evaluation of these patients. These guidelines pertain to the use of local anesthetics and prophylaxis for endocarditis, as well as to the evaluation of patients with cardiac disease, hypertension, pulmonary disease, endocrine disease, neurological disease, hepatic disease, pregnancy, and anticoagulant therapy.     

Update on infective endocarditis

Infectious Endocarditis is a disease almost invariably fatal if it is not treated in the proper manner. A review is presented of the cardiac abnormalities and procedures associated with its development as well as the most recent classification of the different modalities of endocarditis. The clinical manifestation, the causative organisms and diagnostic procedures are summarized. The American Heart Assciation and the American College of Cardiology (AHA/ACC) recommendations for management of native valve endocarditis, infective endocarditis in drug users, prosthetic valve endocarditis and culture negative endocarditis are summarized. The conditions that justify surgical interventions are also presented.     

Assessment of knowledge of guidelines for the prevention of infective endocarditis amongst clinicians in a teaching hospital

A significant minority of instances of endocarditis appear to be the result of invasive procedures performed in susceptible patients with underlying cardiac conditions. Absence, or inappropriate administration, of antimicrobial prophylaxis could expose the patient to the development of a potentially lethal infection. This study was formulated, therefore, to assess the knowledge of guidelines for the prevention of infective endocarditis among hospital-based physicians and surgeons. A multiple choice test was developed, including: (1) cardiac conditions at increased risk for development of infection; (2) procedures more likely to be associated with bacteraemia and endocarditis; and (3) type and route of antimicrobials prescribed when endocarditis prophylaxis is indicated. The quality of the test was determined in several ways. Success was defined as a pass rate of 11 of 18 questions (61%). The test was taken by 153 of 251 (60%) physicians employed by the hospital; 95 (62%) passed the test. No significant difference in success rates was found according to sex, professional status or medical school. Internists performed substantially better (with a pass rate of 41 of 53, 77%) than both paediatricians (13 of 26, 50%, P<0.05) and surgeons (41 of 74, 55%, P<0.01). The range of success varied from 100% to 36% according to specialty (P<0.001). The mean score was 69+/-21 in the study group and 94+/-10 in a control group of 20 infectious disease physicians (P<0.001). In conclusion, this study demonstrates the need for improved education of hospital-based clinicians regarding endocarditis prophylaxis recommendations.     

Gatekeeping in primary care: a comparison of internal medicine and family practice

Five hundred twenty new patients were randomly and prospectively assigned to receive their care in the Internal Medicine Clinic or Family Practice Clinic of a large university hospital. The patients were followed by residents in training under the supervision of board-certified internists or family physicians. After a mean length of care of slightly over two years, the charts were reviewed for frequency of visits to primary care providers (internal medicine or family practice), Emergency Room, Acute Care Clinic, and all clinics other than the two primary care clinics. The records were also reviewed for laboratory tests ordered. Frequency of visits to the clinic of primary care, Emergency Room, Acute Care Clinic, and broken appointments were all significantly higher for patients randomized to the Internal Medicine Clinic. In addition, the median total annual cost of laboratory tests for patients followed by internal medicine physicians was significantly higher, largely because of higher laboratory charges generated by the specialist consultants. Over the study period, internal medicine patients had a significantly higher number of visits to all nonprimary care clinics and specifically to the dermatology, obstetrics and gynecology, and general surgery consultant clinics. It can be concluded that in this clinical environment, the practice styles of internal medicine and family practice are different.     

Diffusion des recommandations de la Conférence de consensus sur la prophylaxie de l’endocardite infectieuse

A card holding specific data was edited to ensure an optimal distribution of Consensus Conference recommendations for the prophylaxis of infectious endocarditis. It is given by cardiologists to their patients with risk heart diseases. It gives information only on antibiotic prophylaxis for dental care and must be presented to the dentist. Articles in medical, paramedical, and public magazines have reported the recommendations and promoted this card. In 9 years, 273,244 cards have been handed out and may be from 84,000 to 210,000 were really given to patients. Surveys show that it is known by 97% of cardiologists, but only by 55% of dentists and 28% of GPs. Enquiries made on patients having received a card show that they have acknowledged and used it, including for those who have held it for a long time.     

Prevention of infective endocarditis: are recommendations about oral health procedures for high or moderate risk patients respected?

BACKGROUND: Infective endocarditis (IE) is a rare but particularly serious disease. It frequently requires surgical treatment with cardiac valve replacement. In-hospital mortality is very high. The guidelines of the Society of Infectious Pathology of French Language (SPILF) for the prevention of infective endocarditis of at-risk patients were updated in 2002. They recommended a bi-annual oral health follow-up and antibiotic prophylaxis for invasive sequences of care for high-risk patients. The objective of the study was to assess the application of the guidelines. METHODS: Using databases and medical files of self-employed persons insured by compulsory national health insurance in the Alps, we studied from January 2001 to December 2002 the oral ambulatory follow-up of patients with permanent health insurance for valvular heart disease or congenital heart disease. RESULTS: Among the 260 patients with valvular heart disease or congenital heart disease, 125 (48.1%) presented medical claims for at least one dental treatment. Antibiotic prophylaxis was found in 15.8% of the invasive sequences of care for high-risk patients. The prescribed antibiotic was amoxicillin in 90% of the cases. CONCLUSION: Guidelines are seldom applied. Public and practitioner awareness should be improved to promote oral health: patients should regularly consult their dentist, and practitioners should follow the guidelines for the prevention of infective endocarditis.     

二尖瓣脱垂综合征163例分析

目的　了解二尖瓣脱垂综合征的临床表现。方法　对 16 3例二尖瓣脱垂综合征患者的症状、体征、心电图以及超声心动图进行分析。结果　 (1)大部分患者无症状 ,有症状的主要表现为胸痛、心悸、头晕、乏力、焦虑等。典型体征为心尖区闻及喀喇音和收缩期杂音。 (2 )心电图表现各异 ,呈非特异性。 (3)超声心动图可直接观察二尖瓣脱垂部位、程度和二尖瓣关闭不全程度。结论　典型的症状、体征对发现本病有一定价值 ,但由于部分患者缺乏症状和体征 ,心电图表现非特异性 ,故诊断有赖于超声心动图     

Depression treatment in primary care

BACKGROUND: Depression costs the United States dollars 40 billion annually. Primary care physicians play a key role in the identification and treatment of depression. This study focused on the treatment options recommended by physicians and whether physicians were following the recommended treatment guidelines. METHODS: We recorded treatment recommendations by examining charts for all patients with newly detected depression. The patients were from 44 family medicine practitioners and 23 general internal medicine practitioners in a Midwest university medical center setting. RESULTS: For both medical specialties combined, pharmacotherapy was the most widely used intervention (recommended for 52% of patients), whereas psychotherapy alone was the least frequently used intervention (recommended for 4% of patients). Family medicine practitioners recommended combination treatment (pharmacotherapy and psychotherapy) more frequently than did general internal medicine practitioners (P = .022), and female physicians recommended combination treatment more frequently than did male physicians (P = .010). CONCLUSIONS: Pharmacotherapy was found to be the most widely used treatment despite current evidence-based recommendations. Barriers to effective treatment plan are discussed. The implications for mental health interventions, combination therapy, and cost offset are also discussed. Further research exploring the negotiation process during the patient-provider encounter would shed light on patient and physician factors influencing treatment decisions.     

Experience in the care of patients with artificial heart valves

Author reports of 164 cases, 145 of whom received mechanic artificial valves and 19 bioprosthesis. 76 valves were implanted in mitral position, 65 in aorta position, 19 in mitral and aorta position, and 4 valves were localized in other positions. Follow-up was 5.9 years meanly. During care paravalvular insufficiency (11 cases) and infectious endocarditis (9 cases) were observed most frequently. Thromboembolic complications developed in 6 patients, artificial-valve-thrombosis and severe haemorrhage occurred in four cases respectively. During care 32 patients died. This is a 5.4 p.c. mortality. The most frequent causes of death were left-ventricle insufficiency (10) and infectious endocarditis (8). Artificial valve thrombosis and subdural haemorrhage lead to death in three cases respectively. Author discusses anticoagulant treatment and emphasizes the importance of regular control to avoid complications and to discover them at an early stage.     

Prophylaxie de l'endocardite infectieuse,risque d'endocardite infectieuse en fonction de l'état cardiaque

Despite its relative scarcity, the frequency of infectious endocarditis remains stable in France and measures must be taken to improve prophylaxis. Thus, the identification of patients at high risk of endocarditis is important so as to focus our prevention efforts on this population. The identification of these risk patients is difficult because of the low number of endocarditis, the bad definition of heart diseases prevalence in the global population, and the time and geographic variability of endocarditis epidemiology. The multiple recommendations published on this issue reflect its difficulty. Nevertheless, reviewing the numerous publications on this issue allows to identify three risk levels. High risk heart diseases, for which antibioprophylaxis is justified, include prosthetic valves, some congenital heart diseases, and history of endocarditis. Low risk heart diseases, for which antibioprophylaxis is not justified, include, for example, inter-atrial communication. The interest of prophylaxis is not as clear-cut for mild risk heart diseases such as mitral prolapsus or hypertrophic cardiomyopathy.     

The incidence of endocarditis caused by a prosthetic valve and its risk factors

To study the incidence and risk factors of prosthetic valve endocarditis (PVE) we followed 99.5% of 912 patients who had valve replacement from January 1, 1981 through December 31, 1985, for 1 to 6 (mean 3) years. PVE occurred in 27 patients (2.96% or 0.98% per patient-year). The incidence of PVE in the aortic position (3.9%) was significantly higher than in the mitral position (1.5%): p less than 0.25. PVE developed in 19 out of 329 patients with bioprostheses (5.8%) and in 8 out of 583 patients with mechanical valves (1.4%): p less than 0.005. Actuarially at 5 years follow-up 90.7% of the bioprosthetic group and 98.4% of the mechanical valve group was free of PVE (p less than 0.01). Bioprosthetic valve replacement in infective endocarditis further increased the risk of PVE compared to valve replacement by mechanical prostheses. In conclusion: in order of importance antecedent endocarditis, bioprostheses, male sex and aortic position are risk factors in the development of PVE. In patients requiring operation for infective endocarditis, mechanical valves are recommended. As the outcome of PVE is still very grave, authors stress the importance of prophylaxis, early diagnosis and timely operation.     

The Montana Model: Integrated Primary Care and Behavioral Health in a Family Practice Residency Program

To address the local health care needs of both patients and primary care providers in Montana, an integrated primary care and behavioral health family practice clinic was developed. In this paper we describe our experience with integrating mental health and substance abuse services into a primary care setting (a community health center) while simultaneously teaching family practice physicians to take the lead in providing these services. The Deering Community Health Center in Billings, Montana, is a Federally Qualified Health Center serving a largely low-income patient population. The medical care at the clinic is provided primarily by the faculty and residents of the Montana Family Medicine Residency. The teaching model was founded on the belief that improved care will result when physicians have increased comfort with, and are able to enjoy the challenges of, patients with mental illnesses. The enhanced longitudinal curriculum incorporates mental health across the 3 years of the family practice residency. Unique characteristics of this model include staffing and the concurrent delivery of a high volume mental health service while teaching family practice resident physicians and the faculty to integrate this competency into their primary care practices.     

Improving preventive care at a medical clinic: how can the patient help?

We developed a comprehensive individualized preventive care reminder system and then tested the hypothesis that directly involving patients in the reminder process would lead to greater use of preventive services than involving physicians only. There were three experimental groups of 350 patients each: in group 1 physicians and patients received the reminder; in group 2 physicians only received the reminder; in group 3 neither physicians nor patients received the reminder. Nine preventive care services were studied: blood pressure measurement; dental exam; ocular pressure measurement; stool exam for occult blood; influenza, pneumococcal, and tetanus vaccinations; mammography; and Papanicolaou smears. Need for these services was determined by telephone interview and chart review. To determine whether services were obtained, charts were reviewed after four to eight months of follow-up. For overall compliance with preventive recommendations and for several individual services (stool exam for occult blood, tetanus vaccination, mammography), group 1 patients received significantly more preventive care than group 2. Likewise, group 2 patients received more preventive care than group 3. These data show that involving patients in reminder efforts is an effective means of raising the level of preventive services.     

Improving the periodic health examination: use of a screening flow chart for patients and physicians

An attempt was made to improve periodic health examinations in a family practice department. Both physicians and patients were instructed in the use of a screening flow sheet that listed the clinic's minimum recommendations for the periodic health examination. Both groups were also educated about the evidence against ordering other tests routinely, such as x-ray examinations and blood tests. Audits were performed before and after physician and patient education on a total of 384 charts. Compliance with all of the screening flow-sheet recommendations improved with education. Significant improvements occurred with the ordering of the tetanus-diphtheria booster and proctosigmoidoscopy examinations. Compliance for most procedures, however, remained well below the recommended level. Unnecessary testing was not decreased by the educational effort. The complete blood count was actually ordered significantly more often after patient education despite the lack of evidence of its value in screening. Although physician and patient education in the use of the screening flow sheet did result in some improvement in the ordering of recommended tests, the optimal method of improving periodic health examinations has yet to be found.     

Noncardiac chest pain in adolescents and children with mitral valve prolapse

Chest pain in adolescents and children is usually not of cardiac origin. Of cardiac conditions commonly linked to chest pain in childhood, mitral valve prolapse (MVP) is the most prevalent, but this association has recently been questioned. In light of recent reports of gastroesophageal sources of chest pain in adults with MVP, we performed a comprehensive gastroesophageal evaluation of 17 preadolescents and adolescents with mitral valve prolapse who had chest pain as their presenting symptom. Evaluation consisted of esophageal manometry, Bernstein test, esophageal pH probe, and/or esophagogastroscopy. Fourteen of the 17 patients had at least one abnormal finding. Five patients had esophagitis, five had gastritis, one had high-amplitude esophageal contractions, one had abnormal esophageal manometry with positive Bernstein test, one had esophageal reflux and positive Bernstein test, and one had abnormal manometry with esophageal reflux. The 13 patients with esophagitis, gastritis, reflux, or positive Bernstein test were treated with antacid, with resolution of chest pain in 12 patients. Two of these patients underwent follow-up endoscopy with documentation of improvement. The patient with high-amplitude esophageal contractions was treated with dicyclomine, which resulted in resolution of chest pain. The observation that the chest pain was not related to mitral valve prolapse is important in clinical practice and raises further questions as to whether mitral valve prolapse causes chest pain.     

The use of the family APGAR in screening for family dysfunction in a family practice center

The Family APGAR questionnaire was used to determine the prevalence of self-reported family dysfunction present in patients who attended a family practice center, to determine whether knowledge of the Family APGAR score increased the frequency with which family physicians evaluated family functioning and diagnosed family dysfunction, and to determine whether certain psychosomatic complaints associated with family dysfunction were more common in a group of patients with a Family APGAR score of less than 6. To achieve these purposes, all patients entering the center were asked to fill out a Family APGAR questionnaire during the month of March 1984. Physicians learned of the results in a randomly selected one half of all cases. A chart review was conducted one month later. Twenty-four percent of patients reported family dysfunction (APGAR less than 6). Knowledge of the APGAR score did not increase the frequency with which physicians evaluated family function (20 percent known vs 17 percent unknown) or diagnosed family dysfunction (6.3 percent known vs 6.4 percent unknown). Patients with self-reported family dysfunction as defined by the Family APGAR did not have more psychosomatic complaints noted in their charts than patients without self-reported family dysfunction. Family dysfunction is a common problem in family practice patients, it is recorded infrequently in patients' charts, and knowledge of the results of a screening device does not increase the frequency with which family dysfunction is noticed.