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Doroshow RW, Aldrich J, Dorner R, Lyons L, McCarter R. A randomized, controlled trial of an innovative, multimedia instructional program for acquiring auditory skill in identifying pediatric heart murmurs. Front Pediatr 2024; 11:1283306. [PMID: 38293663 PMCID: PMC10825047 DOI: 10.3389/fped.2023.1283306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/29/2023] [Indexed: 02/01/2024] Open
Abstract
Objective To create a brief, acceptable, innovative method for self-paced learning to enhance recognition of pediatric heart murmurs by medical students, and to demonstrate this method's effectiveness in a randomized, controlled trial. Materials and methods A curriculum of six 10-min online learning modules was designed to enable deliberate practice of pediatric cardiac auscultation, using recordings of patients' heart murmurs. Principles of andragogy and multimedia learning were applied to optimize acquisition of this skill. A pretest and posttest, given 4 weeks apart, were created using additional recordings and administered to 87 3rd-year medical students during their pediatric clerkship. They were randomized to have access to the modules after the pretest or after the posttest, and asked to use at least the first 2 of the modules. Results 47 subjects comprised the Intervention group, and 40 subjects the Control group. On our primary outcome, distinguishing innocent from pathological with at least moderate confidence, the posttest scores were significantly higher for the Intervention group (60.5%) than for the Control group (20.0%). For our secondary outcomes, the 2 groups also differed significantly in the ability to distinguish innocent from pathological murmurs, and in identifying the actual diagnosis. On all 3 outcomes, those Intervention group subjects who accessed 4-6 modules scored higher than those who accessed 0-3 modules, who in turn scored higher than the Control group. Summary Applying current principles of adult learning, we have created a teaching program for medical students to learn to recognize common pediatric murmurs. Its effectiveness was demonstrated in a randomized, controlled trial. The program results in a meaningful gain in this skill from 1 h of self-paced training with high acceptance to learners.
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Affiliation(s)
- Robin W. Doroshow
- Department of Cardiology, Children’s National Hospital and George Washington School of Medicine and Health Sciences, Washington, DC, United States
| | - Julie Aldrich
- Department of Pediatrics, Children’s National Hospital and George Washington School of Medicine and Health Sciences, Washington, DC, United States
| | - Rebecca Dorner
- Department of Pediatrics, Georgetown University School of Medicine, Washington, DC, United States
| | - Laurie Lyons
- Department of Instructional Design and Technology, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Robert McCarter
- Division of Biostatistics, Children’s National Hospital and George Washington School of Medicine and Health Sciences, Washington, DC, United States
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Saponaro V, Mey C, Vonfeld I, Chamagne A, Alvarado M, Cadoré J, Chetboul V, Desquilbet L. Systolic third sound associated with systolic anterior motion of the mitral valve in cats with obstructive hypertrophic cardiomyopathy. J Vet Intern Med 2023; 37:1679-1684. [PMID: 37448142 PMCID: PMC10472982 DOI: 10.1111/jvim.16806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Third heart sounds in cats frequently are associated with hypertrophic cardiomyopathy (HCM) but their exact characterization and timing within the cardiac cycle remains unknown. OBJECTIVES Characterize third heart sounds in cats by phonocardiography and test the ability of 3 observers with different levels of experience and training to recognize third systolic heart sounds in cats. ANIMALS Fifty client-owned cats of different breeds presented for heart screening. METHODS Cats were prospectively assessed using an electronic stethoscope (with digital recording) and then underwent full conventional echocardiographic examination. Audio recordings were blindly assessed in a random order by 3 observers: the cardiologist who collected clinical data, as well as a trained and an untrained junior veterinarian. Cohen's kappa coefficients were calculated to quantify agreement between the opinion of each observer and the echocardiography results (considered the gold standard). RESULTS Twenty cats had a third systolic sound on phonocardiography and an obstructive HCM phenotype with systolic anterior motion of the mitral valve (SAM) on echocardiography. Agreement with echocardiography was very good for the experienced cardiologist, substantial for the trained junior veterinarian, and poor for the untrained junior veterinarian (kappa of 0.92, 0,64, and 0.08, respectively). CONCLUSIONS AND CLINICAL IMPORTANCE We describe here a new auscultatory abnormality in cats with obstructive HCM. It could help a trained non-cardiologist veterinarian in suspecting obstructive HCM in cats based on auscultation only.
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Affiliation(s)
| | - Clémence Mey
- École Nationale Vétérinaire d'AlfortMaisons‐AlfortFrance
| | - Irène Vonfeld
- École Nationale Vétérinaire d'AlfortMaisons‐AlfortFrance
| | | | | | | | - Valérie Chetboul
- École Nationale Vétérinaire d'AlfortMaisons‐AlfortFrance
- Université Paris Est Créteil, INSERM, IMRBCréteilFrance
| | - Loïc Desquilbet
- École Nationale Vétérinaire d'AlfortMaisons‐AlfortFrance
- Université Paris Est Créteil, INSERM, IMRBCréteilFrance
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Shekhar R, Vanama G, John T, Issac J, Arjoune Y, Doroshow RW. Automated identification of innocent Still's murmur using a convolutional neural network. Front Pediatr 2022; 10:923956. [PMID: 36210944 PMCID: PMC9533723 DOI: 10.3389/fped.2022.923956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background Still's murmur is the most prevalent innocent heart murmur of childhood. Auscultation is the primary clinical tool to identify this murmur as innocent. Whereas pediatric cardiologists routinely perform this task, primary care providers are less successful in distinguishing Still's murmur from the murmurs of true heart disease. This results in a large number of children with a Still's murmur being referred to pediatric cardiologists. Objectives To develop a computer algorithm that can aid primary care providers to identify the innocent Still's murmur at the point of care, to substantially decrease over-referral. Methods The study included Still's murmurs, pathological murmurs, other innocent murmurs, and normal (i.e., non-murmur) heart sounds of 1,473 pediatric patients recorded using a commercial electronic stethoscope. The recordings with accompanying clinical diagnoses provided by a pediatric cardiologist were used to train and test the convolutional neural network-based algorithm. Results A comparative analysis showed that the algorithm using only the murmur sounds recorded at the lower left sternal border achieved the highest accuracy. The developed algorithm identified Still's murmur with 90.0% sensitivity and 98.3% specificity for the default decision threshold. The area under the receiver operating characteristic curve was 0.943. Conclusions Still's murmur can be identified with high accuracy with the algorithm we developed. Using this approach, the algorithm could help to reduce the rate of unnecessary pediatric cardiologist referrals and use of echocardiography for a common benign finding.
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Affiliation(s)
- Raj Shekhar
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, DC, United States
- AusculTech Dx, Silver Spring, MD, United States
| | | | - Titus John
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, DC, United States
- AusculTech Dx, Silver Spring, MD, United States
| | - James Issac
- AusculTech Dx, Silver Spring, MD, United States
| | - Youness Arjoune
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, DC, United States
| | - Robin W. Doroshow
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, DC, United States
- AusculTech Dx, Silver Spring, MD, United States
- Children's National Heart Institute, Children's National Hospital, Washington, DC, United States
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Goethe Doualla FC, Bediang G, Nganou-Gnindjio C. Evaluation of a digitally enhanced cardiac auscultation learning method: a controlled study. BMC MEDICAL EDUCATION 2021; 21:380. [PMID: 34247603 PMCID: PMC8273941 DOI: 10.1186/s12909-021-02807-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/24/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Cardiac auscultation remains an efficient and accessible diagnostic tool, especially in resource-limited countries where modern diagnostic devices like cardiac ultrasound are expensive and difficult to access. However, cardiac auscultation skills of medical students and physicians are declining, mainly because of an ineffective teaching method for this technique. The objective of this study is to evaluate the effect of a digitally enhanced cardiac auscultation learning method on participants' theoretical knowledge and auscultation skills. METHODS This will be a controlled study with two parallel arms (1:1). Participants (fourth-year medical students) will be divided into two groups: an intervention group (receiving additional lectures, clinical internship and audio listening sessions) and a control group (receiving additional lectures and clinical internship). At the beginning of the study, all participants will undergo a pre-test that consist of two parts: a knowledge assessment based on multiple-choice questions and a skills assessment based on recognition of cardiac sounds from audio files. Thereafter, three specific additional lectures on cardiac auscultation will be delivered and all participants will take part in their official clinical internship. During these clinical internships (eight weeks), participants of the intervention group will be invited to two listening sessions based on five digital recordings of heart sounds. At the end of the clinical internship, all participants will be invited to a post-test to evaluate their knowledge, skills and satisfaction according to their learning method. The main outcome will be the participants' knowledge progression. The other outcomes will be the participants' skills progression, participants' total progression and satisfaction. Data will be collected and analyzed in per protocol. DISCUSSION This study could contribute to the development of a learning method that takes into account the advantages of the conventional method and the contribution of digital technology. Positive results could lead to improved cardiac auscultation skills among health professionals, especially in developing countries. TRIAL REGISTRATION The trial is registered on the Pan-African Clinical Trials Registry ( http://www.pactr.org ) under unique identification number: PACTR202001504666847 , registered the 29 November 2019.
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Affiliation(s)
| | - Georges Bediang
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Chris Nganou-Gnindjio
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
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Watsjold B, Ilgen J, Monteiro S, Sibbald M, Goldberger ZD, Thompson WR, Norman G. Do you hear what you see? Utilizing phonocardiography to enhance proficiency in cardiac auscultation. PERSPECTIVES ON MEDICAL EDUCATION 2021; 10:148-154. [PMID: 33438146 PMCID: PMC8187497 DOI: 10.1007/s40037-020-00646-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 12/08/2020] [Accepted: 12/16/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Cardiac auscultation skills have proven difficult to train and maintain. The authors investigated whether using phonocardiograms as visual adjuncts to audio cases improved first-year medical students' cardiac auscultation performance. METHODS The authors randomized 135 first-year medical students using an email referral link in 2018 and 2019 to train using audio-only cases (audio group) or audio with phonocardiogram tracings (combined group). Training included 7 cases with normal and abnormal auscultation findings. The assessment included feature identification and diagnostic accuracy using 14 audio-only cases, 7 presented during training, and 7 alternate versions of the same diagnoses. The assessment-administered immediately after training and repeated 7 days later-prompted participants to identify the key features and diagnoses for 14 audio-only cases. Key feature scores and diagnostic accuracy were compared between groups using repeated measures ANOVA. RESULTS Mean key feature scores were statistically significantly higher in the combined group (70%, 95% CI 67-75%) compared to the audio group (61%, 95% CI 56-66%) (F(1,116) = 6.144, p = 0.015, ds = 0.45). Similarly, mean diagnostic accuracy in the combined group (68%, 95% CI 62-73%) was significantly higher than the audio group, although with small effect size (59%, 95% CI 54-65%) (F(1,116) = 4.548, p = 0.035, ds = 0.40). Time on task for the assessment and prior auscultation experience did not significantly impact performance on either measure. DISCUSSION The addition of phonocardiograms to supplement cardiac auscultation training improves diagnostic accuracy and heart sound feature identification amongst novice students compared to training with audio alone.
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Affiliation(s)
- Bjorn Watsjold
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | - Jonathan Ilgen
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Center for Leadership & Innovation in Medical Education, University of Washington School of Medicine, Seattle, WA, USA
| | - Sandra Monteiro
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Matthew Sibbald
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Zachary D Goldberger
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - W Reid Thompson
- Division of Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Geoff Norman
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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van Staveren MDB, Szatmári V. Detecting and recording cardiac murmurs in clinically healthy puppies in first opinion veterinary practice at the first health check. Acta Vet Scand 2020; 62:37. [PMID: 32586343 PMCID: PMC7315505 DOI: 10.1186/s13028-020-00535-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 06/16/2020] [Indexed: 11/20/2022] Open
Abstract
Background The frequency that cardiac murmurs are identified and recorded in first opinion veterinary practices at the first health check in puppies is unknown. The aims of the study were to assess the agreement between first opinion veterinary practitioners, a veterinary student and a veterinary cardiology specialist on detecting murmurs, and to establish whether abnormal auscultation findings had been recorded in the health certificates of clinically healthy puppies. The study included prospective and retrospective investigations, where the prospectively collected auscultation findings from a veterinary cardiology specialist and a trained veterinary student were compared to auscultation findings recorded by first opinion veterinary practitioners. Results Cardiac auscultation was performed on 331 client-owned, clinically healthy dogs at two time points: at age 34–69 days by a first opinion veterinary practitioner and at age 45–76 days, on average 9 days later, by a veterinary cardiology specialist and a trained veterinary student. Agreement among the three was compared for the presence of a murmur. The degree of inter-observer agreement was evaluated using Cohen’s kappa. Auscultation findings, as noted in the pets’ passports, from 331 puppies and 43 different first opinion veterinary practices, were retrospectively reviewed and prospectively compared with auscultation findings from a veterinary cardiology specialist. Agreement between the veterinary cardiology specialist and the first opinion veterinary practitioners was poor (ϰ = 0.01) and significantly different (P < 0.001). First opinion veterinary practitioners had recorded a cardiac murmur in only 1 of the 97 puppies in which the veterinary cardiology specialist detected a murmur. Two-hundred-and-fifty-two puppies were auscultated by both the veterinary cardiology specialist and the student. Their agreement was fair (ϰ = 0.40) and significantly different (P = 0.024). The agreement between the student and a first opinion veterinary practitioner on these 252 puppies was poor (ϰ = 0.03) and significantly different (P < 0.001). Conclusions This study shows that soft cardiac murmurs are rarely documented during the first veterinary health check in puppies by first opinion veterinary practitioners. Although soft murmurs may not be clinically relevant, finding and recording them is evidence of a carefully performed auscultation. Missing a non-pathological murmur is not of clinical importance; however, missing a pathological murmur could prove detrimental for the individual puppy.
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Ramanathan A, Zhou L, Marzbanrad F, Roseby R, Tan K, Kevat A, Malhotra A. Digital stethoscopes in paediatric medicine. Acta Paediatr 2019; 108:814-822. [PMID: 30536440 DOI: 10.1111/apa.14686] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/29/2018] [Accepted: 12/04/2018] [Indexed: 12/30/2022]
Abstract
AIM To explore, synthesise and discuss currently available digital stethoscopes (DS) and the evidence for their use in paediatric medicine. METHODS Systematic review and narrative synthesis of digital stethoscope use in paediatrics following searches of OVID Medline, Embase, Scopus, PubMed and Google Scholar databases. RESULTS Six digital stethoscope makes were identified to have been used in paediatric focused studies so far. A total of 25 studies of DS use in paediatrics were included. We discuss the use of digital stethoscope technology in current paediatric medicine, comment on the technical properties of the available devices, the effectiveness and limitations of this technology, and potential uses in the fields of paediatrics and neonatology, from telemedicine to computer-aided diagnostics. CONCLUSION Further validation and testing of available DS devices is required. Comparison studies between different types of DS would be useful in identifying strengths and flaws of each DS as well as identifying clinical situations for which each may be most appropriately suited.
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Affiliation(s)
| | - Lindsay Zhou
- Monash Newborn Monash Children's Hospital Melbourne VIC Australia
| | - Faezeh Marzbanrad
- Department of Electrical and Computer Systems Engineering Monash University Melbourne VIC Australia
| | - Robert Roseby
- Department of Paediatrics Monash University Melbourne VIC Australia
- Department of Paediatric Respiratory Medicine Monash Children's Hospital Melbourne VIC Australia
| | - Kenneth Tan
- Department of Paediatrics Monash University Melbourne VIC Australia
- Monash Newborn Monash Children's Hospital Melbourne VIC Australia
- The Ritchie Centre Hudson Institute of Medical Research Melbourne VIC Australia
| | - Ajay Kevat
- Department of Paediatrics Monash University Melbourne VIC Australia
| | - Atul Malhotra
- Department of Paediatrics Monash University Melbourne VIC Australia
- Monash Newborn Monash Children's Hospital Melbourne VIC Australia
- The Ritchie Centre Hudson Institute of Medical Research Melbourne VIC Australia
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Legget ME, Toh M, Meintjes A, Fitzsimons S, Gamble G, Doughty RN. Digital devices for teaching cardiac auscultation - a randomized pilot study. MEDICAL EDUCATION ONLINE 2018; 23:1524688. [PMID: 30499380 PMCID: PMC6282469 DOI: 10.1080/10872981.2018.1524688] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 07/16/2018] [Accepted: 09/05/2018] [Indexed: 05/27/2023]
Abstract
BACKGROUND Competent cardiac auscultation is a declining skill. Digital stethoscopes and hand-held echocardiography (HHE) are modern devices which may improve the accuracy of heart murmur recognition and diagnosis. Their incremental value compared to conventional examination has not been evaluated in depth. OBJECTIVES Our aim was to quantify the utility of digital stethoscopes and HHE as teaching aids to improve medical students' diagnostic accuracy in the evaluation of heart murmurs using a novel clinically weighted scoring system. DESIGN This pilot study involved eight medical students and eight patients with heart murmurs. Four patients were examined at 2 sessions, 1 week apart. Medical students were randomised into two groups: the 'intervention group' examined patients with a standard and digital stethoscope, and then received demonstration of the valvular lesion with HHE to illustrate the diagnosis. The 'control group' used a standard stethoscope only and were taught using traditional methods. Students' scores were compared to a 'gold standard' derived from a consensus of auscultation findings of three cardiologists. RESULTS Overall the mean percent correct of total possible score was 65.4% (SD8.4). Using a mixed models ANOVA approach to repeated measures, the mean [95% CI] increase from training to validation period for the control group was 2.5% [-11.5, 16.5] P(Tukey) = 0.95 and 15.8% [1.7,29.8] P(Tukey) = 0.027 for the intervention group. Between the validation and training sessions for both groups, there was an increase of 9.1% [1.82, 16.4] in scores (p = 0.018). The mean [95% CI] difference in scores of the control and intervention groups was 1.9% [-5.4, 9.2] (p = 0.59). The Cohen's effect size estimate was 0.9. CONCLUSION Digital stethoscopes and hand-held echo may be useful devices for teaching cardiac auscultation. This pilot study provides a novel study design, a heart murmur grading system, and data that will help develop definitive studies to assess new teaching techniques for cardiac auscultation using digital technology.
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Affiliation(s)
- Malcolm E. Legget
- Department of Medicine, University of Auckland, Auckland, New Zealand
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - MeiYen Toh
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Andries Meintjes
- Institute of Biomedical Technologies, Auckland University of Technology, Auckland, New Zealand
| | - Sarah Fitzsimons
- Department of Medicine, University of Auckland, Auckland, New Zealand
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Greg Gamble
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Robert N. Doughty
- Department of Medicine, University of Auckland, Auckland, New Zealand
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
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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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Chatzakis I, Vassilakis K, Lionis C, Germanakis I. Electronic health record with computerized decision support tools for the purposes of a pediatric cardiovascular heart disease screening program in Crete. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2018; 159:159-166. [PMID: 29650310 DOI: 10.1016/j.cmpb.2018.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 01/31/2018] [Accepted: 03/09/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND AND OBJECTIVE Early detection of cardiovascular (CV) disease or associated risk factors during childhood is of paramount importance, allowing for early treatment or lifestyle modifications, respectively. The objective of this study was to describe the development of an electronic health record (EHR), with integrated computerized decision support system (CDSS), specifically designed for supporting the needs of a pilot pediatric CV disease screening program applied on primary school students of a Mediterranean island. METHODS Evidence-based knowledge, national and international practice guidelines regarding sport preparticipation CV screening of children and young athletes has been used for the design of the designated EHR. A CDSS, capable for providing alerts for further cardiology evaluation need, has been incorporated into the EHR, based on normative anthropometric and electrocardiographic data as well as predefined positive history responses. RESULTS We developed a designated EHR with integrated CDSS supporting pediatric CV disease screening, capable for documenting CV-related personal and family history responses, physical evaluation data (weight, height, blood pressure), allowing for entering electrocardiogam (ECG) measurements and for uploading of multimedia files (including ECG images and digital phonocardiogram audio files). The EHR incorporates clinical calculators and referral alerts for the presence (and degree) of adiposity, hypertension, ECG abnormalities and positive history responses indicative of high CV disease risk. In a preliminary EHR validation, performed by entering data from 53 previously available paper-based health records, the EHR was proven to be fully functional. CONCLUSIONS The pediatric cardiology EHR with CDSS features which we developed might serve as a model for EHR for primary health care purposes, capable to document and early detect CV disease and associated risk factors in pediatric populations.
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Affiliation(s)
| | | | - Christos Lionis
- Clinic of Social and Family Medicine, School of Medicine, University of Crete, Greece
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Nathwani JN, Garren A, Laufer S, Kwan C, Pugh CM. Improving diagnosis in healthcare: Local versus national adoption of recommended guidelines for the clinical breast examination. Am J Surg 2018; 215:995-999. [PMID: 29229379 PMCID: PMC5988913 DOI: 10.1016/j.amjsurg.2017.11.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 11/28/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study explores the long-term effectiveness of a newly developed clinical skills curriculum. METHODS Students (N = 40) were exposed to a newly developed, simulation-based, clinical breast exam (CBE) curriculum. The same students returned one year later to perform the CBE and were compared to a convenience sample of medical students (N = 15) attending a national conferences. All students were given a clinical vignette and performed the CBE. CBE techniques were video recorded. Chi-squared tests were used to assess differences in CBE technique. RESULTS Students exposed to a structured curriculum performed physical examination techniques more consistent with national guidelines than the random, national student sample. Structured curriculum students were more organized, likely to use two hands, a linear search pattern, and include the nipple-areolar complex during the CBE compared to national sample (p < 0.01). CONCLUSIONS Students exposed to a structured skills curriculum more consistently performed the CBE according to national guidelines. The variability in technique compared with the national sample of students calls for major improvements in adoption and implementation of structured skills curricula.
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Affiliation(s)
- Jay N Nathwani
- University of Wisconsin, General Surgery, Madison, WI, USA
| | - Anna Garren
- University of Wisconsin, General Surgery, Madison, WI, USA
| | - Shlomi Laufer
- University of Wisconsin, General Surgery, Madison, WI, USA
| | - Calvin Kwan
- University of Wisconsin, General Surgery, Madison, WI, USA
| | - Carla M Pugh
- University of Wisconsin, General Surgery, Madison, WI, USA.
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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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Kang S, Doroshow R, McConnaughey J, Shekhar R. Automated Identification of Innocent Still's Murmur in Children. IEEE Trans Biomed Eng 2016; 64:1326-1334. [PMID: 27576242 DOI: 10.1109/tbme.2016.2603787] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Still's murmur is the most common innocent heart murmur in children. It is also the most commonly misdiagnosed murmur, resulting in a high number of unnecessary referrals to pediatric cardiologist. The purpose of this study was to develop a computer algorithm for automated identification of Still's murmur that may help reduce unnecessary referrals. METHODS We first developed an accurate segmentation algorithm to locate the first and the second heart sounds. Once these sounds were identified, we extracted signal features specific to Still's murmur. Subsequently, machine learning-based classifiers, artificial neural network and support vector machine, were used to identify Still's murmur. RESULTS We evaluated our classifiers using the jackknife method using 87 Still's murmurs and 170 non-Still's murmurs. Our algorithm identified Still's murmur accurately with 84-93% sensitivity and 91-99% specificity. CONCLUSION We have achieved accurate automated identification of Still's murmur while minimizing false positives. The performance of our algorithm is comparable to the rate of murmur identification by auscultation by pediatric cardiologists. SIGNIFICANCE To our knowledge, our solution is the first murmur classifier that focuses singularly on Still's murmur. Following further refinement and testing, the presented algorithm could reduce the number of children with Still's murmur referred unnecessarily to pediatric cardiologists.
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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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Kononowicz AA, Zary N, Edelbring S, Corral J, Hege I. Virtual patients--what are we talking about? A framework to classify the meanings of the term in healthcare education. BMC MEDICAL EDUCATION 2015; 15:11. [PMID: 25638167 PMCID: PMC4318546 DOI: 10.1186/s12909-015-0296-3] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 01/19/2015] [Indexed: 05/11/2023]
Abstract
BACKGROUND The term "virtual patients" (VPs) has been used for many years in academic publications, but its meaning varies, leading to confusion. Our aim was to investigate and categorize the use of the term "virtual patient" and then classify its use in healthcare education. METHODS A literature review was conducted to determine all articles using the term "virtual patient" in the title or abstract. These articles were categorized into: Education, Clinical Procedures, Clinical Research and E-Health. All educational articles were further classified based on a framework published by Talbot et al. which was further developed using a deductive content analysis approach. RESULTS 536 articles published between 1991 and December 2013 were included in the study. From these, 330 were categorized as educational. Classifying these showed that 37% articles used VPs in the form of Interactive Patient Scenarios. VPs in form of High Fidelity Software Simulations (19%) and Virtual Standardized Patients (16%) were also frequent. Less frequent were other forms, such as VP Games. Analyzing the literature across time shows an overall trend towards the use of Interactive Patient Scenarios as the predominant form of VPs in healthcare education. CONCLUSIONS The main form of educational VPs in the literature are Interactive Patient Scenarios despite rapid technical advances that would support more complex applications. The adapted classification provides a valuable model for VP developers and researchers in healthcare education to more clearly communicate the type of VP they are addressing avoiding misunderstandings.
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Affiliation(s)
- Andrzej A Kononowicz
- Department of Learning, Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Krakow, Poland.
| | - Nabil Zary
- Department of Learning, Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
| | - Samuel Edelbring
- Department of Learning, Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
| | - Janet Corral
- School of Medicine at the University of Colorado Denver in Denver, Colorado, USA.
| | - Inga Hege
- Institut für Didaktik und Ausbildungsforschung in der Medizin am Klinikum der Universität München, Ziemssenstr 1, 80336, München, Germany.
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