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Papunen I, Poutanen T, Ylänen K. Major congenital heart defects are rarely diagnosed after newborns' hospital discharge with modern screening. Acta Paediatr 2024; 113:143-149. [PMID: 37522553 DOI: 10.1111/apa.16928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/16/2023] [Accepted: 07/28/2023] [Indexed: 08/01/2023]
Abstract
AIM Our aim was to assess undiagnosed congenital heart defects (CHD) after newborns' hospital discharge in patients with a murmur or CHD suspicion, to find out the signs that predict CHDs and to estimate the costs of the examinations. METHODS We reviewed retrospective medical records of patients (n = 490) referred for the evaluation of CHD suspicion during 2017-2018. RESULTS The median age of the patients was 2.5 (IQR 0.5-7.4) years. Sixty-three (13%) patients had an abnormal echocardiography. Neither ductal-dependent nor cyanotic CHDs were found. Cardiac interventions were performed for 14 out of 63 (22%) patients. Clinical signs indicating CHDs were murmur grade ≥3 (10/11 [91%] vs. 53/479 [11%], p < 0.001) and harsh murmur (15/44 [34%] vs. 48/446 [11%], p < 0.001). Abnormal electrocardiography did not indicate CHD (8/40 [20%] vs. 55/447 [12%], p = 0.165). The total cost of the examinations was 259 700€. The share of the cost of studies assessed as benign was 59%. CONCLUSION Only a few CHDs were found after newborn hospital discharge among patients who received foetal and newborn screening and were examined due to CHD suspicion. The high number of benign murmurs in children leads to many referrals, resulting in unnecessary healthcare costs.
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Affiliation(s)
- I Papunen
- Tampere Center for Child, Faculty of Medicine and Health Technology, Adolescent and Maternal Health Research, Tampere University, Tampere, Finland
| | - T Poutanen
- Tampere Center for Child, Faculty of Medicine and Health Technology, Adolescent and Maternal Health Research, Tampere University, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - K Ylänen
- Tampere Center for Child, Faculty of Medicine and Health Technology, Adolescent and Maternal Health Research, Tampere University, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
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Oswal A, Holman J. Fifteen-minute consultation: Cardiac murmurs in the Newborn Infant Physical Examination (NIPE). Arch Dis Child Educ Pract Ed 2022; 107:326-329. [PMID: 34187902 DOI: 10.1136/archdischild-2020-321206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/11/2021] [Indexed: 11/04/2022]
Abstract
The finding of a cardiac murmur on the initial newborn examination is common but may be a source of anxiety for practitioners due to worries about missing critical congenital heart defects (CHDs). This article aims to provide an approach to this common finding, in particular, reviewing the evidence base behind features of the history, examination and subsequent non-specialist investigations which may increase the likelihood of CHDs. The aim of this structured approach is to give clinicians confidence in dealing with this common clinical finding, to be able to pick out those infants most at risk of having critical CHDs.
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Affiliation(s)
- Abhishek Oswal
- Department of Paediatrics and Neonatology, Gloucestershire Royal Hospital, Gloucester, UK
| | - Jennifer Holman
- Department of Paediatrics and Neonatology, Gloucestershire Royal Hospital, Gloucester, UK
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Penslar J, Webster RJ, Jetty R. Nonauscultatory clinical criteria are sensitive for cardiac pathology in low-risk paediatric heart murmurs. Paediatr Child Health 2020; 26:294-298. [PMID: 34336057 DOI: 10.1093/pch/pxaa067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 04/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background Healthy children with likely innocent heart murmurs are frequently referred to cardiologists for reassurance. Existing guidelines that advise against these referrals are not consistently followed partly because they involve subjective auscultatory judgements with which many care providers are uncomfortable. Here, we investigate whether clinical criteria with no subjective auscultatory component are sensitive for cardiac pathology. Methods A retrospective chart review was performed of all new patients seen in our paediatric cardiology clinic for assessment of a murmur from January 1, 2016 through June 30, 2018. Patients were characterized as "low-risk" if they met all of the following criteria: asymptomatic; normal physical examination other than the murmur; no risk factors for congenital heart disease; and age over 12 months. The primary outcomes were the sensitivity for ruling out pathology and the negative predictive value of the proposed criteria. Results Of 915 total patients, 214 met the low-risk criteria. The sensitivity of our criteria for ruling out pathology was 97.2% (95% confidence interval 94.1% to 99.0%) and the negative predictive value was also 97.2% (95% confidence interval 94.0% to 98.7%). Six of the 214 low-risk patients had pathology (2.8%; 95% confidence interval 1.3% to 6.0%), none of which has required intervention since diagnosis. Each of these six children had a murmur that sounded pathological to the auscultating cardiologist. Conclusions Basic clinical criteria that do not require auscultation are highly sensitive for ruling out significant cardiac pathology in children over 12 months of age.
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Affiliation(s)
- Joshua Penslar
- Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | | | - Radha Jetty
- Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada
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4
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Balasubramanian S, Ramirez FD, Bui Y, Selamet Tierney ES, Behera SK. Comparison of Initial Pediatric Outpatient Echocardiogram Indications between Community and Academic Practice. J Pediatr 2019; 207:23-28.e2. [PMID: 30661793 DOI: 10.1016/j.jpeds.2018.11.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 11/28/2018] [Accepted: 11/30/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the appropriateness and diagnostic yield of initial outpatient transthoracic echocardiography (TTE) between a community pediatric cardiology practice and an academic children's hospital. STUDY DESIGN Initial outpatient pediatric TTE ordered by pediatric cardiologists between January and March 2014 at a community practice (Packard Children's Health Alliance [PCHA]; n = 238) and an academic tertiary center (Lucile Packard Children's Hospital [LPCH]; n = 76) were evaluated based on appropriate use criteria (AUC) released in December 2014. Multivariate logistic regression was used to identify predictors of "rarely appropriate" indications and abnormal TTE findings. RESULTS Of 314 TTEs, 165 (52.5%) were classified as "appropriate," 40 (12.7%) were classified as "may be appropriate," 100 (31.9%) were classified as "rarely appropriate," and 9 (2.9%) were unclassifiable. The proportion of abnormal findings did not differ between the 2 practice settings (5.3% for LPCH vs 7.6% for PCHA; P = .61). TTEs performed at PCHA were significantly more likely to be "rarely appropriate" (OR, 2.57; 95% CI, 1.28-5.15; P = .008). Children aged <1 year (OR, 1.90; 95% CI, 1.03-3.50; P = .04) and ordering providers with <10 years since the completion of their fellowship (OR, 2.15; 95% CI, 1.20-3.87; P = .01) were associated with "rarely appropriate" indications. "Appropriate" TTEs were associated with abnormal findings (OR, 8.69; 95% CI, 1.77-42.68; P = .008). CONCLUSION The community practice was independently associated with greater inappropriate ordering of initial outpatient pediatric TTEs compared with the academic practice. The assessment of practice patterns following AUC release should account for physician and practice-related factors that could influence differences in TTE ordering patterns.
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Affiliation(s)
- Sowmya Balasubramanian
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford School of Medicine, Stanford, CA
| | - Faustine D Ramirez
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford School of Medicine, Stanford, CA
| | - Yen Bui
- Division of Cardiology, Department of Pediatrics, Kaiser Permanente Northern California, San Francisco, CA
| | - Elif Seda Selamet Tierney
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford School of Medicine, Stanford, CA
| | - Sarina K Behera
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford School of Medicine, Stanford, CA; Pediatric Cardiology, Packard Children's Health Alliance, Stanford Children's Health, San Francisco, CA
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Heart murmur in children less than 2 years-old: Looking for a safe and effective referral strategy. An Pediatr (Barc) 2018. [DOI: 10.1016/j.anpede.2018.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Minocha P, Agarwal A, Jivani N, Swaminathan S. Evaluation of Neonates With Suspected Congenital Heart Disease: A New Cost-Effective Algorithm. Clin Pediatr (Phila) 2018; 57:1541-1548. [PMID: 30094999 DOI: 10.1177/0009922818793341] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We assessed the value of existing guidelines for the evaluation of suspected congenital heart disease (CHD) in term neonates and propose a revised algorithm. Retrospective chart review of newborns referred for cardiac evaluation at a tertiary care center was performed. A total of 777 newborns qualified for the study. Among these, 3 critical and 8 major CHD were identified. The sensitivity of the combination of abnormal physical examination and pulse oximetry screening for major and critical CHD was 100%. The cost to detect a case of critical CHD, based on echocardiograms done for all abnormal electrocardiograms, was 3.4 times more than that incurred for performing this test on the basis of abnormal pulse oximetry and physical examination. Adding electrocardiogram to CHD screening increases cost without adding diagnostic yield. Based on our findings, we propose a revised algorithm for a systematic cost-effective approach to cardiac evaluation of term newborns with suspected CHD.
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Affiliation(s)
- Prashant Minocha
- 1 University of Miami, Miller School of Medicine, Miami, FL, USA.,2 Holtz Children's Hospital-Jackson Memorial Medical Center, Miami, FL, USA
| | - Arpit Agarwal
- 1 University of Miami, Miller School of Medicine, Miami, FL, USA.,2 Holtz Children's Hospital-Jackson Memorial Medical Center, Miami, FL, USA
| | - Nurin Jivani
- 1 University of Miami, Miller School of Medicine, Miami, FL, USA.,2 Holtz Children's Hospital-Jackson Memorial Medical Center, Miami, FL, USA
| | - Sethuraman Swaminathan
- 1 University of Miami, Miller School of Medicine, Miami, FL, USA.,2 Holtz Children's Hospital-Jackson Memorial Medical Center, Miami, FL, USA
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Islam S, Kaul P, Tran DT, Mackie AS. Health Care Resource Utilization Among Children With Congenital Heart Disease: A Population-Based Study. Can J Cardiol 2018; 34:1289-1297. [PMID: 30205987 DOI: 10.1016/j.cjca.2018.06.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 06/26/2018] [Accepted: 06/26/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Data regarding health care resource utilization (HRU) in early childhood among children with congenital heart disease (CHD) are scarce. Therefore, we sought to describe the extent of HRU incurred among children with CHD in the first 5 years of life. METHODS This population-based retrospective cohort study included all children born between January 2005 and March 2014 in Alberta, Canada. We linked inpatient, outpatient, practitioner claims, and drug dispensing databases with vital statistics (birth and death registries). RESULTS In the first year of life, the cumulative hospitalization rate per 100 children was 335 (95% confidence interval: 312-360) for single ventricle (SV) children, 200 (194-206) for moderate-complex CHD, and 152 (149-156) for simple CHD vs 109 (108-109) among children without CHD (P < 0.001). The ambulatory-care visit rate per 100 children was 4871 (4780-4963) for SV, 2278 (2258-2299) for moderate-complex, and 1416 (1405-1426) for simple CHD vs 246 (246-247) for children without CHD (P < 0.001). The rates of physician claims and drug dispensing also demonstrated similar patterns. The median total hospitalization length of stay during the first year of life was 54 days (interquartile range: 26-95) in SV, 15 (4-39) in moderate-complex, and 6 (2-26) in simple CHD compared with 2 (1-3) among children without CHD (P < 0.001). These differences remained throughout the first 5 years of life, with children with CHD having consistently higher hospitalization rates and emergency department visit rates in every year of age compared with children without CHD. CONCLUSIONS Cumulative HRU is high among children with CHD in the first 5 years of life and increases with increasing CHD severity. Improving survival of SV lesions will require increasing resource allocation to this group.
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Affiliation(s)
- Sunjidatul Islam
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Dat T Tran
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew S Mackie
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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Bozkurt B, Germanakis I, Stylianou Y. A study of time-frequency features for CNN-based automatic heart sound classification for pathology detection. Comput Biol Med 2018; 100:132-143. [PMID: 29990646 DOI: 10.1016/j.compbiomed.2018.06.026] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 06/24/2018] [Accepted: 06/24/2018] [Indexed: 10/28/2022]
Abstract
This study concerns the task of automatic structural heart abnormality risk detection from digital phonocardiogram (PCG) signals aiming at pediatric heart disease screening applications. Recently, various systems based on convolutional neural networks trained on time-frequency representations of segmental PCG frames have been presented that outperform systems using hand-crafted features. This study focuses on the segmentation and time-frequency representation components of the CNN-based designs. We consider the most commonly used features (MFCC and Mel-Spectrogram) used in state-of-the-art systems and a time-frequency representation influenced by domain-knowledge, namely sub-band envelopes as an alternative feature. Via tests carried on two high quality databases with a large set of possible settings, we show that sub-band envelopes are preferable to the most commonly used features and period synchronous windowing is preferable over asynchronous windowing.
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Affiliation(s)
- Baris Bozkurt
- Electrical and Electronics Engineering Department, Izmir Democracy University, Turkey.
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Abstract
BACKGROUND Although transthoracic echocardiography is the dominant imaging modality in CHD, optimal utilisation is unclear. We assessed whether adherence to the paediatric Appropriate Use Criteria for outpatient transthoracic echocardiography could reduce inappropriate use without missing significant cardiac disease. METHODS Using the Appropriate Use Criteria, we determined the indication and appropriateness rating for each initial echocardiogram performed at our institution during calendar year 2014 (N=1383). Chart review documented ordering provider training, patient demographics, and study result, classified as normal, abnormal, or abnormal motivating treatment within a 2-year follow-up period. We tested whether provider training level or patient age correlated with echocardiographic findings or appropriateness rating. RESULTS We found that 83.9% of echocardiograms were normal and that 66.7% had an appropriate indication. Nearly all abnormal results and all results motivating treatment were in appropriate studies, giving an odds ratio of 2.73 for an abnormal result if an appropriate indication was present (95% confidence interval 1.92-3.89, p<0.001). None of the remaining initial abnormal results with less than appropriate indications became significant, resulting in treatment over 2 years. Results suggest a potential reduction in imaging volume of as much as 33% with application of the criteria. Cardiologists ordered nearly all studies resulting in treatment but also more echocardiograms with less appropriate indications. Most examinations were in older patients; however, most abnormal results were in patients younger than 1 year. CONCLUSIONS The Appropriate Use Criteria can be used to safely reduce echocardiography volume while still detecting significant heart disease.
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10
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Rodríguez-González M, Alonso-Ojembarrena A, Castellano-Martínez A, Estepa-Pedregosa L, Benavente-Fernández I, Lubián López SP. [Heart murmur in children less than 2 years-old: looking for a safe and effective referral strategy]. An Pediatr (Barc) 2018; 89:286-293. [PMID: 29803643 DOI: 10.1016/j.anpedi.2018.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/30/2017] [Accepted: 01/09/2018] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Current guidelines in Spain recommend performing transthoracic echocardiography (TTE) in all children under 2 years of age with a heart murmur. In 2014, the American Paediatric Association published the first appropriate use criteria (AUC) for outpatient paediatric transthoracic echocardiography (TTE) to promote its cost-efficient use. The aim of this article is to analyse the AUC and other clinical factors as predictors of congenital heart disease (CHD) in children less than 2 years of age with a heart murmur, and to develop a safe and efficient referral strategy. PATIENTS AND METHOD Case-control study conducted with children less than 2 years of age, referred from Paediatric Primary Care to Paediatric Cardiology during a 4-year study. A predictive model for CHD was determined using multivariate analysis. RESULTS A total of 688 patients were included, with 129 (19%) cases of CHD. An age less than 3 months (adjusted odds ratio [ORa] 3.8 [1.5-8.4], p=.030) and fulfilling AUC (ORa 16.3 [9.4-28.3], p<.001) were predictors of CHD. Concurrent infection (ORa 0.6 [0.2-0.8], p<.001) and a negative neonatal screening with pulse oximetry (ORa 0.1 [0.05-0.4], p=.001) decreased the risk of CHD. The referral strategy that included these criteria had a 98% sensitivity, 39% specificity, and positive and negative predictive values of 27% and 99%, respectively. It could not diagnose 2% of CHD (all mild), and showed a 32% TTE reduction rate compared to our current strategy. CONCLUSION To refer children less than 3 months old, fulfilling AUC, without a concurrent infection, or without negative neonatal pulse oximetry screening, is a safe and efficient strategy for the management of heart murmur in children under 2 years of age.
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Affiliation(s)
- Moisés Rodríguez-González
- Unidad de Gestión Clínica de Pediatría, Sección de Cardiología Pediátrica, Hospital Universitario Puerta del Mar, Cádiz, España.
| | - Almudena Alonso-Ojembarrena
- Unidad de Gestión Clínica de Pediatría, Sección de Cardiología Pediátrica, Hospital Universitario Puerta del Mar, Cádiz, España
| | - Ana Castellano-Martínez
- Unidad de Gestión Clínica de Pediatría, Sección de Cardiología Pediátrica, Hospital Universitario Puerta del Mar, Cádiz, España
| | - Lorena Estepa-Pedregosa
- Unidad de Gestión Clínica de Pediatría, Sección de Cardiología Pediátrica, Hospital Universitario Puerta del Mar, Cádiz, España
| | - Isabel Benavente-Fernández
- Unidad de Gestión Clínica de Pediatría, Sección de Cardiología Pediátrica, Hospital Universitario Puerta del Mar, Cádiz, España
| | - Simon P Lubián López
- Unidad de Gestión Clínica de Pediatría, Sección de Cardiología Pediátrica, Hospital Universitario Puerta del Mar, Cádiz, España
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Abstract
An asymptomatic child with a murmur can be challenging practice management conundrum. Some providers refer all patients with a "new" murmur to a cardiologist, likely resulting in excessive resource utilization and parental anxiety. This study examines whether the prevalence of significant cardiac pathology differs in asymptomatic patients aged 2 to 18 years who were referred for a murmur that was "new" versus those referred for a murmur that was known to exist and followed conservatively during the previous 2 years. Of 473 patients meeting inclusion criteria, 33/473 (7.0%) were diagnosed with cardiac pathology, with 21/357 (5.9%) occurring among "new" murmur referrals and 12/116 (10.3%) occurring among "known" murmur referrals. Notably, 34/357 (9.5%) patients referred for a "new" murmur had no murmur present when assessed by the cardiologist. This study suggests that asymptomatic children with a "new" murmur may be conservatively managed. This may lessen health care resource utilization rates and overall parental anxiety.
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Affiliation(s)
- Lisa J Gupta
- 1 Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Joseph W May
- 1 Walter Reed National Military Medical Center, Bethesda, MD, USA
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Sachdeva R, Travers CD, McCracken CE, Samai C, Campbell RM, Slesnick TC, Border WL. Temporal Trends in Utilization of Transthoracic Echocardiography for Common Outpatient Pediatric Cardiology Diagnoses over the Past 15 Years. J Am Soc Echocardiogr 2017; 30:201-208. [DOI: 10.1016/j.echo.2016.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Indexed: 10/20/2022]
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13
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Sachdeva R, Douglas PS, Kelleman MS, McCracken CE, Lopez L, Stern KW, Eidem BW, Benavidez OJ, Weiner RB, Welch E, Campbell RM, Lai WW. Educational intervention for improving the appropriateness of transthoracic echocardiograms ordered by pediatric cardiologists. CONGENIT HEART DIS 2017; 12:373-381. [DOI: 10.1111/chd.12455] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 12/06/2016] [Accepted: 01/20/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Ritu Sachdeva
- Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology; Atlanta Georgia USA
| | | | - Michael S. Kelleman
- Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology; Atlanta Georgia USA
| | - Courtney E. McCracken
- Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology; Atlanta Georgia USA
| | - Leo Lopez
- Nicklaus Children's Hospital; Miami Florida USA
| | | | | | | | - Rory B. Weiner
- Massachusetts General Hospital; Boston Massachusetts USA
| | | | - Robert M. Campbell
- Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology; Atlanta Georgia USA
| | - Wyman W. Lai
- NewYork-Presbyterian, Morgan Stanley Children's Hospital; New York New York USA
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Satou GM, Rheuban K, Alverson D, Lewin M, Mahnke C, Marcin J, Martin GR, Mazur LS, Sahn DJ, Shah S, Tuckson R, Webb CL, Sable CA. Telemedicine in Pediatric Cardiology: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e648-e678. [PMID: 28193604 DOI: 10.1161/cir.0000000000000478] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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15
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Diagnostic Yield of Outpatient Pediatric Echocardiograms: Impact of Indications and Specialty. Pediatr Cardiol 2017; 38:162-169. [PMID: 27826707 DOI: 10.1007/s00246-016-1497-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
Abstract
Multiple reports have shown that echocardiograms are neither cost-effective nor of high diagnostic yield for a number of indications. This study sought to evaluate the impact of indications and provider type on the diagnostic yield of first-time outpatient pediatric echocardiograms. All initial echocardiograms interpreted at our institution from February 2009 to December 2014 were reviewed retrospectively. Positive findings were defined as any abnormality of structure or function. Ordering physicians were grouped as Primary Care, Subspecialist, or Cardiologist. A cost analysis of cardiac consultation versus direct echocardiogram ordering was performed using 2014 Arkansas Medicaid office-based allowables. A total of 7854 echocardiograms had complete data and were included in the study. Median age was 7.2 years (range 2 days to 18.9 years). There were 1179 (15%) abnormal first-time echocardiograms. Diagnostic yields were particularly low for the indications of chest pain (4.9%), syncope (5.3%), and palpitations (9.1%). When ordered by the Cardiology group, echocardiographic yields were increased 35% for all indications (p < 0.001) and 100% for murmurs (p < 0.001) when compared to the Primary Care group. Cost analysis using the model of cardiology consultation rather than direct primary care echocardiogram ordering estimated a 19.6% reduction in medical costs for the most common indication, murmur. The diagnostic yield of outpatient pediatric echocardiograms is low for most indications. Overall, cardiologists had an improved diagnostic yield compared to other ordering physicians. For the indication of murmur, cardiology evaluation before echocardiogram might decrease unnecessary testing and healthcare expenses. This study provides a framework for improving resource utilization in the pediatric population.
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16
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Lang SM, Bolin E, Daily JA, Tang X, Thomas Collins R. Appropriateness and diagnostic yield of inpatient pediatric echocardiograms. CONGENIT HEART DIS 2016; 12:210-217. [DOI: 10.1111/chd.12428] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 10/12/2016] [Accepted: 10/21/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Sean M. Lang
- Arkansas Children's Hospital; Little Rock Arkansas USA
- Arkansas Children's Research Institute; Little Rock Arkansas USA
- University of Arkansas for Medical Sciences; Little Rock Arkansas USA
| | - Elijah Bolin
- Arkansas Children's Hospital; Little Rock Arkansas USA
- Arkansas Children's Research Institute; Little Rock Arkansas USA
- University of Arkansas for Medical Sciences; Little Rock Arkansas USA
| | - Joshua A. Daily
- Arkansas Children's Hospital; Little Rock Arkansas USA
- Arkansas Children's Research Institute; Little Rock Arkansas USA
- University of Arkansas for Medical Sciences; Little Rock Arkansas USA
| | - Xinyu Tang
- Arkansas Children's Hospital; Little Rock Arkansas USA
- Arkansas Children's Research Institute; Little Rock Arkansas USA
- University of Arkansas for Medical Sciences; Little Rock Arkansas USA
| | - R. Thomas Collins
- Arkansas Children's Hospital; Little Rock Arkansas USA
- Arkansas Children's Research Institute; Little Rock Arkansas USA
- University of Arkansas for Medical Sciences; Little Rock Arkansas USA
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17
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Abstract
BACKGROUND Heart murmurs are common in children and may represent congenital or acquired cardiac pathology. Auscultation is challenging and many primary-care physicians lack the skill to differentiate innocent from pathologic murmurs. We sought to determine whether computer-aided auscultation (CardioscanTM) identifies which children require referral to a cardiologist. METHODS We consecutively enrolled children aged between 0 and 17 years with a murmur, innocent or pathologic, being evaluated in a tertiary-care cardiology clinic. Children being evaluated for the first time and patients with known cardiac pathology were eligible. We excluded children who had undergone cardiac surgery previously or were unable to sit still for auscultation. CardioscanTM auscultation was performed in a quiet room with the subject in the supine position. The sensitivity and specificity of a potentially pathologic murmur designation by CardioscanTM - that is, requiring referral - was determined using echocardiography as the reference standard. RESULTS We enrolled 126 subjects (44% female) with a median age of 1.7 years, with 93 (74%) having cardiac pathology. The sensitivity and specificity of a potentially pathologic murmur determination by CardioscanTM for identification of cardiac pathology were 83.9 and 30.3%, respectively, versus 75.0 and 71.4%, respectively, when limited to subjects with a heart rate of 50-120 beats per minute. The combination of a CardioscanTM potentially pathologic murmur designation or an abnormal electrocardiogram improved sensitivity to 93.5%, with no haemodynamically significant lesions missed. CONCLUSIONS Sensitivity of CardioscanTM when interpreted in conjunction with an abnormal electrocardiogram was high, although specificity was poor. Re-evaluation of computer-aided auscultation will remain necessary as advances in this technology become available.
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Rose-Felker K, Kelleman MS, Campbell RM, Oster ME, Sachdeva R. Appropriate Use and Clinical Impact of Echocardiographic “Evaluation of Murmur” in Pediatric Patients. CONGENIT HEART DIS 2016; 11:721-726. [DOI: 10.1111/chd.12379] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2016] [Indexed: 01/08/2023]
Affiliation(s)
- Kirsten Rose-Felker
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Michael S. Kelleman
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Robert M. Campbell
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Matthew E. Oster
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Ritu Sachdeva
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
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Begic Z, Dinarevic SM, Pesto S, Begic E, Dobraca A, Masic I. Evaluation of Diagnostic Methods in the Differentiation of Heart Murmurs in Children. Acta Inform Med 2016; 24:94-8. [PMID: 27147798 PMCID: PMC4851509 DOI: 10.5455/aim.2016.24.94-98] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 02/25/2016] [Indexed: 11/04/2022] Open
Abstract
Introduction: The most common clinical sign in pediatric cardiology is a heart murmur (organic and inorganic). Organic are sign of heart disease, while inorganic (basically divided into accidental and functional) murmurs occur on anatomically healthy heart. Aim: To determine the justification of the application of the methods of cardiac treatment. Patients and methods: Study included 116 children aged from 1 to 15 years, who were referred due to cardiac treatment to Pediatric Clinic, of Sarajevo University Clinical Center. Results: The first group consisted of children with innocent heart murmur, 97 (53 males). The second group consisted of patients with organic murmur, 19 (13 males). The average age of the first group was 7.69 (1.01–15.01) years old, and of the second group 3.15 (1.01- 8.06) years old, and there is a significant difference between these two groups (p <0.001). Medical history questions about potentially harmful habits of mother in pregnancy, found significant differences in the frequency of the existence of habits between the first and second groups of subjects (14.44% vs. 85.1%, p = 0.013). The values of the pulse of patients showed statistically significant difference (p = 0.012). The most common place of the murmurs’ appearance is the second left intercostal space. In the first group, the most common were vibratory (32.3%) and ejection (31.9%) and in the second the most common were holosystolic (73.7%) murmur. Analyzing the R/S ratio of V1, a significant difference among the two groups was found (mean 0.78 vs. the values for 1.45, p = 0.003). There is a significance in terms of developed hypertrophy of the heart cavities (BVH) between the two groups. The most common accidental murmur was classic vibratory Still’s murmurs (55.43%) and the most common congenital heart defects was ASD (36.8%). Conclusions: A heart murmur itself, should not be the purpose of auscultation. One of the tasks of pediatricians, pediatric cardiologists in particular would be to improve auscultation, as a sovereign method of heart murmurs assessment. Heart murmur assessment should be adapted to recognize whether heart murmur is innocent, or there is suspected or probable congenital heart defect.
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Affiliation(s)
- Zijo Begic
- Pediatric Clinic Sarajevo, Clinical center of Sarajevo University, Sarajevo, Bosnia and Herzegovina
| | | | - Senad Pesto
- Clinic for Emergency medicine, Clinical center of Sarajevo University, Bosnia and Herzegovina
| | - Edin Begic
- Clinic for Emergency medicine, Clinical center of Sarajevo University, Bosnia and Herzegovina
| | - Amra Dobraca
- Medical and Biological Engineering Society of BiH, Sarajevo, Bosnia and Herzegovina
| | - Izet Masic
- Department of Family medicine, Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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Lai LS, Redington AN, Reinisch AJ, Unterberger MJ, Schriefl AJ. Computerized Automatic Diagnosis of Innocent and Pathologic Murmurs in Pediatrics: A Pilot Study. CONGENIT HEART DIS 2016; 11:386-395. [DOI: 10.1111/chd.12328] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Lillian S.W. Lai
- Children's Hospital of Eastern Ontario, University of Ottawa; Ottawa Ontario Canada
| | - Andrew N. Redington
- The Heart Institute, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
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Abstract
This study was performed to determine the prevalence of CHD among children referred with asymptomatic murmurs and to determine the diagnostic accuracy of the assessment of asymptomatic heart murmurs by general paediatricians. We reviewed the records of children who had been referred by general paediatricians to a cardiology clinic for further evaluation of a heart murmur. The referring paediatricians' clinical assessment of the murmur was compared with the cardiologist's echocardiographic diagnosis. A total of 150 children were referred by paediatricians to a paediatric cardiologist for further assessment of a heart murmur. Out of 150 children, 72 had a paediatrician's diagnosis of innocent murmur; of these 72 patients, two (3%) had heart disease on echocardiography. In all, after echocardiography, a range of congenital heart lesions was found in 28 (19%) of the 150 children. CHD is not rare among children with asymptomatic heart murmurs. In this series of children with asymptomatic murmurs, 19% had heart lesions on echocardiography. Most, but not all, of the children with heart lesions were identified on clinical examination by general paediatricians.
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Chantepie A, Soulé N, Poinsot J, Vaillant MC, Lefort B. [Heart murmurs in asymptomatic children: When should you refer?]. Arch Pediatr 2015; 23:97-104. [PMID: 26552619 DOI: 10.1016/j.arcped.2015.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 08/31/2015] [Accepted: 10/05/2015] [Indexed: 11/25/2022]
Abstract
Heart murmurs are common in children and adolescents. Although most are innocent, an isolated heart murmur in asymptomatic children may be the sole finding indicating serious heart disease. Historical elements of familial heart disease, cardiovascular symptoms and a well-conducted medical examination can identify children with an increased risk of heart disease. The distinction between an innocent heart murmur and a pathologic heart murmur is not always easy for primary care physicians because most of them have little experience with auscultation searching for congenital heart malformation. Echocardiography provides a definitive diagnosis of heart disease but is not required in case of innocent murmur. Inappropriate pediatric cardiologist and echocardiographic referral leads to useless and expensive examinations, resulting in a work overload for pediatric cardiologists. The objective of this review is to provide the keys to differentiate innocent and pathologic murmurs, and to help physicians decide on the optimal diagnostic strategy.
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Affiliation(s)
- A Chantepie
- Service de médecine pédiatrique, hôpital Clocheville, CHU de Tours, université François-Rabelais, 49, boulevard Béranger, 37044 Tours cedex, France.
| | - N Soulé
- Service de médecine pédiatrique, hôpital Clocheville, CHU de Tours, université François-Rabelais, 49, boulevard Béranger, 37044 Tours cedex, France
| | - J Poinsot
- Service de médecine pédiatrique, hôpital Clocheville, CHU de Tours, université François-Rabelais, 49, boulevard Béranger, 37044 Tours cedex, France
| | - M C Vaillant
- Service de médecine pédiatrique, hôpital Clocheville, CHU de Tours, université François-Rabelais, 49, boulevard Béranger, 37044 Tours cedex, France
| | - B Lefort
- Service de médecine pédiatrique, hôpital Clocheville, CHU de Tours, université François-Rabelais, 49, boulevard Béranger, 37044 Tours cedex, France
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Campbell RM, Douglas PS, Eidem BW, Lai WW, Lopez L, Sachdeva R. ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria for initial transthoracic echocardiography in outpatient pediatric cardiology: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Academy of Pediatrics, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography. J Am Soc Echocardiogr 2015; 27:1247-66. [PMID: 25479897 DOI: 10.1016/j.echo.2014.10.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Sachdeva R, Samai C, Vincent RN. Pediatric appropriate use criteria for echocardiography: implications for clinical practice. Pediatrics 2015; 135:e1128-30. [PMID: 25917995 DOI: 10.1542/peds.2014-3537] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ritu Sachdeva
- Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, and Emory University School of Medicine, Atlanta, Georgia
| | - Cyrus Samai
- Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, and Emory University School of Medicine, Atlanta, Georgia
| | - Robert N Vincent
- Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, and Emory University School of Medicine, Atlanta, Georgia
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Ali SH, Mohammed MA. Evaluation of heart murmurs in children: One year of observational study. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2015. [DOI: 10.1016/j.epag.2015.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Kardasevic M, Kardasevic A. The importance of heart murmur in the neonatal period and justification of echocardiographic review. Med Arch 2015; 68:282-4. [PMID: 25568554 PMCID: PMC4240565 DOI: 10.5455/medarh.2014.68.282-284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Accepted: 06/06/2014] [Indexed: 12/21/2022] Open
Abstract
Introduction: Heart murmurs can be functional (innocent) and pathological (organic). Although it is not considered a major sign of heart disease, it may be a sign of a serious heart defect. In most cases the noise is initiation for cardiac treatment. Is it possible to differentiate on the basis of auscultation innocent from pathological heart murmur? In this article we present the results of ultrasonography of newborns with positive auscultation finding of the heart in the neonatal and early infancy period. Goal: To determine the role of murmurs in the heart detected by routine clinical examination in the neonatal period and early infancy, and to establish the legitimacy of cardiology consultation and ultrasound of the heart. Methods: A retrospective review of medical records in the period from January 1 to December 31, 2011 at the Maternity ward of Cantonal Hospital in Bihac 1899 children was born. In 32 neonates was registered a heart murmur, in the period from birth up to 6 weeks of life. All children with positive auscultation finding of the heart were examined echocardiography by ultrasound ALOCA 2000, multifrequency probe from 3.5 to 5 MHz, and used M-mode, 2-D, continuous, pulsed and color Doppler. Results: Of the 32 examined children regular echocardiographic findings had two children (6.25%), aberrant bunch of left ventricle 11 (34.37%), patent foramen ovale 5 (15.62%), atrial septal defect 3 children (9.37%), ventricular septal defect 8 children (25%), cyanogen anomaly 2 children (6.25%), stenosis of the pulmonary artery 1 child (3.12%). We see that 14 children (43.75%) had a structural abnormality of the heart that requires further treatment and monitoring. Conclusion: Echocardiography is necessary to set up or refute the diagnosis of structural heart defect in children with positive auscultation finding in the neonatal period.
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Caddell AJ, Wong KK, Barker AP, Warren AE. Trends in Pediatric Cardiology Referrals, Testing, and Satisfaction at a Canadian Tertiary Centre. Can J Cardiol 2015; 31:95-8. [DOI: 10.1016/j.cjca.2014.10.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Revised: 10/25/2014] [Accepted: 10/27/2014] [Indexed: 11/30/2022] Open
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Friederichs H, Weissenstein A, Ligges S, Möller D, Becker JC, Marschall B. Combining simulated patients and simulators: pilot study of hybrid simulation in teaching cardiac auscultation. ADVANCES IN PHYSIOLOGY EDUCATION 2014; 38:343-347. [PMID: 25434018 DOI: 10.1152/advan.00039.2013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Auscultation torsos are widely used to teach position-dependent heart sounds and murmurs. To provide a more realistic teaching experience, both whole body auscultation mannequins and torsos have been used in clinical examination skills training at the Medical Faculty of the University of Muenster since the winter term of 2008-2009. This training has since been extended by simulated patients, which are normal, healthy subjects who have undergone attachment of the electronic components of the auscultation mannequins to their chests to mimic pathophysiological conditions ("hybrid models"). The acceptance of this new learning method was examined in the present pilot study. In total, 143 students in their second preclinical year who were participating in auscultation training were randomized into an intervention group (hybrid models) and a control group (auscultation mannequins). One hundred forty-two (99.3%) of these students completed a self-assessment Likert-scale questionnaire regarding different teaching approaches (where 1 = "very poor" to 100 = "very good"). The questionnaire focused on the "value of learning" of different teaching approaches. Direct comparison showed that students evaluated the hybrid models to be significantly more effective than the auscultation mannequins (median: 83 vs. 64, P < 0.001). The cardiac auscultation training was generally assessed positively (median: 88). Additionally, verbal feedback was obtained from simulated patients and tutors (trained students who had successfully passed the course a few semesters earlier). Personal feedback showed high satisfaction from student tutors and simulated patients. Hybrid simulators for teaching cardiac auscultation elucidated positive responses from students, tutors, and simulated patients.
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Affiliation(s)
| | | | - Sandra Ligges
- Institute of Biostatistics and Clinical Research, Muenster, Germany
| | - David Möller
- University of Muenster, Studienhospital, Muenster, Germany
| | - Jan C Becker
- University of Muenster, Institute of Medical Education, Muenster, Germany
| | - Bernhard Marschall
- University of Muenster, Institute of Medical Education, Muenster, Germany
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Campbell RM, Douglas PS, Eidem BW, Lai WW, Lopez L, Sachdeva R. ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 Appropriate Use Criteria for Initial Transthoracic Echocardiography in Outpatient Pediatric Cardiology. J Am Coll Cardiol 2014; 64:2039-60. [DOI: 10.1016/j.jacc.2014.08.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Turiy Y. Evaluation of a newborn with a murmur. J Pediatr Health Care 2013; 27:226-9. [PMID: 22658380 DOI: 10.1016/j.pedhc.2012.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 03/13/2012] [Accepted: 04/11/2012] [Indexed: 10/28/2022]
Affiliation(s)
- Yuliya Turiy
- University of Texas School of Medicine, Houston, TX, USA.
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31
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Germanakis I, Petridou ET, Varlamis G, Matsoukis IL, Papadopoulou-Legbelou K, Kalmanti M. Skills of primary healthcare physicians in paediatric cardiac auscultation. Acta Paediatr 2013; 102:e74-8. [PMID: 23082851 DOI: 10.1111/apa.12062] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 09/04/2012] [Accepted: 10/17/2012] [Indexed: 11/29/2022]
Abstract
AIM To evaluate the performance of primary healthcare physicians in paediatric cardiac auscultation and the impact of a multimedia-based teaching intervention. METHODS A total of 106 primary healthcare physicians (77 paediatricians, 14 general practitioners and 15 medical graduates) attended four paediatric cardiac auscultation teaching courses based on virtual patients' presentation (digital phonocardiography). Their auscultatory performance was documented at the beginning of each course and at the end of two of the courses. RESULTS Participants initially detected 73% of abnormal murmurs and 17% of additional sounds, while 22% of innocent murmurs were interpreted as abnormal. Overall cardiac auscultation performance, assessed by a combined auscultation score, was low and independent of training level (graduates: 39.5/trainees: 42.8/board certified: 42.6, p = 0.89) or specialty (paediatricians: 42.7/general practitioners: 43.1, p = 0.89). Multimedia-based teaching was associated with a significant improvement in abnormal murmur (92.5%) and additional sound (40%) detection (p < 0.001), while 25% of innocent murmurs were still interpreted as abnormal (p = 0.127). CONCLUSION Clinical skills of primary healthcare physicians in paediatric cardiac auscultation, independent of training level or specialty, still leave potential for improvement. Multimedia-based teaching interventions represent an effective means of improving paediatric cardiac auscultatory skills.
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Affiliation(s)
- Ioannis Germanakis
- Department of Paediatrics; Faculty of Medicine; University of Crete; University Hospital Heraklion; Crete; Greece
| | - Eleni Th Petridou
- Department of Hygiene; Epidemiology and Medical Statistics; Athens University Medical School; Athens; Greece
| | - George Varlamis
- 4th Department of Paediatrics; School of Medicine; General Hospital Papageorgiou; Aristotle University of Thessaloniki; Thessaloniki; Greece
| | - Ioannis L Matsoukis
- Department of Hygiene; Epidemiology and Medical Statistics; Athens University Medical School; Athens; Greece
| | - Kiriaki Papadopoulou-Legbelou
- 4th Department of Paediatrics; School of Medicine; General Hospital Papageorgiou; Aristotle University of Thessaloniki; Thessaloniki; Greece
| | - Maria Kalmanti
- Department of Paediatrics; Faculty of Medicine; University of Crete; University Hospital Heraklion; Crete; Greece
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Abstract
AIM To review the findings and outcomes of predischarge echocardiography service for postnatal heart murmurs provided by neonatologists. METHODS We retrospectively reviewed all predischarge echocardiograms performed on babies from the postnatal wards (PNW) over the last 3 years. We evaluated the indications, median age, findings and outcome. RESULTS A total of 408 echocardiograms were performed on 350 babies on the PNW. The most common indication was presence of a murmur (58%). In babies with a heart murmur, 26% had a normal echocardiogram, 2% had major structural heart defects, 38% had minor structural heart defects and 34% had transient circulatory changes. 32% were discharged with no follow-up, 28% were followed up in the local cardiac clinic and 40% were referred to the cardiologist. CONCLUSION Predischarge echocardiography service for postnatal heart murmurs provided by neonatologists has the benefit of providing an early diagnosis, counselling of the parents and arranging appropriate follow-up. It helps to triage the referrals to the cardiologist. We felt that we were able to alleviate parental anxieties by providing a definitive diagnosis and written information prior to discharge from hospital. We strongly believe that this service should only be provided by those appropriately trained and skilled in echocardiography.
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Affiliation(s)
- Anju Singh
- Neonatal Intensive Care Unit, Birmingham Women's Hospital, Edgbaston, Birmingham, UK.
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Kwiatkowski D, Wang Y, Cnota J. The Utility of Outpatient Echocardiography for Evaluation of Asymptomatic Murmurs in Children. CONGENIT HEART DIS 2012; 7:283-8. [DOI: 10.1111/j.1747-0803.2012.00637.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Can cardiologists distinguish innocent from pathologic murmurs in neonates? J Pediatr 2009; 154:50-54.e1. [PMID: 18692204 DOI: 10.1016/j.jpeds.2008.06.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 05/22/2008] [Accepted: 06/18/2008] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To determine the sensitivity and specificity of the clinical assessment of murmurs in neonates, as performed by pediatric cardiologists, and to identify clinical features that predict the presence of congenital heart disease (CHD) in this population. STUDY DESIGN Neonates (n = 201) referred for outpatient evaluation of a heart murmur were enrolled consecutively. After a clinical evaluation, the cardiologist documented whether the murmur was "likely innocent" or "likely pathologic." The cardiologist repeated his/her assessment after an electrocardiogram. Echocardiography served as the gold standard. RESULTS The median age was 12 days (range, 2-31 days). CHD was present in 113 of 201 (56%). Clinical assessment alone identified patients with CHD with a sensitivity of 80.5% (95% CI, 73.2-87.8), specificity of 90.9% (95% CI, 84.9-96.9), positive predictive value of 91.9% (95% CI, 86.6-97.3), and negative predictive value of 78.4% (95% CI, 70.4-86.4). The addition of an electrocardiogram did not improve these test characteristics. Features that were predictive of CHD were murmur quality (P < .0001), location (P = .02), and timing (P = .04). No patients requiring catheter or surgical intervention were missed by clinical assessment. CONCLUSIONS The prevalence of CHD in this referral population was high. Clinical assessment detected all complex CHD, although some simple lesions were missed. Murmur quality, location, and timing were predictive of CHD.
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Koo S, Yung TC, Lun KS, Chau AKT, Cheung YF. Cardiovascular symptoms and signs in evaluating cardiac murmurs in children. Pediatr Int 2008; 50:145-9. [PMID: 18353047 DOI: 10.1111/j.1442-200x.2008.02560.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of the present study was to determine the usefulness of cardiovascular symptoms and signs in the recognition of significant congenital heart lesions that required surgical or catheter interventions in different pediatric age groups. METHODS A retrospective chart review was carried out of 110 patients with significant heart anomalies that required surgical or catheter interventions (group I) and 113 children, presenting with cardiac murmurs, with congenital heart conditions not requiring any interventions. (group II). RESULTS Clinical symptoms or signs were significantly more common in group I than in group II subjects (85% vs 32%, P < 0.0001). The odds of having significant lesions requiring interventions in the presence of either cardiovascular symptoms or signs were 37.5 (95% confidence interval [CI]: 6.5-218.1) for neonates, 14.5 (95%CI: 4.7-51.7) for infants, and 8.0 (95%CI: 3.3-19.2) for children and adolescents. In neonates, the negative predictive values of the absence of symptoms or signs in isolation were relatively low at 64% and 65%, respectively. In children beyond infancy, the positive predictive values of the presence of symptoms or signs in isolation were also low at 62% and 68%, respectively. CONCLUSIONS Clinical assessment of cardiovascular symptoms and signs remains useful in the evaluation of the significance of pathological cardiac murmurs in children in the present era of technology. Nonetheless, the predictive values vary with different pediatric age groups.
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Affiliation(s)
- Sergio Koo
- Division of Paediatric Cardiology, Department of Paediatrics and Adolescent Medicine, Grantham Hospital, University of Hong Kong, Hong Kong
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Germanakis I, Dittrich S, Perakaki R, Kalmanti M. Digital phonocardiography as a screening tool for heart disease in childhood. Acta Paediatr 2008; 97:470-3. [PMID: 18307543 DOI: 10.1111/j.1651-2227.2008.00697.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To evaluate the performance of experienced cardiologists by use of digital phonocardiography for the correct identification of heart disease and innocent murmurs in children. METHODS Two independent paediatric cardiologists blindly evaluated 83 digital phonocardiograms obtained from consecutive paediatric cardiology outpatients. Each observer had to document the presence and characteristics of murmurs (intensity, quality, location), the presence of additional abnormal auscultatory findings (systolic click, second heart tone abnormalities) and whether he would recommend echocardiography (ECHO). The accuracy of their diagnoses was tested against the ECG diagnosis within two severity levels of heart disease. RESULTS Twenty-three out of 24 cases (95.8%) with moderate-to-severe heart defects and 12 to 13 out of 19 cases (63.2%-68.4%) with trivial-to-mild heart defects were correctly identified by phonocardiography. Additionally, 37 to 38 out of 40 cases (92.5%-95.0%) without ECHO evidence of heart disease were correctly interpreted as having innocent murmurs. The level of agreement between the two observers was substantial regarding their recommendations for ECHO (kappa, kappa=0.83) and in identifying abnormal murmurs (kappa=0.78). CONCLUSION Evaluation of digital phonocardiography by experienced cardiologists could allow for correct identification of moderate-to-severe forms of heart disease while preventing the majority of children with innocent murmurs from unnecessary referral.
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Affiliation(s)
- Ioannis Germanakis
- Paediatric Cardiology Unit, Department of Paediatrics, University Hospital, Heraklion, Crete, Greece.
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Pushparajah K, Garvie D, Hickey A, Qureshi SA. Managed Care Network for the assessment of cardiac problems in children in a district general hospital: a working model. Arch Dis Child 2006; 91:892-5. [PMID: 16717084 PMCID: PMC2082959 DOI: 10.1136/adc.2005.086058] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM To assess a model for cardiology assessments in children with suspected heart disease by a general paediatrician with special expertise in paediatric cardiology (PsePC) in a district general hospital. METHODS A new monthly "screening" clinic was established in May 2004 by the PsePC to reduce the burden of new referrals on outreach tertiary paediatric cardiology services. All patients were to have echocardiograms as part of their referral for cardiac assessment. Over a one year period (May 2004-April 2005), through audit, details of referrers, indications for referral, echocardiography assessments, and subsequent management were recorded. This was compared with the pattern of patients seen in the joint paediatric cardiology outreach clinics over a two year period (May 2003-April 2005). RESULTS In the "screening" clinic, there were 75 appointments for 65 patients seen in 12 months. Fifty five of these patients had normal echocardiographic studies. Of the 47 referrals with heart murmurs in asymptomatic children, four had structurally abnormal hearts on echocardiographic assessment. Between May-October 2003 and November 2003-April 2004, the number of new patients with normal echocardiographic studies seen in the paediatric cardiology outreach clinic was 33/106 (31%) and 28/110 (25.4%) respectively. Following the introduction of the "screening" clinic, the number decreased to 21/99 (21%) during May-October 2004, and 10/102 (9.8%) during November 2004-April 2005. CONCLUSION This model can work effectively in order to identify pathology requiring input of a paediatric cardiologist more appropriately. Paediatricians with specific training in paediatric cardiology are potentially well equipped to provide this basic screening service.
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Affiliation(s)
- K Pushparajah
- Department of Paediatrics, University Hospital Lewisham, London, UK
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Arlettaz R, Bauschatz AS, Mönkhoff M, Essers B, Bauersfeld U. The contribution of pulse oximetry to the early detection of congenital heart disease in newborns. Eur J Pediatr 2006; 165:94-8. [PMID: 16211399 DOI: 10.1007/s00431-005-0006-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Accepted: 08/18/2005] [Indexed: 10/25/2022]
Abstract
UNLABELLED Approximately half of all newborns with congenital heart disease are asymptomatic in the first few days of life. Early detection of ductal-dependant cardiac malformations prior to ductal closure is, however, of significant clinical importance, as the treatment outcome is related to the time of diagnosis. Pulse oximetry has been proposed for early detection of congenital heart disease. The aims of the present study were: 1) to determine the effectiveness of a pulse-oximetric screening performed on the first day of life for the detection of congenital heart disease in otherwise healthy newborns and 2) to determine if a pulse-oximetric screening combined with clinical examination is superior in the diagnosis of congenital heart disease to clinical examination alone. This is a prospective, multi-centre study. Postductal pulse oximetry was performed between six and twelve hours of age in all newborns of greater than 35 weeks gestation. If pulse-oximetry-measured arterial oxygen saturation was less than 95%, echocardiography was performed. Pulse oximetry was performed in 3,262 newborns. Twenty-four infants (0.7%) had repeated saturations of less than 95%. Of these infants, 17 had congenital heart disease and five of the remaining seven had persistent pulmonary hypertension. No infant with a ductal-dependant or cyanotic congenital heart disease exhibited saturation values greater or equal to 95%. CONCLUSION postductal pulse-oximetric screening in the first few days of life is an effective means for detecting cyanotic congenital heart disease in otherwise healthy newborns.
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Affiliation(s)
- Romaine Arlettaz
- Clinic of Neonatology, University Hospital, Frauenklinikstrasse 10, CH-8091, Zurich, Switzerland.
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Ching M, Straznicky I, Goss AN. Cardiac murmurs: echocardiography in the assessment of patients requiring antibiotic prophylaxis for dental treatment. Aust Dent J 2005; 50:S69-73. [PMID: 16416721 DOI: 10.1111/j.1834-7819.2005.tb00389.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Traditionally patients who indicate that they have a heart murmur or who indicate that they have had rheumatic fever are given antibiotic prophylaxis for dental treatment. This is commonly done without further assessment of the patient's actual endocarditis risk. Echocardiography is a non-invasive method of assessing cardiac valve function and haemodynamics. METHODS Consecutive patients who were referred to a private practice oral and maxillofacial surgeon for dentoalveolar surgery and indicated that they had a cardiac problem and usually had antibiotic prophylaxis, were evaluated. Those with a clear indication for prophylaxis, for example had prosthetic heart valves or previous infective endocarditis, received antibiotic prophylaxis. Where there was uncertainty, they were referred for an echocardiogram, and if abnormal, a formal cardiology review. RESULTS Three hundred and seventy patients out of approximately 20 000 (1.85 per cent) indicated that they had a cardiac murmur and usually received antibiotic prophylaxis for dental treatment between 1 February 1997 and 1 February 2005. Two hundred and sixty-two (71 per cent) were female and 108 (29 per cent) were male; age range 0.7 to 98 years, average 37.6 years. Two hundred and seventy (72 per cent) had normal hearts with no indication for antibiotic prophylaxis. Of the 100 (28 per cent) patients with abnormal findings, they were on average older; 49.5 years, range 0.7 to 87 years. Of these, 50 (14 per cent) met current indications for antibiotic prophylaxis. CONCLUSION Patients who present for dental treatment indicating that they require antibiotic prophylaxis for cardiac condition need to be fully evaluated. In this study only 50 of 370 patients (14 per cent) required antibiotic prophylaxis. The remaining 320 (86 per cent) would have no benefit but a risk of adverse reaction to the antibiotic.
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Bhave S, Kohli V. Cardiac Issues in the Adolescent Age Group. APOLLO MEDICINE 2004. [DOI: 10.1016/s0976-0016(12)60035-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abdurrahman L, Bockoven JR, Pickoff AS, Ralston MA, Ross JE. Pediatric cardiology update: Office-based practice of pediatric cardiology for the primary care provider. Curr Probl Pediatr Adolesc Health Care 2003; 33:318-47. [PMID: 14627960 DOI: 10.1016/s1538-5442(03)00137-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Lubabatu Abdurrahman
- Wright State University, Department of Pediatrics, Dayton Children's Cardiology, The Children's Medical Center, OH, USA
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Danford DA. Sorting through the haystack--decision analysis and the search for heart disease among children with murmur. J Pediatr 2002; 141:465-7. [PMID: 12378181 DOI: 10.1067/mpd.2002.128657] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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