Impact of transthoracic echocardiography at district hospital level.

BACKGROUND: The use of and demand for echocardiography (ECHO) has increased worldwide. In developed countries, this has not translated into improved access outside tertiary centres. Previous studies have favoured the appropriate use of ECHO over its clinical impact, limiting generalisability to resource-constrained settings. OBJECTIVES: To assess the impact of an ECHO service at district hospital level in Cape Town, South Africa. METHODS: A prospective, cross-sectional study was performed. A total of 210 consecutive patients, referred to the ECHO clinic over a 5-month period, were recruited. Transthoracic ECHO was evaluated in terms of its indication, new information provided, correlation with the referring doctor's diagnosis and subsequent management plan. Impact included the escalation and de-escalation of treatment, as well as usefulness without a change in management. RESULTS: The results show that 83.8% of the patients' management was impacted on by echocardiography. Valvular lesions were the main indication. The most frequent contribution was information provided towards the diagnosis of heart failure and assessment after myocardial infarction. Of the echocardiograms, 56.2% confirmed the referring doctor's diagnosis, yet were still associated with a significant impact. The rational prescription of medication had the major impetus, followed by de-escalation of therapy and screening patients to determine referral to a tertiary facility. CONCLUSION: ECHO has a positive impact on patient management outside tertiary settings, where the definition of impact appears to be different. The value of a normal study, screening prior to upstream referral and usefulness irrespective of change have been established. This should alert policy makers against restriction of access to ECHO and promote training of personnel in its use.

The clinical utility and cost effectiveness of routine thyroid screening in adult psychiatric patients presenting at Stikland Hospital, Cape Town, South Africa.

OBJECTIVE: The use of thyroid tests to assess psychiatric patients remains debatable. Therefore, this study was conducted to examine the utility and cost effectiveness of the current protocol used in thyroid testing in adult psychiatric patients presenting at Stikland Hospital, Cape Town, South Africa. METHOD: This was a retrospective chart review conducted at Stikland Hospital between 1 January 2000 and 31 December 2005. The following data was recorded: demographic variables, clinical diagnoses at admission and discharge, number of days from admission to a thyroid test request, the reason for thyroid screening, number of thyroid tests, their yield and costs involved, as well as the action taken following an abnormal thyroid test result. RESULTS: The mean age of patients (n = 1080: n = 364 male, n = 716 female) was 42.8 years (SD ± 16.6). Pre-existing thyroid disease was documented in 70 (6%) of patients. Normal Thyroid Stimulating Hormone (TSH) test results significantly (p = 0.0001) increased, whilst abnormal TSH test results significantly (p = 0.0001) decreased from baseline to follow-up. Except for gender, the outcome of TSH screening was independent of demographic and clinical diagnoses. Only 16% of TSH tests yielded clinically significant results. CONCLUSION: The findings of this study do not support the early, routine screening for thyroid dysfunction in psychiatric patients at this facility. It is possible that thyroid screening may present with transient abnormalities of no particular clinical significance, and would therefore not be a cost effective practice.

Mitral valve prolapse and body habitus in children.

Mitral valve prolapse has generally been associated in adults with a thin body habitus. However, prior studies used biased samples or limited anthropometric measures. In addition, no information has been available on the subjective assessment of body habitus and diagnosis of mitral valve prolapse, especially in children. We conducted a cross-sectional study on 813 children with uniform assessment of anthropometric measures and mitral valve prolapse. Consistent with research conducted on adults, those subjects with mitral valve prolapse were lighter, thinner, and had, on average, lower values for several, quantifiable anthropometric parameters with the exception of height. However, the subjective assessment showed that while the assessment did not differ by diagnosis, those subjects with mitral valve prolapse were never described as fat. These data support an association between mitral valve prolapse and slender body habitus and extends it to children, thus underscoring the clinical importance that a thin body habitus may be a marker for mitral valve prolapse throughout the age span. This association may partly explain the observed genetic distribution of mitral valve prolapse.

[Transthoracic lung punctures]. / Les ponctions pulmonaires transthoraciques.

Transcutaneous needle aspiration (PTT) is a diagnostic technique which consists of biopsying pathological lung tissue using a needle (which in general is specifically designed for the purpose) which is introduced into the thorax transcutaneously. The target is lined up, either radioscopically or using a CT scanner and this enables the needle to be positioned in the centre of the lesion radiologically where one or more biopsies can be taken. According to the type and diameter of the needle these biopsies will enable a histological examination to be performed in addition to a cytological and bacteriological examination. This performance is particularly indicated in the final assessment of a periphery pulmonary nodule which is suspected of being neoplastic where bronchofibroscopy has been non contributory and where an immediate thoracotomy (diagnostic or therapeutic) is not recommended for one or other reason. When performed for this indication the technique often achieves a sensitivity of 90% with an average specificity of 98%. The diagnostic yield for benign tumours is less. It is always necessary to maintain a degree of vigilance in view of the risk of false negative or "benign" results. The complications exist above all of pneumothoraces which occur in 20-30% of cases and which will require a drain in 5-10% of cases. Haemorrhage and haemoptysis are less frequent but potentially fatal even in the absence of any coagulation disturbance.

[Hyperventilation syndrome: current advances]. / Syndrome d'hyperventilation: mise au point.

The hyperventilation syndrome has been described for half a century but clearly remains underdiagnosed. Its acute manifestation is easily diagnosed ("the tip of the iceberg") but its recognition in numerous subtle forms requires a particular degree of alertness on the part of the clinician ("the hidden part of the iceberg"). The incidence of this syndrome in the general population varies according to different authors as between 6-11% and may mimic diverse organic disorders. The physiological consequences of hyperventilation are reviewed as well as their contribution in the clinical picture. The aetiology of the syndrome and its links with organic pathology or psychiatric disturbances continues to be debated. Is hyperventilation the expression of abnormal respiratory function or a preferred manifestation of anxiety? This article discusses and reviews the variety of tests which enable the presumptive diagnosis to be confirmed. The response to the proposed treatments is generally excellent when one takes account of the numerous possible options. These include comportmental therapies such as respiratory re-education, the utilisation of betablockers and psychotrophic drugs or psychotherapy.

[Exercise tests in pneumology. C.R.E.D.O]. / L'épreuve d'effort en pneumologie. C.R.E.D.O.

Exercise tests have proved very useful in numerous areas such as sports medicine, research, clinical medicine and rehabilitation to exercise and therapeutic trials. It is not always easy for a pneumologist to decide what sort of effort and which protocol to use. There is also the question of which parameter to use and the relationship between parameters and which are the most pertinent as a function of the aim of the research. Above all the exercise test should be adaptable in view of the diversity of the objectives. In routine pneumology the exercise test using a bicycle ergometer and a triangular type of protocol are recommended for numerous reasons. The usual parameters (ventilation, oxygen consumption, production of carbonic dioxide, cardiac rate and blood gases) and their derivatives all have a value in the domain of cardiorespiratory physiology. It is important in clinical practice not to give too great an emphasis to the exact relationship expressed as a function of the workload, because the cycloergometer is practically never calibrated or even checked by the user. Dyspnoea was the major symptom leading the patient to seek a consultation and it is of primary importance that all effort tests include an estimation of the sensation of breathlessness.

[Contribution of polysomnography in the assessment of patients with chronic obstructive bronchopneumopathy]. / Apport de la polysomnographie à la mise au point des malades atteints d'une bronchopneumopathie chronique obstructive (BPCO).

15 COPD patients underwent a polysomnographic study demonstrating poor quality of sleep, a mean of SAO2 of 88.8 +/- 3.9% and a apneic-hypopnea index (AHI) of 5.7 +/- 11.8. AHI was higher in sleep stages I and II than in REM sleep. SAO2 showed a progressive drop when going from an awake stage to REM sleep. Respiratory events responsible for the most important desaturation where mostly observed in REM sleep and corresponded in 8 patients to obstructive events (overlap syndrome). The lower mean SAO2 in REM probably explains the best the importance in desaturation related to the respiratory events (Hb dissociation curve). Ear oximetry recordings however interesting are not able to quantify and recognise correctly the respiratory events. Therefore a polysomnographic study remains necessary in order to diagnose adequately the overlap syndrome.

Mitral valve prolapse: associations with symptoms and anxiety.

Mitral valve prolapse has been studied extensively in the adult population, but less is known about it in children. Therefore, 813 children between 9 and 14 years of age were examined by a team of cardiologists and technicians. The children also responded to a questionnaire concerning the presence of symptoms and the What I Think and Feel anxiety instrument. The prevalence of mitral valve prolapse using auscultatory criteria was 4.2% (6.2% for girls, 2.3% for boys). Of those with mitral valve prolapse, 85% had a solitary click, 9% had a click and systolic murmur, and 6% had multiple clicks. Children with auscultatory mitral valve prolapse were less likely to have symptoms than those free of cardiac abnormalities. No difference in average anxiety scores was detected between the two groups. It is concluded that auscultatory mitral valve prolapse is common in children and not accompanied by an increased likelihood of symptoms or anxiety.

[Sleep studies in adults: interest in snoring disorders and the sleep apnea syndrome]. / Les études de sommeil chez l'adulte: intérêt dans la ronchopathie et dans le syndrome d'apnée du sommeil.

The authors review the concept of sleep apnea syndrome in adults. A description of a polysomnigraphic study is given. Personal results in a population of obese heavy snorers are summarized.

Beat-to-beat left ventricular performance in atrial fibrillation: radionuclide assessment with the computerized nuclear probe.

There is wide beat-to-beat variability in cycle length and left ventricular performance in patients with atrial fibrillation. In this study, left ventricular ejection fraction and relative left ventricular volumes were evaluated on a beat-to-beat basis with the computerized nuclear probe, an instrument with sufficiently high sensitivity to allow continuous evaluation of the radionuclide time-activity curve. Of 18 patients with atrial fibrillation, 5 had mitral stenosis, 6 had mitral regurgitation, and 7 had coronary artery disease. Fifty consecutive beats were analyzed in each patient. The mean left ventricular ejection fraction ranged from 17 to 51%. There was substantial beat-to-beat variation in cycle length and left ventricular ejection fraction in all patients, including those with marked left ventricular dysfunction. In 14 patients who also underwent multiple gated cardiac blood pool imaging, there was an excellent correlation between mean ejection fraction derived from the nuclear probe and gated ejection fraction obtained by gamma camera imaging (r = 0.90). Based on beat-to-beat analysis, left ventricular function was dependent on relative end-diastolic volume and multiple preceding cycle lengths, but not preceding end-systolic volumes. This study demonstrates that a single value for left ventricular ejection fraction does not adequately characterize left ventricular function in patients with atrial fibrillation. Furthermore, both the mean beat-to-beat and the gated ejection fraction may underestimate left ventricular performance at rest in such patients.

Exercise left ventricular performance in patients with chest pain, ischemic-appearing exercise electrocardiograms, and angiographically normal coronary arteries.

Left ventricular performance was evaluated using first-pass radionuclide angiocardiography in 31 patients with chest pain, an ischemic-appearing exercise electrocardiogram, and angiographically normal coronary arteries at rest and during maximal upright bicycle exercise. Thallium-201 (201 TI) imaging was done in all patients after treadmill exercise and in selected patients after ergonovine provocation. Resting left ventricular performance was normal in all patients. An abnormal ejection fraction response to exercise was detected in 12 of 31 patients. Regional dysfunction was present during exercise in four patients, all of whom also had abnormal global responses. Three of these 12 patients and two additional patients had exercise-induced 201 TI perfusion defects. In all nine patients who underwent ergonovine testing, there was no suggestion of coronary arterial spasm. Thus, left ventricular dysfunction during exercise, in the presence of normal resting performance, was found in a substantial number of patients with chest pain, an ischemic-appearing exercise electrocardiogram, and normal coronary arteries.

Innocent murmurs and third heart sounds in Black schoolchildren.

Normal auscultatory findings were studied during a heart survey in which 12 050 Black schoolchildren, aged 2 to 18 years, were examined by cardiologists. Physiological third heart sounds were detected in 96 per cent of children, innocent systolic murmurs in 72 per cent, and innocent mid-diastolic murmurs in 0.27 per cent. The term 'innocent systolic murmur" was used for vibratory systolic murmurs (70%) and pulmonary ejection systolic murmurs (4.2%) but distinct separation of these two murmurs was often difficult. Vibratory systolic murmurs were present throughout the age range. Important features in differentiating innocent systolic murmurs from those caused by mild organic heart disease included the intonation, site of maximal intensity, timing in systole, and behaviour with postural change. Innocent mid-diastolic murmurs are short murmurs occurring immediately after the third heart sound in children, with no supportive evidence of organic heart disease.

Mitral valve commissurotomy versus replacement. Considerations based on examination of operatively excised stenotic mitral valves.

Among 164 patients who underwent mitral valve replacement because of mitral stenosis (with or without mitral regurgitation) and had radiographs taken of their operatively excised mitral valves, 20 had absent or minimal calcific deposits in the excised valves and absent or minimal mitral regurgitation as determined, except for one patient, by left ventricular angiography preoperatively. This report focuses on these 20 patients to ask if mitral valve replacement was preferable to mitral valve commissurotomy. Although in the pre-valve replacement era, all 20 patients almost surely would have been considered good candidates for mitral commissurotomy, other factors, namely, the need to replace one or more other cardiac valves (13 patients), the utilization of cardiopulmonary bypass allowing visual inspection rather than simple palpation of the diseased mitral valve (all 20 patients), relatively little experience with mitral commissurotomy in four of the five surgeons (17 patients), displeasure with attempted commissurotomy (three patients), previous mitral commissurotomy (11 patients), and incorrect identification of mitral calcific deposits (two patients), each contributed in one or more patients to the final decision of replacement versus commissurotomy. Even though mitral commissurotomy has been in use for 30 years, the mere alternative of valve replacement may have altered somewhat the definition of the stenotic mitral valve previously considered ideal for mitral commissurotomy.

Prevalence of congenital heart disease in black schoolchildren of Soweto, Johannesburg.

A survey conducted by cardiologists in Soweto, Johannesburg, provided an opportunity of assessing the frequency of congenital heart disease in black schoolchildren. Among 12,050 schoolchildren aged 2 to 18 years, 48 had a congenital heart defect, yielding a prevalence of 3.9 per 1000. Only in 2- to 6-year-old children did the prevalence exceed that of rheumatic heart disease. The distribution of the types of defects was largely similar to that reported in other surveys with a predominance (52%) of ventricular septal defects. Two unusual findings were the unexplained absence of persistent ductus arteriosus in these children, and the detection of 5 children with situs inversus (1 in 2410). In all but one child, the congenital heart defect was first discovered during the survey. Despite the limitations of a prevalence study, it can be concluded that congenital heart disease is at least as common in this South African black community as in Caucasians.