Cardiac auscultatory skills of academic family physicians: strength of association with an academic pediatric cardiologist.

Aim. Heart murmur is common in children, and it is one of the main reasons for referral among children in primary care. The aim of this study is to evaluate agreement and consistency of normal, innocent, and pathologic murmur decision between academic family physicians and academic pediatric cardiologist. Methods. Seven hundred fifteen primary school children were examined by family physicians and paediatric cardiologist. Auscultatory examination was performed. Intensity, frequency, duration, quality, location, and radiation of the murmur were described if present. Agreement of normal, innocent, and pathologic murmur classification decision between family physician and paediatric cardiologist was analyzed by using kappa statistic. Results. Normal, innocent and pathologic murmurs were reported for 419, 228, and 54 children in family physicians' reports, respectively. Paediatric cardiologist agreed on 383 (91.4%) children as normal, 191 (83.7%) children having innocent murmur, and 19 (35.2%) children having pathologic murmur among family physician's reports. There was good consistency between family physicians and paediatric cardiologist (κ value = 0.679, 95% CI 0.630-0.727, P < .001). They agreed on the majority of normal and innocent murmur decisions. However family physicians reported pathologic murmur more frequently. Conclusion. Cardiac auscultatory skills of academic family physicians may be concordant with paediatric cardiologist.

Obesity and open-heart surgery in a developing country.

OBJECTIVE: The aim of the present study was to assess obesity as a risk of adverse outcomes following cardiac surgery. METHODS: The data of 324 consecutive patients who underwent elective procedures requiring cardiopulmonary bypass in a single cardiac center in South-Western Anatolia were retrospectively analyzed. There were 250 males and 74 females. Median age was 58.8 years (range 17 to 90 years). A body mass index (BMI)> or =30 kg/m2 was defined as obesity. Adverse outcomes analyzed included in-hospital mortality, chest tube drainage, reopening, inotropic support, arrhythmias, deep sternal wound infection, superficial surgical site infection and hospital stay duration. Multiple logistic regression analysis was performed to assess the relationship of obesity with clinical outcomes after cardiac surgery. Covariates considered in the logistic model included age, gender, pulmonary disease, cerebrovascular disease, smoking, hypertension, and diabetes. RESULTS: Fourteen percent of patients (47/324) were obese and this ratio is quite smaller than reported for industrialized countries. The results of multiple regression analysis demonstrated that obesity was a risk factor only for superficial sternal or harvesting site infection (odds ratio--4.5, 95% CI--1.404-14.679, p=0.012). CONCLUSION: Obesity was associated with increased risk of superficial surgical wound infections following cardiac surgery. In comparison with industrialized countries, obesity may account for fewer adverse events in patients undergoing open-heart surgical procedures in South-Western Anatolia, a developing country sample.

Correlation between N-terminal pro B-natriuretic peptide and ultrasonic backscatter: implications for diastolic dysfunction in hypertension.

OBJECTIVE: This study was designed to determine how N-terminal pro brain-natriuretic peptide (NT-proBNP) levels correlate with cyclic variation of integrated backscatter (CVIBS) as a reflection of abnormal diastolic function in hypertension. PATIENTS: Forty essentially hypertensive patients were studied. CVIBS values were obtained from the septal wall in the parasternal long-axis view. Twelve had normal diastolic function, 18 had impaired relaxation, and 10 had pseudonormal pattern. RESULTS: Patients with normal diastolic function had a mean NT-proBNP concentration of 34 +/- 17 pg/ml and a mean CVIBS value of 7.1 +/- 0.9 dB; those with impaired relaxation had a mean NT-proBNP concentration of 71 +/- 25 pg/ml and a mean CVIBS value of 6.7 +/- 1.1 dB. Patients with pseudonormal pattern had the highest NT proBNP levels (206 +/- 75 pg/ml) and lowest CVIBS values (5.7 +/- 0.9 dB). An NT-proBNP value of 62 pg/ml had a sensitivity of 83% and a specificity of 91%; a CVIBS value of 7.2 dB had a sensitivity of 83.3% and a specificity of 66.7% for detecting diastolic dysfunction. An NT-proBNP value of 120 pg/ml had a sensitivity of 76% and a specificity of 96%; a CVIBS value of 6.1 dB had a sensitivity of 87.5% and a specificity of 75% for detecting severe diastolic dysfunction. A close correlation was found between the NT-proBNP and CVIBS values (r: 0.54, P < 0.05). CONCLUSION: Combinative use of NT-proBNP and CVIBS can detect the presence of diastolic abnormalities on echocardiography. A good correlation was found between the NT-proBNP and CVIBS values in detecting diastolic dysfunction in essentially hypertensive patients.

Identifying osteoporosis in a primary care setting with quantitative ultrasound: relationship to anthropometric and lifestyle factors.

Dual-energy X-ray absorptiometry (DXA), the "gold standard" for diagnosis of osteoporosis, is not recommended for population screening, and thus quantitative ultrasound (QUS) of the calcaneus is gaining popularity. The aim of the present study was to evaluate the relationship between QUS values and anthropometric and lifestyle factors, and to assess the diagnostic performance of QUS in predicting DXA-defined osteoporosis. Eight hundred and thirty-two women and 87 men aged 40-88 years were included in the study. Anthropometric measurements, the questionnaire, and QUS and DXA measurements were performed by trained physicians. Both QUS and DXA T-scores were lower for women than for men. Postmenopausal women had significantly lower QUS T-scores compared to premenopausal women (P < 0.001). Age over 50, female sex, sedentary lifestyle, fracture history, presence of chronic disease, and > or =5 years since menopause were associated with QUS T-scores lower than -1.00 by multivariate analysis. Low QUS T-scores were related to lack of direct sun exposure, high parity, fair skin color, and no education by univariate analysis (P < 0.005). A weak correlation was found between calcaneal QUS and DXA T-scores at lumbar spine (r = 0.310, P < 0.001) and femoral neck (r = 0.288, P < 0.001). The sensitivity and specificity of the QUS test were 73.7% and 57.4%, respectively, regarding the identification of osteoporotic patients. Lower QUS T-scores were associated with several osteoporotic risk factors, and the sensitivity and specificity of QUS for predicting DXA-defined osteoporosis were at optimum values at ages between 50 and 59 years. We conclude that, even though the accuracy of QUS for predicting DXA-defined osteoporosis is not remarkably high, it can be applied to identify subjects at risk in this age group in developing countries and rural districts who should be the focus of fracture prevention.

Hypotension induced by lateral decubitus or supine spinal anaesthesia in elderly with low ejection fraction undergone hip surgery.

OBJECTIVE: The aim of the study was to assess the effect of low ejection fraction (EF) on hypotension during lateral or supine position of spinal anaesthesia in patients older than 75 years old. METHODS: We analyzed 41 patients who had undergone hip surgery between August 2000 and October 2001 in the Aydin SSK State Hospital retrospectively. Patients older than 75 years of age and an EF less than 50% were selected and spinal anaesthesia was performed with hyperbaric bupivacaine 0.5%, lateral decubitus or supine position. The patients were divided into two groups: Group I (unilateral group, n = 23) and Group II (supine group, n = 18). History of hypertension, diabetes mellitus, and ASA status, preoperative value of EF and cardiac index, and intraoperative hypotension, bradycardia, ephedrine use, and maximal sensorial block levels were recorded. RESULTS: The age range of patients was between 75 and 103. The maximal sensorial block level was evaluated due to lower or higher than thoracic sixth segment for each patient in intraoperative period. The sensorial block level higher than thoracic sixth segment were determined 2 patient in Group I and 14 patients in Group II (p = 0.001). Hypotension was observed in five patients in Group I and 10 patients in Group II (p = 0.015). In Group I, the number of ephedrine used patient was lower than Group II (p = 0.015). CONCLUSIONS: Elderly patients with low EF were more likely to predispose to higher sensorial block level and hypotension was more common during spinal anaesthesia with supine position compared to lateral decubitus position.

Trimetazidine in the prevention of contrast-induced nephropathy after coronary procedures.

OBJECTIVE: To evaluate the efficacy of trimetazidine (TMZ) in the prevention of contrast-induced nephropathy (CIN) in patients with high serum creatinine levels undergoing coronary angiography/angioplasty. METHODS: TMZ (20 mg thrice daily) was administered orally for 72 h starting 48 h before the procedure. All patients were given intravenous saline (0.9%) at a rate of 1 ml/kg of body weight per hour for 24 h starting 12 h beforehand. Serum creatinine levels were measured before the procedure, 48 h and 7 days after the procedure. Increase in serum creatinine level exceeding 0.5 mg/day or one quarter of the basal value is considered as CIN. Venous blood samples for serum total antioxidant capacity (TAC) measurement were drawn before and after coronary angiography. RESULTS: Basal serum creatinine levels and TAC were similar in TMZ and control groups. Serum creatinine levels in the control group increased significantly 2 days after the procedure, and returned to the baseline values on the seventh day. However, it did not change significantly on the second day, and even significantly decreased on the seventh day in the TMZ group. CIN developed in 2.5% (1/40) of patients in the TMZ group and in 16.6% (7/42) of patients in the control group (p<0.05). TAC values were not different between treatment groups. CONCLUSION: TMZ along with isotonic saline infusion is more effective than isotonic saline alone in reducing the risk of CIN in patients with pre-existing renal dysfunction.

Profile of menopausal women in west Anatolian rural region sample.

OBJECTIVES: The aim of this study was to evaluate age at menopause, climacteric symptoms and related factors in women living in west Anatolian rural region of Turkey. METHOD: This study included 761 menopausal women living in three rural towns. Questionnaires regarding to 10 climacteric symptoms, menopausal status, sociodemographic characteristics, parity, breastfeeding, presence of chronic illness, direct sun exposure, smoking, caffeine use and hormone replacement therapy (HRT) were filled out by face-to-face interview. Logistic regression analysis was used to assess confounding factors on the age of menopause and menopausal status. RESULTS: Mean age at menopause was 44.38+/-5.30 years. Breastfeeding more than one year, low level of direct sun exposure and mother's early age at menopause were associated with early onset of menopause. The most prevalent climacteric symptoms were urine leakage, decreased libido, lack of energy and poor memory in post-menopausal and hot flushes in peri-menopausal women. Somatic and psychological symptoms were associated with hot flushes. HRT and osteoporosis treatment usage were higher in surgical menopause group. Osteoporosis and Type 2 Diabetes Mellitus (DT) were more common in natural menopause group. No association was found with onset of menopause and smoking, excess caffeine use, BMI, marital status and presence of chronic illness. Cardiovascular risk factors such as hypertension (HT), diabetes and obesity were common in post-menopausal women. CONCLUSION: Onset of menopause in Turkish women living in rural region is earlier on average women living in western or industrialized countries. Hot flushes in peri-menopausal, and urogenital, and psychological in post-menopausal women are the most prevalent symptoms. Primary care services in rural districts should focus on cardiovascular risks of menopausal women.