Cardiac murmurs can be a source of anxiety for both physicians and parents until serious cardiac disorders are excluded. The innocent cardiac murmur is still the most common finding in healthy children and can usually be diagnosed through obtaining a complete history and performing a complete physical examination. However, a cardiac murmur may be the first sign of a structural cardiac disease and should not be ignored. Referral to a pediatric cardiologist for further evaluation is required when murmur assessment is not clear and diagnostic uncertainty is present. Educating and reassuring parents remains an important aspect of this evaluation. This article discusses features of innocent and pathological murmurs and provides an approach to cardiac murmurs in children.

A multiphysics simulation approach is developed for predicting cardiac flows as well as for conducting virtual echocardiography (ECHO) and phonocardiography (PC) of those flows. Intraventricular blood flow in pathological heart conditions is simulated by solving the three-dimensional incompressible Navier-Stokes equations with an immersed boundary method, and using this computational hemodynamic data, echocardiographic and phonocardiographic signals are synthesized by separate simulations that model the physics of ultrasound wave scattering and flow-induced sound, respectively. For virtual ECHO, a Doppler ultrasound image is reproduced through Lagrangian particle tracking of blood cell particles and application of sound wave scattering theory. For virtual PC, the generation and propagation of blood flow-induced sounds ('hemoacoustics') is directly simulated by a computational acoustics model. The virtual ECHO is applied to reproduce a color M-mode Doppler image for the left ventricle as well as continuous Doppler image for the outflow tract of the left ventricle, which can be verified directly against clinically acquired data. The potential of the virtual PC approach for providing new insights between disease and heart sounds is demonstrated by applying it to modeling systolic murmurs caused by hypertrophic cardiomyopathy. Copyright © 2013 John Wiley & Sons, Ltd.

A young man presented with a 2-month history of fever and malaise. Cardiac auscultation revealed the presence of a diastolic murmur. Subsequently, a cardiac echocardiogram was done, which showed a large vegetation adherent to an anterior mitral leaflet. The blood culture was positive for Brucella species. The patient was given antibiotic therapy for brucellosis and referred for surgery. Brucella endocarditis is one of the rarest, yet most notorious complications of this infection. This condition requires a high degree of clinical suspicion in order to facilitate prompt diagnosis and treatment.

Detection of murmurs and gallops may help to identify cats with heart disease. However, auscultatory findings may be subject to clinically relevant observer variation. The objective of this study was to evaluate an electronic stethoscope (ES) in cats. We hypothesized that the ES would perform at least as well as a conventional stethoscope (CS) in the detection of abnormal heart sounds. One hundred and fifty consecutive cats undergoing echocardiography were enrolled prospectively. Cats were ausculted with a CS (WA Tycos Harvey Elite) by two observers, and heart sounds were recorded digitally using an ES (3M Littmann Stethoscope Model 3200) for off-line analysis. Echocardiography was used as the clinical standard method for validation of auscultatory findings. Additionally, digital recordings (DRs) were assessed by eight independent observers with various levels of expertise, and compared using interclass correlation and Cohen's weighted kappa analyses. Using the CS, a heart murmur (n = 88 cats) or gallop sound (n = 17) was identified in 105 cats, whereas 45 cats lacked abnormal heart sounds. There was good total agreement (83-90%) between the two observers using the CS. In contrast, there was only moderate agreement (P <0.001) between results from the CS and the DRs for murmurs, and poor agreement for gallops. The CS was more sensitive compared with the DRs with regard to murmurs and gallops. Agreement among the eight observers was good-to-excellent for murmur detection (81%). In conclusion, DRs made with the ES are less sensitive but comparably specific to a CS at detecting abnormal heart sounds in cats.

Background Investigation and management of neonatal heart murmurs varies widely and is dependent on local resources. In order to standardise the management of heart murmurs in our hospital a guideline (based on clinical examination with selective cardiology review) was introduced. Aims To establish adherence to and safety of the guideline; to review workload implications and to define the causes of neonatal heart murmurs in our population. Methods Patients were prospectively identified over a 2-year period (August 2006 to July 2008). Case notes were reviewed and examination findings, investigations, follow up and diagnosis recorded. Results 89 babies were identified. The guideline was generally well adhered to. In total 51 (57%) of babies were referred for cardiology assessment. In 40 babies this assessment included an echocardiogram. 30 babies (34%) had an underlying cardiac malformation: 25 were identified before discharge home. 15/30 (50%) of the babies with a cardiac malformation remain under cardiology follow up at the age of 1 year. No baby discharged from follow up without cardiology review subsequently presented with a cardiac problem. Conclusion A significant minority of babies with a heart murmur have an underlying cardiac malformation. Our guideline appears to ensure the timely identification of these babies and rationalises our use of specialist services.

BACKGROUND:

Endocarditis may precede or complicate bacterial meningitis, but the incidence and impact of endocarditis in bacterial meningitis is unknown.

METHODS AND RESULTS:

We assessed the incidence and clinical characteristics of patients with meningitis and endocarditis from a nationwide cohort study of adults with community-acquired bacterial meningitis in the Netherlands performed from 2006 to 2012. Endocarditis was identified in 24 of 1025 (2%) episodes of bacterial meningitis. Cultures yielded Streptococcus pneumoniae in 13 patients, Staphylococcus aureus in 8 patients, and Streptococcus agalactiae, Streptococcus pyogenes and Streptococcus salivarius each in 1 patient. Clues leading to the diagnosis of endocarditis were cardiac murmurs, persistent or recurrent fever, a history of heart valve disease and S. aureus as causative pathogen of bacterial meningitis. Treatment consisted of prolonged antibiotic therapy in all patients and surgical valve replacement in 10 patients (42%). Two patients were treated with oral anticoagulants and both developed life-threatening intracerebral hemorrhage. Systemic (70%) and neurologic complications (54%) occurred frequently, leading to a high proportion of patients with unfavorable outcome (63%). Seven of 24 patients (29%) with meningitis and endocarditis died.

CONCLUSIONS:

Endocarditis is an uncommon co-existing condition in bacterial meningitis, but is associated with a high rate of unfavorable outcome.

To investigate the hypothesis that junior doctors' examination skills are deteriorating by assessing the medical admission note examination record.Retrospective study of the admission record.Tertiary care hospital.The admission records of 266 patients admitted to Wellington hospital between 1975 and 2011 were analysed, according to the total number of physical examination observations (PEOtot), examination of the relevant system pertaining to the presenting complaint (RelSystem) and the number of body systems examined (Nsystems). Subgroup analysis proceeded according to admission year, level of experience of the admitting doctor (registrar, house surgeon (HS) and trainee intern (TI)) and medical versus surgical admission notes. Further analysis investigated the trend over time in documentation with respect to cardiac murmurs, palpable liver, palpable spleen, carotid bruit, heart rate, funduscopy and apex beat location and character.PEOtot declined by 34% from 1975 to 2011. Surgical admission notes had 21% fewer observations than medical notes. RelSystem occurred in 94% of admissions, with no decline over time. Medical notes documented this more frequently than surgical notes (98% and 86%, respectively). There were no differences between registrars and HS, except for the 2010s subgroup (97% and 65%, respectively). Nsystems declined over the study period. Medical admission notes documented more body systems than surgical notes. There were no differences between registrars, HSs and TIs. Fewer examinations were performed for palpable liver, palpable spleen, cardiac murmur and apex beat location and character over the study period. There was no temporal change in the positive findings of these observations or heart rate rounding.There has been a decline in the admission record at Wellington hospital between 1975 and 2011, implying a deterioration in local doctors' physical examination skills. Measures to counter this trend are discussed.

An aneurysm of the sinus of Valsalva (SVA) may rupture into the cardiac cavities and cause abnormal connections between these cavities and the aorta. The right atrium and/or right ventricle are the cavities into which the SVA is most commonly observed to rupture. A 30-year-old patient presented to our cardiology clinic with the complaint of dyspnea. His physical examination revealed a thrill localized in the 5th intercostal space on the right edge of the sternum and systolic-diastolic murmur beginning from the aortic focus and spreading to the neck and back along the right edge of the sternum. The echocardiographic and invasive examinations revealed two defects leading to a passage from the right sinus Valsalva to the right ventricle. While the left-to-right shunt ratio was calculated as 3.8, the anatomic locations and dimensions of the defects were found to be eligible for percutaneous closure. Using the Amplatzer Duct Occluder I device, the defects were closed in two sessions. Although the classical treatment method of ruptured SVA is surgical repair, percutaneous closure devices may be used as a reliable alternative method in suitable patients.

Cardiac simulators have been developed as an alternative training model in order to improve the cardiac auscultation skills of medical students. The effectiveness of the cardiac simulator's use in cardiac auscultatory training is presently not yet well established.The authors aimed to investigate whether the use of a cardiac simulator can improve the auscultation skills of medical students.The students taking the auscultation training on the cardiac simulator were grouped as Group A and the students not taking the auscultation training on the cardiac simulator were grouped as Group B (before). The students in Group B (before) were grouped as Group B (after) after receiving the auscultation training on the cardiac simulator. The percentages of accurate diagnoses for the tested heart murmurs were compared between Group A and Group B (before), and between Group B (before) and Group B (after).The rate of making correct diagnoses of normal heart sounds was similar in all the groups (Group A, Group B (before), and Group B (after)). By contrast, the percentage of accurate diagnoses for the tested heart murmurs was notably improved among the students in Group A with respect to Group B (before) (p < 0.01). Similarly, the rate of correct diagnoses for the tested heart murmurs was markedly higher among the students in Group B (after) than in Group B (before) (p < 0.01).The use of a cardiac simulator as a training tool can improve the auscultation skills of medical students quickly and efficiently.