International trial of online auditory training programme for distinguishing innocent and pathological murmurs.

AIM: Recognition of normal and abnormal heart sounds and murmurs is an important but declining clinical skill among practitioners. Current teaching methods are often ineffective. This may result from inadequate repetition and normal-abnormal comparisons needed for auditory recognition. This paper describes a rapid new method of teaching murmur recognition using principles of auditory training. METHODS: Participants were 120 Australian and 42 Canadian medical students. The medical students were randomised to intervention and control (no intervention) groups. The 1-h online programme structured like a computer game used auditory training methodology to teach students to distinguish between innocent and pathological murmurs. Participants underwent pre- and post-testing on 20 paediatric murmurs. Post-testing occurred immediately following training and after 2 months. Twenty-two Canadian medical students were retested 1 year later with a brief mastery-style reinforcement programme. RESULTS: Median pre- and post-test scores improved in about 1 h from 75-95% (P < 0.001) for Australian students and 85-95% (P = 0.004) for Canadian students. Two-month post-test scores declined for Australian students to 85% (P = 0.001), and for Canadian students to 85% (P = 0.02). Australian controls had no significant change during the study period, whereas Canadian controls improved slightly. The group receiving reinforcement after 1 year had a median final score of 90%. CONCLUSIONS: This auditory training programme rapidly teaches students to distinguish innocent and pathological murmurs with at least 90% accuracy. The skill declines within 2 months but can be restored with brief mastery reinforcement 1 year later.

Bilateral aortico-atrial tunnels.

This report describes the investigation, diagnosis, and surgical correction of two aortico-atrial tunnels running from the noncoronary sinus of Valsalva to both the left and right atria in an asymptomatic 8-year-old boy.

Benefits of an international working exchange in pediatric cardiology.

This report describes a 1-year exchange between members of two pediatric cardiology centers: one in Canada and one in Australia. Five cardiologists participated in sequence, fully engaging in the activities of the host department. The motivation of the exchange was broadly educational including clinical experience, shared expertise, teaching, and research collaboration. Structured debriefing confirmed the value of the exchange. In addition to the experience of working in a different medical system, eight research papers were developed, with two research projects ongoing as well as subsequent exchanges of nursing and technical personnel. Interchange between two academic departments can add strength to both and allow development of new skills and research activity.

A Risk Management Strategy for Managing Critical Human Resource Changes in a Pediatric Heart Program.

BACKGROUND: Relocation, recruitment, or retirement of critical team members may lead to changes in the expertise pool that could threaten patient outcomes in a pediatric heart program. We developed a quality initiative aimed at risk management that uses risk-stratified case complexity and outcomes to guide a program during critical fluxes in the expert staff. The Ramp Down/Up protocol is a systematic, voluntary reduction in the complexity of cases performed, followed by a transparent and intentional escalation of case complexity. METHODS: Institutional Ethics Review Board approval for this quality initiative was obtained. Patient/caregiver consent for quality data collection is obtained at the time of hospital admission. Every surgical patient having their index cardiac surgical procedure at the Izaak Walton Killam (IWK) from January 1, 2003, to December 2015 is included. The Ramp Down/Up protocol evolved to have to 4 critical elements: (1) a trigger and a reduction in case complexity; (2) an external/objective expert observer; (3) an escalation in case complexity; and (4) data (qualitative and quantitative) collection and analysis. RESULTS: The Ramp Down/Up protocol was used 3 times over a 12-year period to address critical expert human resource challenges. The protocol was used for variable duration (3.5-9 months). Patient operative mortality was benchmarked to the Congenital Cardiac Surgery database, and outcomes were stable during and after protocol employment. CONCLUSIONS: A quality initiative aimed at risk management has allowed 1 pediatric heart team to ensure that patient outcomes were maintained during critical human resource changes.

CONTEXTE: La relocalisation, le recrutement ou le départ à la retraite de membres critiques d'une équipe peuvent amener des changements dans le bassin d'expertises pouvant compromettre les résultats obtenus par les patients au sein d'un programme de pédiatrie cardiaque. Nous avons conçu une initiative relative à la qualité de la gestion des risques, qui évalue la complexité des cas et les résultats, stratifiés selon le risque, afin d'orienter le programme durant les flux critiques de personnel spécialisé. Le protocole de réduction/d'augmentation réalise une diminution méthodique et délibérée de la complexité des cas suivie d'une intensification transparente et intentionnelle de celle-ci. MÉTHODOLOGIE: Cette initiative sur la qualité a obtenu l'approbation du comité d'examen de l'éthique des établissements. Le consentement du patient/de l'aidant requis pour la collecte de données sur la qualité est obtenu au moment de l'admission à l'hôpital. L'initiative incluait tous les patients de chirurgie pour lesquels on disposait de l'indice de chirurgie cardiaque établi au centre Izaak Walton Killiam (IWK) entre le 1er janvier 2003 et décembre 2015. Le protocole de réduction/d'augmentation a évolué pour intégrer quatre éléments critiques : 1) un facteur déclencheur et une réduction de la complexité des cas; 2) un observateur externe/expert objectif; 3) une intensification de la complexité des cas; 4) la collecte et l'analyse des données (qualitatives et quantitatives). RÉSULTATS: Le protocole de réduction/d'augmentation a été utilisé à trois reprises sur une période de 12 ans et sur des durées variables (de 3,5 à 9 mois) dans le but de relever des défis majeurs liés aux ressources humaines spécialisées. Les taux de mortalité opératoire des patients ont été comparés à ceux de la base de données sur les chirurgies cardiaques congénitales, et les résultats se sont révélés stables durant et après l'emploi du protocole. CONCLUSIONS: Une initiative sur la qualité ciblant la gestion des risques a permis à une équipe de pédiatrie cardiaque de s'assurer que les patients continuaient d'obtenir des résultats similaires lors de changements critiques des ressources humaines.

Cardiac Auscultation in the Modern Era: Premature Requiem or Phoenix Rising?

Competent cardiac auscultation remains a most important skill for the detection of heart disease. Currently it is poorly taught and often ignored or poorly performed, resulting in inaccurate and inefficient patient assessments. This review documents that teaching can be over 90% effective with new, proven teaching methods emphasizing repetition and normal-abnormal comparisons of sounds, using computer-aided and online resources. At present, these concepts are not widely adopted by medical schools. Our current knowledge of teaching heart auscultation is critically reviewed, including traditional bedside, clinic and classroom settings, as well as computer, simulator, and multimedia-based learning. The assessment of auscultation skill in the learning process. The adoption of competence-based learning promises to integrate the assessment of auscultation skill in the learning process. Newer teaching methods, such as auditory training and repetitive listening, offer excellent murmur recognition and diagnosis learning, and hand-held ultrasound is proposed as a helpful adjunct to teaching auscultation. Although ongoing research remains important to develop better teaching methods, the adoption of proven existing concepts has great potential to improve teaching and practice of this valuable skill.

Maternal anti-Ro and anti-La antibody-associated endocardial fibroelastosis.

BACKGROUND: Maternal anti-Ro and anti-La antibodies are associated with congenital heart block (CHB). Although endocardial fibroelastosis (EFE) has been described in isolated cases of autoantibody-mediated CHB, the natural history and pathogenesis of this disease are poorly understood. METHODS AND RESULTS: We retrospectively reviewed the clinical history, echocardiography, and pathology of fetuses and children with EFE associated with CHB born to mothers positive for anti-Ro or anti-La antibodies at 5 centers. Thirteen patients were identified, 6 with a prenatal and 7 with a postnatal diagnosis. Six mothers were positive for anti-Ro and anti-La antibodies, and 7 were positive for anti-Ro antibodies only. Only 1 mother had autoimmune disease. Severe ventricular dysfunction was seen in all fetal and postnatal cases. Four fetal and 3 postnatal cases had EFE at initial presentation. However, 2 fetal and 4 postnatal cases developed EFE 6 to 12 weeks and 7 months to 5 years from CHB diagnosis, respectively, even despite ventricular pacing in 6 postnatal cases. Eleven (85%) either died (n=9) or underwent cardiac transplantation (n=2) secondary to the EFE. Pathologic assessment of the explanted heart, available in 10 cases, revealed moderate to severe EFE in 7 and mild EFE in 3 cases, predominantly involving the left ventricle. Immunohistochemistry in 4 cases (including 3 fetuses) demonstrated deposition of IgG in 4 and IgM in 3 and T-cell infiltrates in 3 cases, suggesting an immune response by the affected fetus or child. CONCLUSIONS: EFE occurs in the presence of autoantibody-mediated CHB despite adequate ventricular pacing. Autoantibody-associated EFE has a very high mortality rate, whether developing in fetal or postnatal life.

The effect of bandwidth on the quality of transmitted pediatric echocardiograms.

BACKGROUND: Remote access to pediatric cardiology diagnostic services is enabled by real-time transmission of echocardiographic images. Several transmission bandwidths have been used but there has been little analysis of image quality provided by different bandwidths. We designed a study of the quality of transmitted images at various bandwidths. METHODS: Two echocardiographers viewed randomly a series of 13 recorded pediatric echocardiographic images either directly or after transmission using 1 of 4 bandwidths: 256; 384; 512; or 768 kbps. An image clarity scoring scale was used to assess image quality of cardiac structures. RESULTS: Measurable differences were found in image quality with different transmission bandwidths; 512 kbps was the minimum for consistently clear imaging of all cardiac structures examined. CONCLUSION: Bandwidth greater than 512 kbps confers sharper images subjectively although this could not be quantified by our methods.

Paediatric telecardiology in Canada.

Telemedicine is now an integral part of regular clinical and educational activity in Canadian paediatric cardiac centres. Transmission of echocardiograms is available to most paediatric cardiology centres from regional hospitals, allowing cardiac diagnosis at a distance. Teleconferencing networks are in frequent use for educational purposes, case conferencing and consultation with families. Teleauscultation is being investigated for remote screening of murmurs in children.

Assessing children's heart sounds at a distance with digital recordings.

OBJECTIVE: The objective of this study was to assess whether computer-stored digital sound recordings can be used to distinguish innocent from pathologic systolic murmurs. METHODS: Recordings of 55 children aged 1 month to 19 years were made remotely with the use of a digital stethoscope and were e-mailed to a computer in our center for later assessment. Eight-second recordings were made by a physician in 2 to 4 locations on the chest. Three cardiologists who were blinded to the diagnosis reviewed the recordings independently using stethophones to assess the splitting of the second heart sound and whether murmurs were innocent or pathologic. Diagnoses were confirmed with echocardiography. RESULTS: Seventeen children had innocent murmurs and 38 had pathologic murmurs. For the 3 cardiologists, sensitivity was 0.87 to 1.0, specificity was 0.82 to 0.88, negative predictive value was 0.75 to 1.0, and positive predictive value was 0.93 to 0.95. Assessment of splitting of second heart sound was highly accurate. CONCLUSIONS: Digital recordings of children's heart sounds allow reliable differentiation between innocent and pathologic murmurs. Use of this technology may allow remote diagnosis of childhood murmurs and avoid the expense and stress of travel to pediatric cardiology centers for some children. Cardiologists who use recordings should assess their diagnostic accuracy before clinical application.