Cardiopulmonary Auscultation Research Articles

Craniolacuna, cribriform skull associated with myelomeningocele and chiari type II malformation: A case report.

Cranial lacuna is a low density radiological image of the cranial vault giving the appearance of beaten copper, the rarefaction zones which are several, producing radiologically a "soap bubble" or "honeycomb" effect. due either to an absence of the internal and external tables or to the absence of a single table or to localized demineralization. They are either physiological or pathological. They are associated with neurological malformations especially hydrocephalus, myelomeningocele and chiari type II malformations. We report the case of a newborn aged one day, admitted for the management of myelomeningocele associated with a chiari type II malformation and a lacunar skull diagnosed postnatally. The newborn is a male, 39 weeks pregnancy, cesarean section. Weight 3500 g, Apgar: 7/10, 8/10. Mother: G6/P5. His clinical examination reveals good skin-mucosal coloration, eupnea, slight axial hypotonia, normal cardiopulmonary auscultation, permeable choanae and esophagus, cranial perimeter at 33 cm, ruptured spina bifida. The skull X-ray reveals a beaten copper appearance of the skull with marked convolutions. The normal chest X-ray. The Abdomino-Pelvic ultrasound finds bilateral uretero-hydronephrosis more marked on the left, with distended bladder and signs of neurogenic bladder. The normal echocardiogram. The brain CT scan reveals a type 2 Chiari malformation, absence of hydrocephalus, The negative infectious assessment, The correct renal assessment, The newborn received neurosurgical management of spina bifida, with a reserved neurological prognosis. This condition is associated with neurological malformations that can have a poor prognosis. Prognosis is reserved in the event of an association with a myelomeningocele because it is dominated by the risk of infection and the dark neurological outcome. The lacunar images resolve spontaneously after 4 to 6 months.

VPExam in Heart Failure Innovating Virtual Cardiac Care

Telehealth and Virtual care are growing fields of importance, but the loss of comprehensive physical exam creates barriers to managing complex patients especially those with heart failure. Disruptive digital tools such as VPExam virtual care combine augmented reality instruction of visuals with bluetooth stethoscopes and ECGs to improve accuracy by assessing volume status, cardiopulmonary auscultation, arrythmia detection, and providing structured data including remote patient monitoring (RPM) data, vitals, medication reconciliation, and labs. VPExam intervention has significantly improved outcomes for high-risk and underserved populations with heart failure discharged to Skilled Nursing Facilities and Home Care. VPExam QI revealed workflows for both routine and urgent cardiology consultation following heart failure hospitalizations resulted in moderate significance modification in clinical management in 84% of encounters, while being associated with a 40% relative risk reduction in 30-day hospital readmission rate and a 56% relative risk reduction in 30-day mortality rate. The review summarizes both challenges to cardiac transitions of care and the evolution of cardiac virtual care with actionable physical exam data to optimize readmissions and mortality that is especially relevant to the underserved populations of skilled nursing facilities and home bound patients served by home care agencies.

Contribution of Computed Tomography in the Diagnosis of Multifocal Non-Hodgkin’s Lymphoma at the Mother-Child University Hospital the ‘’Luxembourg’’ About a Case

Lymphoma is a malignant proliferation of lymphoid tissue cells. We report a case of multi-focal lymphoma of lymph node, pharyngeal, cardiac and splenic sites. This was a 19-year-old patient received in February 2023, at the radiology and medical imaging department of the Mother and Child University Hospital Center ''Luxembourg'' as part of the CT exploration of a lateral mass. -left cervical. On admission, the clinical examination found a patient with an altered general condition, moderately colored conjunctiva, normal blood pressure and temperature. Examination of the lymph node areas revealed a left latero-cervical swelling, and fixed bilateral axillary swellings, of firm consistency and irregular contours. Palpation revealed hepatosplenomegaly. Cardiopulmonary auscultation was normal. A cervico-thoraco-abdominal CT scan revealed irregular thickening of the left lateral wall of the oropharynx, a hypodense tissue mass in the right cardiac chambers, heterogeneous splenomegaly, cervical, mediastinal, axillary and abdominal ADP. The histological examination carried out after lymph node biopsy revealed a histological appearance of small cell lymphoma. Conclusion: Lymphoma is a very common malignant tumor that can occur at any age. This tumor can affect all organs, however its cardiac location is rare. The positive diagnosis remains histological. Imaging plays an important role in the initial assessment, extension and surveillance.

Clinical decision support system using a machine learning model to assist simultaneous cardiopulmonary auscultation: Open-label randomized controlled trial.

The utility of a clinical decision support system using a machine learning (ML) model for simultaneous cardiac and pulmonary auscultation is unknown. This study aimed to develop and evaluate an ML system's utility for cardiopulmonary auscultation. First, we developed an ML system for cardiopulmonary auscultation, using cardiopulmonary sound files from our previous study. The technique involved pre-processing, feature extraction, and classification through several neural network layers. After integration, the output class was categorized as "normal," "abnormal," or "undetermined." Second, we evaluated the ML system with 24 junior residents in an open-label randomized controlled trial at a university hospital. Participants were randomly assigned to the ML system group (intervention) or conventional auscultation group (control). During training, participants listened to four cardiac and four pulmonary sounds, all of which were correctly classified. Then, participants classified a series of 16 simultaneous cardiopulmonary sounds. The control group auscultated the sounds using noise-cancelling headphones, while the intervention group did so by watching recommendations from the ML system. The total scores for correctly identified normal or abnormal cardiopulmonary sounds in the intervention group were significantly higher than those in the control group (366/384 [95.3%] vs. 343/384 [89.3%], P = 0.003). The cardiac test score in the intervention group was better (111/192 [57.8%] vs. 90/192 [46.9%], P = 0.04); there was no significant difference in pulmonary auscultation. The ML-based system improved the accuracy of cardiopulmonary auscultation for junior residents. This result suggests that the system can assist early-career physicians in accurate screening.

POST HOC ERGO PROPTER HOC? NOT EVERYTHING THAT HAPPENS AFTER COVID-19 IS LONG COVID. OR, THE MANY MASQUERADES OF PHEOCHROMOCYTOMA

Objective: A seemingly endless list of symptoms and conditions are being labeled as long COVID or post-COVID syndrome, but not everything that happens after a COVID-19 episode can be attributed to it. We hereby present a clinical case in which pheochromocytoma was masquerading as long COVID. Design and method: Review of the patient's clinical record and the relevant literature. Results: A previously healthy, non-smoker, 57-year-old woman was admitted in October 2020 with fever, dyspnea and asthenia. She was diagnosed with SARS-CoV-2 bilateral bronchopneumonia and required oxygen therapy but not assisted ventilation or intensive care. Three months after discharge the patient was asymptomatic but in the two following years she progressively developed symptoms of confusion, dizziness, inability to concentrate, gait instability, tachycardia, palpitations, anxiety and insomnia. The syndrome was labeled as post-COVID and in March 2022 began treatment with alprazolam and propranolol. Subsequently she complained of severe non-pulsatile holocranial headache accompanied by vertigo, nausea and skin pallor. In October 2022 she was admitted in Emergency Care with a BP reading of 226/118 mmHg, HR 132 bpm, ECG: sinus rhythm without repolarization anomalies. She was referred to our Outpatient Hypertension Clinic for workup of suspected secondary hypertension. Physical exam: BMI 27.3 kg/m2, BP 156/94 mmHg, FC 112 lpm, normal cardiopulmonary auscultation, no murmurs or oedema. Lab: Plasma glucose, ionogram, lipid profile, blood count, free T4, TSH, aldosterone, renin, ARR, NT-pro-BNP: normal, metanephrines 876/1238 pg/mL, albuminuria 56 mg/g Cr. Echocardiography: slight LVH (13 mm septum and posterior wall) with preserved function. Abdominal CT: Left adrenal mass, 54 mm, hyperdense, heterogeneous. MIBG scintigraphy: hyperintense left adrenal uptake without additional anomalies. After standard presurgical conditioning the patient underwent laparoscopic adrenalectomy, uneventfully. Pheochromocytoma was pathologically confirmed, without suggestion of malignancy (Ki-67 <2%). Three months afterwards the patient is normotensive and asymptomatic without medication, with normal plasma metanephrines. Conclusions: The clinical presentation of pheochromocytoma may be atypical and sometimes bizarre. Sustained hypertension may be absent, but the paradoxical hypertensive response to beta-adrenergic blockade is highly suggestive. Anyhow, a ‘post-COVID syndrome’ label may be masking unrelated and solvable serious diseases.

Successful Treatment of Urolith in a Neutered Persian Cat: A Case Report

Introduction: Uroliths or calculi are the formations of stones in the bladder. The formation of stones is influenced by specific metabolic conditions such as nutritional factors (e.g., protein-rich diet), hydration (lack of water), pH modification, low urine volume, hypercalcemia, or hypophosphatemia. In pet medicine, urolithiasis is common, particularly in cats.
 Case report: In October 2022, a 2-year-old neutered male Persian cat with a weight of 4 kg was referred to Ardebili Veterinary Pet Clinic (Mashhad, Iran) due to urinating outside the litter box, painful urination, and blood in the urine. A physical examination, ultrasonography, and blood analysis were performed. The physical examination included an assessment of the cat’s body temperature, heart rate, respiratory rate, mental state, mucous membrane color, capillary refill time, cardiopulmonary auscultation, and abdominal palpation. The cat appeared to be in good general health. No abnormalities were detected during the palpation of the bladder. Ultrasonography was performed using a real-time scanner with a 7.5-10 MHz broadband curvilinear probe, and the kidney parenchyma was examined. During the examination, a urolith with a size of 1 mm was observed. According to history and ultrasonography, and physical examination, the diagnosis was urolithiasis. To treat intermittent bladder pain, a spasmolytic drug (Prazosin) was administered at a dose of 0.5 mg/kg for 7 days. By the second day, the symptoms of pain had subsided.
 Additionally, ciprofloxacin at 20 mg/kg was used to combat infections. Fluoxetine at a 1 mg/kg dose was also administered to control inappropriate urination outside the litter box. After 3 days, the owner reported that the pet’s health improved, and most clinical signs disappeared.
 Conclusion: Administering appropriate medication (spasmolytic drug, antibiotic, and antidepressant in case of depressed animal and behavioral problems) can alleviate the calculi crystals in a cat’s urinary bladder and prevent future recurrences. In this instance, fluoxetine was discovered to be a successful option for managing pain and solving behavioral problems.

Monaural cardiopulmonary sound separation via complex-valued deep autoencoder and cyclostationarity

Objective. Cardiopulmonary auscultation is promising to get smart due to the emerging of electronic stethoscopes. Cardiac and lung sounds often appear mixed at both time and frequency domain, hence deteriorating the auscultation quality and the further diagnosis performance. The conventional cardiopulmonary sound separation methods may be challenged by the diversity in cardiac/lung sounds. In this study, the data-driven feature learning advantage of deep autoencoder and the common quasi-cyclostationarity characteristic are exploited for monaural separation. Approach. Different from most of the existing separation methods that only handle the amplitude of short-time Fourier transform (STFT) spectrum, a complex-valued U-net (CUnet) with deep autoencoder structure, is built to fully exploit both the amplitude and phase information. As a common characteristic of cardiopulmonary sounds, quasi-cyclostationarity of cardiac sound is involved in the loss function for training. Main results. In experiments to separate cardiac/lung sounds for heart valve disorder auscultation, the averaged achieved signal distortion ratio (SDR), signal interference ratio (SIR), and signal artifact ratio (SAR) in cardiac sounds are 7.84 dB, 21.72 dB, and 8.06 dB, respectively. The detection accuracy of aortic stenosis can be raised from 92.21% to 97.90%. Significance. The proposed method can promote the cardiopulmonary sound separation performance, and may improve the detection accuracy for cardiopulmonary diseases.

Regularity and mechanism of fake crackle noise in an electronic stethoscope.

Background: Electronic stethoscopes are widely used for cardiopulmonary auscultation; their audio recordings are used for the intelligent recognition of cardiopulmonary sounds. However, they generate noise similar to a crackle during use, significantly interfering with clinical diagnosis. This paper will discuss the causes, characteristics, and occurrence rules of the fake crackle and establish a reference for improving the reliability of the electronic stethoscope in lung auscultation. Methods: A total of 56 participants with healthy lungs (no underlying pulmonary disease, no recent respiratory symptoms, and no adventitious lung sound, as confirmed by an acoustic stethoscope) were enrolled in this study. A 30-s audio recording was recorded from each of the nine locations of the larynx and lungs of each participant with a 3M Littmann 3200 electronic stethoscope, and the audio was output in diaphragm mode and auscultated by the clinician. The doctor identified the fake crackles and analyzed their frequency spectrum. High-pass and low-pass filters were used to detect the frequency distribution of the fake crackles. Finally, the fake crackle was artificially regenerated to explore its causes. Results: A total of 500 audio recordings were included in the study, with 61 fake crackle audio recordings. Fake crackles were found predominantly in the lower lung. There were significant differences between lower lung and larynx (p < 0.001), lower lung and upper lung (p = 0.005), lower lung and middle lung (p = 0.005), and lower lung and infrascapular region (p = 0.027). Furthermore, more than 90% of fake crackles appeared in the inspiratory phase, similar to fine crackles, significantly interfering with clinical diagnosis. The spectral analysis revealed that the frequency range of fake crackles was approximately 250-1950Hz. The fake crackle was generated when the diaphragm of the electronic stethoscope left the skin slightly but not completely. Conclusion: Fake crackles are most likely to be heard when using an electronic stethoscope to auscultate bilateral lower lungs, and the frequency of a fake crackle is close to that of a crackle, likely affecting the clinician's diagnosis.

Evaluation of Internet-Connected Real-Time Remote Auscultation: An Open-Label Randomized Controlled Pilot Trial.

The utility of remote auscultation was unknown. This study aimed to evaluate internet-connected real-time remote auscultation using cardiopulmonary simulators. In this open-label randomized controlled trial, the physicians were randomly assigned to the real-time remote auscultation group (intervention group) or the classical auscultation group (control group). After the training session, the participants had to classify the ten cardiopulmonary sounds in random order as the test session. In both sessions, the intervention group auscultated with an internet-connected electronic stethoscope. The control group performed direct auscultation using a classical stethoscope. The total scores for correctly identified normal or abnormal cardiopulmonary sounds were 97/100 (97%) in the intervention group and 98/100 (98%) in the control group with no significant difference between the groups (p &gt; 0.99). In cardiac auscultation, the test score in the control group (94%) was superior to that in the intervention group (72%, p &lt; 0.05). Valvular diseases were not misclassified as normal sounds in real-time remote cardiac auscultation. The utility of real-time remote cardiopulmonary auscultation using an internet-connected electronic stethoscope was comparable to that of classical auscultation. Classical cardiac auscultation was superior to real-time remote auscultation. However, real-time remote cardiac auscultation is useful for classifying valvular diseases and normal sounds.

Cardiopulmonary auscultation enhancement with a two-stage noise cancellation approach

For cardiopulmonary auscultation using electronic stethoscopes, signal quality is a key point. During signal acquisition various background sounds may be inevitably captured, severely degrading the auscultation signal quality. In the existing auscultation denoising methods, conventional adaptive noise canceller (ANC) approaches or shallow-layer artificial neural networks were used, while advanced noise cancellation methods still need to be developed to fulfill real auscultation requirements. In this paper, we propose a novel denoising method for cardiopulmonary auscultation enhancement, which is a two-stage approach with a cascade of ANC and deep neural networks (DNNs). In the first stage, the ANC provides coarsely denoised auscultation signal and estimated interference. In the second stage, a DNN termed the dual-channel interactive noise cancellation network (DINC-Net) is proposed, which exploits both the coarsely denoised auscultation signal and the estimated interference. The DINC-Net consists of two deep encoders extracting features of dual-channel inputs separately, one dual-channel interactive denoising module generating a denoising mask, and one deep decoder giving the denoised output. The performance of the proposed method is evaluated through synthetic data generated using two public heart/lung sound databases, and the great promotion in normalized covariance measure (NCM) and frequency-weighted segmental signal-to-noise ratio (fwSNRseg) has been verified, compared to the existing methods. An online noise cancellation prototype is further developed on an electronic stethoscope, and the signal quality promotion is shown on healthy subjects as well as aortic stenosis patients.

Severe Symptomatic SIADH as a Sign of Unknow Hypopituitarism: A Case Report

Abstract Background: SIADH due to secondary adrenal insufficiency is a rare condition that can be life-threatening. Treatment with glucocorticoids is highly effective, but, as symptomatology of hypopituitarism can be mild and unspecific, a high level of clinical suspicion is necessary. Clinical Case: A 64-year-old postmenopausal woman, with a previously diagnosed and treated hypothyroidism and depressive syndrome, presented at the emergency room with nausea, vomits, asthenia and recurrent syncopes over the past three weeks and weight loss in the last months. One week before, she had been admitted at other hospital due to the same complaints and a serum Na+ of 112mmol/L (N 135-145 mmol/L) was detected. One year earlier, she had reported the same symptomology and hyponatremia had also been found, but no etiologic study was performed. At admission, she was conscient, hydrated, pale, hemodynamically stable, with unremarkable cardiopulmonary auscultation. A severe hyponatremia was found (Na+ 111mmol/L), with low serum osmolarity (241mOsm/Kg, N 280-301mOsm/Kg), low urine osmolality (125mOsm/kg N 300-900 mOsm/Kg) and low urinary sodium (33mmol/24h, N 40-220mmol/24h). Treatment with saline fluids was initiated and the patient was admitted for etiological investigation, which showed a low morning serum cortisol (3.7 µg/dl)) with inappropriately low-normal ACTH level (12.2 pg/mL), low FSH (15.07 mUI/mL, N 23.0-116.3 mUI/mL) and LH (4.28 mUI/mL, N 15.9-54 mUI/mL), estradiol of 78.81 pmol/L (N &amp;lt;118.2 pmol/L), undetectable IGF-1 (&amp;lt;25 ng/mL, N 36-244 ng/mL) and PRL of 21.98 ng/mL (N 1.8-20.3 ng/mL). Under 50µg of levothyroxine, TSH was 2.5 µUI/mL (N 0.358-3.74 µUI/ml), and FT4 was 1.1 ng/dL (N 0.76-1.46 ng/dL). Anti-thyroglobulin and anti-TPO antibodies were negative. A pituitary MRI revealed an empty sella with arachnoidocele. Other differential diagnosis of SIADH were excluded. The patient was started on oral hydrocortisone 30 mg/day, with a remarkable recovery, with better mood, more energy and appetite, resolution of all symptoms and normalization of the natremia. Conclusion: Hypopituitarism due to an empty sella is a relative rare disorder, whose etiology may be difficult to prove. It usually develops insidiously, with unspecific symptoms, which often delays the diagnosis. In our patient, this severe hyponatremia likely developed over a long time, allowing adaptation to such low levels of Na+. Moreover, the presence of a previously diagnosed hypothyroidism raises the suspicion if this wasn’t the first manifestation of the pituitary disease and if treatment of levothyroxine did not worsen an undetected secondary adrenal insufficiency.

Evaluation de l'utilisation d'un logiciel de simulation dans l'apprentissage de l'auscultation cardio-pulmonaire chez les étudiants en premier cycle d'études médicales

IntroductionMedsounds™ software allows to create an auscultation learning platform, by providing real pre-recorded cardiopulmonary sounds on virtual chests. The study aimed at comparing the skills in cardiopulmonary auscultation between students who benefited from this platform and students who did not have access to it. MethodsA controlled trial was conducted with 2nd year medical students randomised into three groups. Groups A, B and C received 10 h of cardiopulmonary clinical training. In addition, group B benefited from an online access to the educative platform, and group C had a demonstration of the platform during their clinical training, then an online access. The main outcome was a 3-point multiple-choice questionnaire based on 2 original case vignettes about the description of cardiopulmonary sounds. The secondary outcome was the faculty exam on high-fidelity cardiopulmonary simulator. ResultsGroups A and B included 127 students, and group C 117. Students in group C had a significantly higher score than those in group A (1.72/3 versus 1.48/3; p = 0.02), without difference between the groups B and C. Students who actually had a demonstration of the platform and used it at home had a higher score than those who did not use it (1.87 versus 1.51; p = 0.01). Students who had a demonstration of the platform before using it performed a better pulmonary examination on high-fidelity simulators. ConclusionThe supervised use of an online auscultation simulation software in addition to the traditional clinical training seems to improve the auscultation performances of undergraduated medical students.

Use of Simulation Based Training to Enhance Cardiac Auscultation Proficiency.

Cardiopulmonary auscultation is an important skill for medical professionals with deficiencies being well documented with broad implications on healthcare. Providing ideal bedside auscultatory teaching presents many difficulties. Simulation has been used as a means to improve cardiac auscultatory training and circumvent some of these limitations. We studied the use of Harvey © simulation in teaching cardiac murmurs and whether there was improvement in short term knowledge, as well as testing long term knowledge retention, as measured through a standardized test. From 2014-2019, 124 medical students in their 2 nd and 3 rd year of school (during the clinical portion of medical school curriculum) rotating through an Internal Medicine rotation completed a 2 hour training course on cardiac auscultation using Harvey © to identify six common cardiac murmurs. The session contained a pretest, didactic session, and posttest. 124 students participated in the auscultatory training session. Of them, 42 (34%) underwent the session a second time at an average of 1.29 months from their first session. There was statistically significant improvement between tests. Notably, the most often missed murmurs were mitral stenosis and benign (innocent) flow murmur. As shown in our study, simulation based cardiac auscultatory education is feasible and likely beneficial in medical education as it can be delivered to a large group of trainees and overcomes the challenges of bedside teaching.

Deep Vein Thrombosis Revealing Prostate Cancer about a Case in the Cardiology Department of the Ignace Deen National Hospital in Conakry

Introduction: Deep vein thrombosis is a frequent disease, its origin is most often multifactorial. Venous thromboembolic disease (MVTE) and cancer are two frequently entangled pathologies. Here we report the diagnosis of deep vein thrombosis that discovered prostate cancer in an 88-year-old Guinean man. On clinical examination, there was a painful and hot swelling of the right leg, an absence of sloshing of the calf, a positive sign of Homans. The digital rectal examination revealed an enlarged prostate with an irregular surface. Cardiopulmonary auscultation was normal. The electrocardiogram showed a regular sinus rhythm at 65 cycles/min, with no sign of enlarged cavities or conduction disturbance. Venous Doppler ultrasound of the lower limbs showed the presence of an extensive acute deep venous thrombosis of the right sural vein extended to the popliteal and to the homolateral deep femoral. The reino-vesico-prostatic ultrasound concluded in a heterogeneous prostatic hypertrophy with projection of a median lobe associated with a bladder of fight with an important post voiding residue evaluated at 170 ml; the rate of specific antigen of the prostate PSA was at 84.87 ng/ml. The pathology analysis made after a prostate biopsy puncture concluded with an adenocarcinoma with a Gleason score of 3. Conclusion: The association of venous thromboembolic disease (MVTE) and neoplasia is frequent. The existence of active cancer in a patient is a known risk factor for MVTE and, conversely, the discovery of a first episode of deep vein thrombosis (DVT) or pulmonary embolism (PE) may be the mode of revelation of cancer.

P844 A stroke of bad fortune

Abstract Case description We report the case of a 78 year old man who was referred to our hospital following identification of an intracardiac mass on transthoracic echocardiogram (TTE). The study was for work-up of a recent left middle cerebral artery thromboembolic stroke, with successful endovascular clot retrieval. His only other active medical issue was metastatic prostate cancer with bony involvement, on palliative hormone therapy with a well controlled prostate specific antigen level. He was an ex-smoker and and had an ECOG performance status of zero. On physical examination, the patient was clinically well, with unremarkable cardiopulmonary auscultation. The TTE demonstrated an echodense mass in the left atrium (LA), with Doppler colour giving a suggestion of its size (image A). The subsequent transoesophageal echocardiogram illustrated a large, well defined, heterogenous, echodense mass dominating the LA (image B). It was not adherent to the interatrial septum. There was no significant spontaneous echocontrast or thrombus formation in the left atrial appendage (LAA). Considering the location of the mass, the presumptive diagnosis of atrial myxoma was less likely. Differential diagnoses we considered included pure thrombus, infection and benign or malignant cardiac tumours. It was unlikely that this patient had a pure thrombus only considering the LAA was clear. He also did not have any non-specific or focal clinical features suggestive of infection. The patient went on to have a gated CT thoracic aortogram, which showed a contrast-enhancing soft tissue mass within the LA measuring approximately 50x40 millimetre, which invaded into the left inferior pulmonary vein, and was contiguous with a soft tissue mass in the left lower lobe of the lung (image C). He also had a positon emission tomography scan, which showed the highly metabolically active mass in the lung invading into the left inferior pulmonary vein, and as well as left atrium (image D). The patient underwent a biopsy of this left lower lung lesion, which confirmed squamous cell carcinoma of lung origin. Due to the large tumour burden in the LA, the joint decision with medical and radiation oncology teams, was not to administer systemic chemo- or localised radiotherapy, as this would lead to high risk of tumour embolisation. The patient also had a short period of therapeutic anticoagulation with intravenous unfractionated heparin to treat the likely thrombotic coating to the left atrial tumour extension, but developed a retroperitoneal haematoma, and hence anticoagulation was ceased. The patient was referred to palliative care services, and returned back to the community. Conclusion Cardiac tumours, whether primary or secondary, are rare. They are most frequently identified on post-mortem examination. This case is unusual, in that the patient had a second primary tumour and has remained completely asymptomatic prior to embolic presentation, despite the large size of the mass. Abstract P844 Figure 1.

Adhesión ovárica-intestinal congénita en una perra

Congenital adhesions are present since birth as an embryological anomaly in the development of the peritoneal cavity. The present study aimed to report the case of congenital adherence of a Yorkshire bitch of 9 months submitted to elective ovariosalpingohysterectomy (OSH). In the anamnesis, the owner reported that the animal had never undergone any surgical procedure and its physiological state was within normal range. In the clinical examination, no changes in the parameters (heart rate, respiratory rate, temperature, capillary filling time, body score, lymph nodes, abdominal palpation and cardiopulmonary auscultation) were observed in the animal, as well as in the laboratory tests (Hemogram, ALT, FA, urea and creatinine). Thus, the animal was referred and subsequently submitted to the surgical procedure, during the exploratory laparotomy was identified the ovary-intestinal adhesion. Surgical correction (adhesiolysis) was performed, without complication during the procedure.

Expanded VAD Guided Subdivision of Cardiopulmonary Sounds

Cardiopulmonary auscultation is a diagnostic procedure that has a challenging task since the components of heart rate and lung sounds overlap. There were many approaches to quantify the characteristics of these signals, and one of the newest is the voice activity detection (VAD) and the Gaussian Mixture Models (GMM). Considering the lung and heart sounds as acoustic events, this paper proposes a novel assessment methodology of these diagnostic indicators. Here, VAD-GMM was applied to detect and extract the main events in lung sound and heart sounds. VAD-GMM results were compared with other VAD methodology based on statistical approach, and it was found that VAD-GMM give more definite results. Since Mel Frequency Cepstral coefficients (MFCC) and Quartiles feature vectors, were already successful in pattern recognition, VAD-GMM was carried out using this kind of acoustic vectors. Therefore, this method could add in a transition from qualitative traditional auscultation to quantitative assessment and assisted computerized diagnosis by identifying abnormal acoustic indicators. Diagnosis by computerized detection promises to be a more efficient method than traditional methods, which are limited by the auditory capability and experience of a medical professional.

Investigation of Stethoscope Technology for En Route Care

ObjectiveOccupational challenges in air transport domains make auscultation with traditional stethoscopes difficult. This study aimed to investigate two commercial off-the-shelf stethoscopes for use in high noise military patient transport environments. The stethoscopes were assessed by Aeromedical Evacuation providers in a simulated C-130 trainer on live standardized mock patients. Device 1 was a dual-mode stethoscope developed for rotary wing military airframes. Device 2 was an electronic stethoscope developed for high noise civilian environments. Twenty clinicians performed cardiopulmonary auscultation using the devices on the same two standardized patients in a simulated C-130 then completed a subjective questionnaire on their ability to identify heart and lung sounds. Results indicated the dual-mode stethoscope had limited utility with clinician likeliness of use rated as low (median = 2; interquartile range = 1.75-3.25), whereas the electronic stethoscope had potential utility with likeliness of use rated as good (median = 4; interquartile range = 3.25-5). We conclude that further examination of devices capable of auscultation in high noise military environments is needed. In-flight testing of device 2 for use by end users has been completed and will be reported in a separate manuscript.

Endocardite por Escherichia Coli: Quando o Improvável Acontece

Homem, 88 anos, recorre à urgência por astenia generalizada, anorexia e diminuição do débito urinário. Estava febril, hipotenso e com auscultação cardiopulmonar normal. Analiticamente apresentava leucocitose, creatinina de 3,1 mg/dL e leucocitúria. O doente foi internado por lesão renal aguda e medicado com ciprofloxacina assumindo uma infeção urinária. Foi isolada uma Escherichia coli na urocultura e 2 amostras de hemoculturas e o antibiótico foi alterado para meropenem de acordo com o antibiograma. Pela febre persistente e aumento dos parâmetros inflamatórios, foi realizado ecocardiograma transtorácico ao dia 14 de internamento, que revelou uma vegetação na válvula mitral, tendo-se adicionado à antibioterapia a gentamicina e vancomicina. Um acidente vascular cerebral isquémico, com transformação hemorrágica e plegia esquerda, e uma perfuração severa da válvula mitral posterior, complicaram o curso clínico. O estado clínico gradualmente melhorou e o doente transitou para uma unidade de reabilitação ao fim de 59 dias de internamento.Este caso pretende exemplificar como a endocardite é ainda uma entidade muitas vezes de difícil diagnóstico associada a complicações graves e obrigando a internamento prolongado.

Digital stethoscope: technology update.

Cardiovascular disease (CVD) is recognized as the leading cause of mortality throughout the world. About one-third of global mortality is attributable to CVD. In addition to clinical presentation, specific clinical exam findings can assist in treating and preventing CVD. CVD may initially manifest as pulmonary pathology, and thus, accurate cardiopulmonary auscultation is paramount to establishing accurate diagnosis. One of the most powerful tools available to physicians is the stethoscope. The stethoscope first emerged in the year 1818, invented by a French physician, René Laennec. Since then, the initial modest monaural wooden tube has evolved into a sophisticated digital device. This paper provides an analysis of the evolution of the stethoscope as well as highlights the advancement made by the modern digital stethoscope including the application of this tool in advancing care for patients suffering from CVD.