Correlação entre ausculta cervical e eletromiografia de superfície na fase faríngea da deglutição / Correlation between cervical auscultation and electromyography in the pharyngeal phase of swallowing / Correlación entre auscultación cervical y electromiografía de superficie en la fase faríngea de la deglución

Objetivo: Correlacionar os dados acústicos da ausculta cervical com a atividade elétrica dos músculos envolvidos na fase faríngea da deglutição. Métodos: Trata-se de um estudo observacional, transversal, de abordagem quantitativa, aprovado em janeiro pelo CEP/UFSCPA (número 1.389.050). Todos os participantes do estudo assinaram o termo de consentimento livre e esclarecido. A fase faríngea da deglutição foi avaliada por meio de ausculta cervical e eletromiografia de superfície. Os indivíduos ingeriram 90 ml de água. Os dados da ausculta foram transferidos para o DeglutiSom® software, a duração e amplitude da atividade eletromiográfica foram mensuradas durante a deglutição com aparelho de eletromiografia de superfície Miotec®. O nível de significância adotado foi de 5%. Resultados:Cinquenta e sete mulheres participaram deste estudo. A média de idade foi de 23,4 anos. Ressalta-se que quanto maior a frequência média do pico da ausculta, menor é a média do pico do músculo supra-hióideo e quanto maior a intensidade, maior é o pico, assim como a média dos picos supra-hióideos. Foi possível demonstrar que o pico de atividade do músculo supra-hióideo foi significativamente maior do que o pico de atividade do músculo infra-hióideo para a deglutição de 90 ml de água. Conclusão:Os parâmetros acústicos da deglutição em indivíduos saudáveis estão correlacionados com a atividade elétrica dos músculos envolvidos na fase faríngea da deglutição.

Objective: Correlate the acoustic data of cervical auscultation to the electrical activity of the muscles involved in the pharyngeal phase of swallowing. Methods: This is an observational, cross-sectional study involving a quantitative approach and was approved on January by CEP/UFSCPA (number 1.389.050). All participants of the study signed an informed consent form. The pharyngeal phase of swallowing was assessed by employing auscultation and surface electromyography. Individuals ingested 90 ml of water. The auscultation data were transferred to DeglutiSom® software, the duration and amplitude of electromyographic activity was measured during swallowing using a Miotec® surface electromyography device. The level of significance adopted was 5%. Results: Fifty-seven women participated in this study. The average age was 23.4 years on average. It must be highlighted that the greater the average peak frequency of auscultation, lower was the average peak of the suprahyoid muscle and the greater the intensity, the greater was the peak, as well as the average of the suprahyoid peaks. It was possible to demonstrate that the peak of suprahyoid muscle activity was significantly higher than the peak of infra hyoid muscle activity for swallowing 90 ml of water. Conclusion: The acoustic swallowing parameters in healthy individuals are correlated with the electrical activity of muscles involved in the pharyngeal phase of swallowing.

Objetivo: Correlacionar los datos acústicos de la auscultación cervical con la actividad eléctrica de los músculos involucrados en la fase faríngea de la deglución. Métodos: Se trata de un estudio observacional, transversal, de abordaje cuantitativo y aprobado en enero por CEP/UFSCPA (número 1.389.050). Todos los participantes del estudio firmaron un formulario de consentimiento informado. La fase faríngea de la deglución se evaluó mediante auscultación y electromiografía de superficie. Los individuos ingirieron 90 ml de agua. Los datos de auscultación fueron cargados em el software DeglutiSom®, la duración y la amplitud de la actividad electromiográfica se midió durante la deglución utilizando un dispositivo de electromiografía de superficie Miotec®. El nivel de significancia adoptado fue del 5%. Resultados: Cincuenta y siete mujeres participaron en este estudio. La edad promedio fue 23,4 años. Cabe destacar que a mayor frecuencia de pico promedio de auscultación, menor fue el pico promedio del músculo suprahioideo y a mayor intensidad, mayor fue el pico, así como el promedio de los picos suprahioideos. Fue posible demostrar que el pico de actividad del músculo suprahioideo era significativamente más alto que el pico de actividad del músculo infrahioideo para tragar 90 ml de agua. Conclusión: Los parámetros de deglución acústica en individuos sanos se correlacionan con la actividad eléctrica de los músculos involucrados en la fase faríngea de la deglución.

Characterizing Swallows From People With Neurodegenerative Diseases Using High-Resolution Cervical Auscultation Signals and Temporal and Spatial Swallow Kinematic Measurements.

Purpose The prevalence of dysphagia in patients with neurodegenerative diseases (ND) is alarmingly high and frequently results in morbidity and accelerated mortality due to subsequent adverse events (e.g., aspiration pneumonia). Swallowing in patients with ND should be continuously monitored due to the progressive disease nature. Access to instrumental swallow evaluations can be challenging, and limited studies have quantified changes in temporal/spatial swallow kinematic measures in patients with ND. High-resolution cervical auscultation (HRCA), a dysphagia screening method, has accurately differentiated between safe and unsafe swallows, identified swallow kinematic events (e.g., laryngeal vestibule closure [LVC]), and classified swallows between healthy adults and patients with ND. This study aimed to (a) compare temporal/spatial swallow kinematic measures between patients with ND and healthy adults and (b) investigate HRCA's ability to annotate swallow kinematic events in patients with ND. We hypothesized there would be significant differences in temporal/spatial swallow measurements between groups and that HRCA would accurately annotate swallow kinematic events in patients with ND. Method Participants underwent videofluoroscopic swallowing studies with concurrent HRCA. We used linear mixed models to compare temporal/spatial swallow measurements (n = 170 ND patient swallows, n = 171 healthy adult swallows) and deep learning machine-learning algorithms to annotate specific temporal and spatial kinematic events in swallows from patients with ND. Results Differences (p < .05) were found between groups for several temporal and spatial swallow kinematic measures. HRCA signal features were used as input to machine-learning algorithms and annotated upper esophageal sphincter (UES) opening, UES closure, LVC, laryngeal vestibule reopening, and hyoid bone displacement with 66.25%, 85%, 68.18%, 70.45%, and 44.6% accuracy, respectively, compared to human judges' measurements. Conclusion This study demonstrates HRCA's potential in characterizing swallow function in patients with ND and other patient populations.

Características demográficas, clínicas, radiológicas y de función pulmonar en pacientes con bronquiectasias / Radiological and pulmonary function clinical demographic characteristics in patients with bronchiectasias

OBJETIVOS: determinar las principales características demográficas, clínicas, radiológicas y de función pulmonar de los pacientes con bronquiectasias en la Clínica del Pulmón. MATERIAL Y MÉTODOS: estudio observacional, retrospectivo. Se revisaron las historias clínicas de 23 pacientes con diagnóstico de dilataciones bronquiales. RESULTADOS: de los 23 pacientes, con una edad media de 49,4 ± 3,87 años, 13 corresponden al sexo femenino y 10 al sexo masculino, el tiempo de evolución de la enfermedad desde el diagnóstico de la patología inicial es de 17,3 ± 2,92 años. La tuberculosis es la etiología principal en 15 pacientes (65,2%). Las manifestaciones clínicas más frecuentes son la tos y expectoración mucopurulenta por varios años en la mayoría de los pacientes, al que añadimos la disnea y hemoptisis, la auscultación pulmonar revela la presencia de crépitos en 17 pacientes (73,9%). La Tomografía de Tórax de Alta Resolución distingue dos tipos de bronquiectasias: La sacular o quística y la cilíndrica, de localización unilobar, bilobar y multilobar (difuso). La Espirometría Forzada fue indicada en 10 pacientes (43,5%) 7 mujeres y 3 varones, el Síndrome Bronquial Obstructivo fue el hallazgo más frecuente. La asociación de Tetraciclina con Metronidazol indicado en 9 pacientes (39,1%) mejoró el cuadro clínico. La fisiopatología de esta entidad clínica está sujeta a una constante actualización. CONCLUSIONES: en pacientes tosedores crónicos, las bronquiectasias deben tener prioridad diagnóstica, se trata de una patología antigua, pero de actualidad permanente.

The purpose of this document is to determine the main epidemiological and clinical characteristics of patients with bronchiectasis at the Lung Clinic. METHOD: observational, retrospective study. The medical records of 23 patients diagnosed with bronchial dilation were reviewed. RESULTS: the results of the 23 patients studied, with a mean age of 49,4 ± 3,87 years, 13 correspond to the female sex and 10 to the male sex, indicate that the time of evolution of the disease from the diagnosis of the initial pathology is: 17,3 ± 2,92 years. Tuberculosis is the main etiology in 15 patients (65,2%). The most frequent clinical manifestations were cough and mucopurulent expectoration of several years in most of the patients, to which we must add dyspnea and hemoptysis, pulmonary auscultation reveals the presence of crepitus in 17 patients (73,9%). High Resolution Chest Tomography distinguishes two types of bronchiectasis: the saccular or cystic and the cylindrical, the localization is unilobar, bilobar and multilobar (diffuse). Forced spirometry was indicated in 10 patients (43,5%), 7 women and 3 men, Chronic Obstructive Pulmonary Disease is the main diagnosis. The association of Tetracycline with Metronidazole indicated in 9 patients (39,1%) had positive results. The pathophysiology of this clinical entity is subject to constant updating. CONCLUSIONS: in chronic coughing patients, bronchiectasis must have diagnostic priority, it is an old pathology, but it is permanently current

Ausculta cervical en el paciente pediátrico con parálisis cerebral Revision narrativa / Cervical auscultation in pediatric patient with cerebral palsy Narrative review

Dentro de la atención clínica, el profesional de la fonoaudiología cuenta con recursos evaluativos para describir la biomecánica secuencial de la ingesta; uno de los recursos utilizados es la Auscultación Cervical (AC). (Dudik et al., 2016) Teniendo en cuenta la descripción de la importancia de la intervención oportuna y efectiva de los procesos de alimentación en los niños con parálisis cerebral, se considera necesario resolver aspectos relevantes alrededor de la relación de las características clínicas de estos niños en su proceso de deglución y los registros del perfil espectrográfico en su fase faríngea de la deglución a partir de la aplicación de la AC. La organización de la revisión establece la búsqueda de artículos científicos en la utilización de la AC en la evaluación clínica de la deglución en sujetos pediátricos y diagnosticados con Parálisis Cerebral. La información encontrada muestra cómo en ausencia de procesos instrumentales de evaluación deglutoria, la AC aporta como beneficio la accesibilidad del procedimiento, además de características de temporalidad en la secuencia de los sonidos deglutorio, sin ningún tipo de factor adverso para su realización. Es por ello que la auscultación es un recurso importante en la evaluación clínica y se puede establecer como un primer paso en el análisis de los aspectos fisiológicos de la fase faríngea de la deglución, pone a la auscultación en una posición privilegiada, pero que debe ser estandarizada por los estudiosos y teóricos del tema.

In the clinical care, the speech language pathologist has evaluative resources to describe the biomechanics of swallowing; one of the resources used is Cervical Auscultation (CA). (Dudik et al., 2016) Taking into account the description of the importance of the timely and effective intervention of the swallowing processes in children with cerebral palsy, it is considered necessary to solve relevant aspects around the relationship of the clinical characteristics of these children in their swallowing process and the records of the spectrographic profile in their pharyngeal phase of swallowing from the application of CA. In the absence of instrumental swallowing evaluation processes, CA provides the accessibility of the procedure as a benefit, in addition to temporality characteristics in the sequence of swallowing sounds, without any type of adverse factor for its performance. The CA is an important resource in clinical evaluation, it establishes a first step in the physiological analysis of swallowing with the physiological aspects of the pharyngeal phase. This puts auscultation in a privileged position, but it must be standardized by cientifics and theorists on the subject.

Instrumentos para captação e análise acústica dos sinais de ausculta cervical na prática clínica fonoaudiológica: uma revisão integrativa de literatura / Instruments for acoustic capture and analysis of cervical auscultation signals in speech-language pathology clinic practice: an integrative literature review

RESUMO Objetivo Descrever os instrumentos utilizados para captação e análise acústica dos sinais de ausculta cervical e identificar aqueles com maior potencial para aplicação na clínica fonoaudiológica. Estratégia de pesquisa Trata-se de uma revisão integrativa de literatura. As buscas foram realizadas nas bases de dados MEDLINE/PubMed, Scopus e Web of Science, a partir da combinação de termos de relevância e operadores booleanos, durante o mês de novembro de 2020. Critérios de seleção Artigos científicos publicados nos idiomas português, espanhol ou inglês, nos últimos cinco anos (2016-2020) e que apresentassem estudo da ausculta cervical. Resultados Foram encontrados 98 artigos. Após a aplicação dos critérios de seleção, 26 artigos foram selecionados para esta revisão. Para captação dos sinais de ausculta cervical, o microfone foi o instrumento mais utilizado, seguido pela técnica de ausculta cervical de alta resolução, que combina sinais acústicos e vibratórios registrados por um microfone e um acelerômetro, respectivamente. Softwares e/ou algoritmos foram selecionados para análise acústica dos sinais, de acordo com o objetivo de cada estudo. Conclusão O método de ausculta cervical de alta resolução e a análise acústica por meio de algoritmos de aprendizado de máquina apresentaram grande potencial para utilização na prática clínica fonoaudiológica para avaliação e monitoramento da deglutição.

ABSTRACT Purpose Describe the instruments used to capture and analyze the acoustic signals obtained from cervical auscultation, and identify those with the greatest potential for application in the speech pathology clinic. Research strategy This is an integrative literature review. Searches were performed in the MEDLINE/PubMed, Scopus and Web of Science databases in November 2020, using relevant keywords combined with Boolean operators. Selection criteria Scientific articles published in Portuguese, Spanish or English in the last five years (2016-2020) and that presented a study of cervical auscultation. Results Ninety-eight articles were found. After the application of selection criteria, 26 articles were selected for this review. Microphones were the most common instruments used to perform cervical auscultation, followed by high-resolution cervical auscultation techniques, which combine acoustic and vibrational signals recorded by a microphone and an accelerometer, respectively. Acoustic analysis was performed using different software packages and/or algorithms depending on the goals of each study. Conclusion The combination of high-resolution cervical auscultation and machine learning for acoustic analysis has great potential for utilization in the clinical assessment and monitoring of swallowing in speech pathology.

Accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement: a study protocol for a prospective study.

INTRODUCTION: Patients using a nasogastric tube (NGT) are vulnerable to adverse events, therefore proper assessment of these patients, verification of the correct tube placement and constant monitoring by the nursing staff are strategies that can reduce adverse events and risks associated with the care. The aim of this study will be to assess the accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement compared with the X-ray method. A further aim will be to measure and provide evidence for the direct costs of each method of confirming NGT placement and to evaluate the impact of each method on the mean direct cost of the patient. METHODS AND ANALYSIS: This is a prospective, single-centre study of diagnostic accuracy. Data will be collected in the clinical and surgical wards, intensive care unit and coronary care unit of a Brazilian teaching hospital. The sample will consist of 385 assessments, performed in adult patients that agree to participate in the study and that receive an NGT. The combined method and the ultrasound will be the index tests and will be performed on all study participants for later comparison with an X-ray examination, considered the reference standard and the gold standard to distinguish between gastric and pulmonary placement. Sensitivity, specificity, positive predictive value and negative predictive value will be calculated to assess the diagnostic accuracy of the methods investigated in this study, with Cohen's kappa analysis used to evaluate the degree of concordance. ETHICS AND DISSEMINATION: The study was approved by the Research Ethics Committee of the University of São Paulo at Ribeirão Preto College of Nursing, registration number: 83087318.4.0000.5393. The findings will be reported through academic journals, seminars and conference presentations, social media, print media, the internet and community/stakeholder engagement activities.

René Théophile Hyacinthe Laënnec (1781-1826). Two hundred years of the stethoscope. A brief overview. / René Théophile Hyacinthe Laënnec (1781-1826). Doscientos años del uso del estetoscopio. Una breve reseña.

Two hundred years have passed since the publication that revealed the clinical use of the stethoscope. René Théophile Hyacinthe Laënnec published it in 1819. Laënnec spent his childhood in the social effervescence of the French Revolution and studied medicine in Paris, where he graduated in 1804. His clinical experience at Necker Hospital peaked with the invention of the stethoscope in 1816. Three years later, he published his masterpiece De L'Auscultation Médiate, which underlined a more rational clinical-pathological approach, especially in the understanding of cardiopulmonary diseases. Undoubtedly, Laënnec revolutionized medicine by perfecting the art of thoracic semiology, which allowed him to translate the sounds he heard into an image that could be visualized. In the bicentennial of the invention of such fundamental milestone in modern medicine, the purpose of this article is to go over its history.

Se han cumplido doscientos años desde la publicación en la que se dio a conocer la aplicación clínica del estetoscopio. Esta fue realizada en 1819 por René Théophile Hyacinthe Laënnec. El Dr. Laënnec vivió su infancia en la efervescencia social de la Revolución francesa y estudió Medicina en París, donde se graduó en 1804. Su experiencia clínica en el Hospital Necker culminó con la invención del estetoscopio en 1816. Tres años después, la publicación de su obra maestra De l'auscultation médiate enfatizó un enfoque clínico-patológico más racional, en especial, para el entendimiento de las enfermedades cardiorrespiratorias. Sin duda, el Dr. Laënnec revolucionó la medicina al perfeccionar el arte de la semiología torácica, que permitió al médico transformar los sonidos que escuchaba en una imagen, la cual podía visualizar. Con ocasión del bicentenario de este trascendental hito de la medicina moderna, se recuerda su historia.

La auscultación pulmonar en el siglo 21 / Lung auscultation in the 21th century

La auscultación pulmonar es parte fundamental del examen físico para el diagnóstico de las enfermedades respiratorias. La estandarización que ha alcanzado la nomenclatura de los ruidos respiratorios, sumado a los avances en el análisis computacional de los mismos, han permitido mejorar la utilidad de esta técnica. Sin embargo, el rendimiento de la auscultación pulmonar ha sido cuestionado por tener una concordancia variable entre profesionales de la salud. Aun cuando la incorporación de nuevas herramientas diagnósticas de imágenes y función pulmonar han revolucionado la precisión diagnóstica en enfermedades respiratorias, no existe tecnología que permita reemplazar la técnica de auscultación pulmonar para guiar el proceso diagnóstico. Por una parte, la auscultación pulmonar permite seleccionar a aquellos pacientes que se beneficiarán de una determinada técnica diagnóstica, se puede repetir cuantas veces sea necesario para tomar decisiones clínicas, y frecuentemente permite prescindir de exámenes adicionales que no siempre son fáciles de realizar o no se encuentran disponibles. En esta revisión se presenta el estado actual de la técnica de auscultación pulmonar y su rendimiento objetivo basado en la nomenclatura actual aceptada para los ruidos respiratorios, además de resumir la evidencia principal de estudios de concordancia de auscultación pediátrica y su análisis objetivo a través de nueva tecnología computacional.

Lung auscultation is an essential part of the physical examination for diagnosing respiratory diseases. The terminology standardization for lung sounds, in addition to advances in their analysis through new technologies, have improved the use of this technique. However, traditional auscultation has been questioned due to the limited concordance among health professionals. Despite the revolu tionary use of new diagnostic tools of imaging and lung function tests allowing diagnostic accuracy in respiratory diseases, no technology can replace lung auscultation to guide the diagnostic process. Lung auscultation allows identifying those patients who may benefit from a specific test. Moreover, this technique can be performed many times to make clinical decisions, and often with no need for- complicated and sometimes unavailable tests. This review describes the current state-of-the-art of lung auscultation and its efficacy based on the current respiratory sound terminology. In addition, it describes the main evidence on respiratory sound concordance studies among health professionals and its objective analysis through new technology.

High-Resolution Cervical Auscultation and Data Science: New Tools to Address an Old Problem.

High-resolution cervical auscultation (HRCA) is an evolving clinical method for noninvasive screening of dysphagia that relies on data science, machine learning, and wearable sensors to investigate the characteristics of disordered swallowing function in people with dysphagia. HRCA has shown promising results in categorizing normal and disordered swallowing (i.e., screening) independent of human input, identifying a variety of swallowing physiological events as accurately as trained human judges. The system has been developed through a collaboration of data scientists, computer-electrical engineers, and speech-language pathologists. Its potential to automate dysphagia screening and contribute to evaluation lies in its noninvasive nature (wearable electronic sensors) and its growing ability to accurately replicate human judgments of swallowing data typically formed on the basis of videofluoroscopic imaging data. Potential contributions of HRCA when videofluoroscopic swallowing study may be unavailable, undesired, or not feasible for many patients in various settings are discussed, along with the development and capabilities of HRCA. The use of technological advances and wearable devices can extend the dysphagia clinician's reach and reinforce top-of-license practice for patients with swallowing disorders.

Abdominal Palpation Does Not Modify the Number of Bowel Sounds in Healthy Volunteers and Gastrointestinal Outpatients.

BACKGROUND: The effect of abdominal palpation on bowel sounds is controversial. The authors developed an auscultation apparatus to count bowel sounds and determined whether abdominal palpation modifies the number of bowel sounds in healthy volunteers and gastrointestinal outpatients. METHODS: Four medical students developed an auscultation apparatus by attaching a Littmann stethoscope to an electret condenser microphone. The students examined 20 healthy volunteers and 20 gastrointestinal outpatients between March and June 2018. Abdominal auscultation lasting 4 minutes (1-minute each quadrant) was performed before and after abdominal palpation with registration of sound tracings. The software Audacity was used to count the bowel sounds. The effect of palpation on bowel sounds was analyzed using Generalized Estimating Equations. RESULTS: The volunteers were predominantly young (mean ± SD, 21 ± 2 years) and men (70%), whereas the outpatients were older (60 ± 11 years) and women (80%). The apparatus was able to generate sound tracings with good quality from all participants. In the comparison before/after palpation, the number of bowel sounds did not differ either in volunteers (mean ± SD, 12.6 ± 4.7 and 11.6 ± 3.5; P = 0.482) or in patients (15.6 ± 7.5 and 15.8 ± 7.9; P = 0.714). In the analysis of all participants, the difference before-after palpation was not statistically significant (mean ± SD, 14.1 ± 6.3 and 13.7 ± 6.4, respectively; P = 0.550; mean difference = 0.4; 95% CI -1.2 to 2.0) and did not depend on the group studied. CONCLUSIONS: Using an apparatus devised by medical students, the authors found that abdominal palpation did not modify the number of bowel sounds in healthy volunteers and gastrointestinal outpatients.

Deslocamento de abomaso à esquerda em bovino: relato de caso / Displacement of abomaso to the left in bovine: case of report

O trabalho objetivou relatar um caso um caso de deslocamento de abomaso à esquerda em bovino. O deslocamento de abomaso é uma patologia multifatorial, que afeta principalmente bovinos de alta produção leiteira, podendo ocorrer por uma dieta associada a um manejo errático ou até mesmo pelo desencadeamento do parto, ou seja, fatores que estão ligados ao acúmulo de gás e/ou hipomotilidade abomasal. Essa enfermidade pode gerar diversos prejuízos econômicos aos produtores, devido à queda na produção leite e gastos com o tratamento, diante disso, é importante revisar a importância do deslocamento de abomaso à esquerda e relatar o caso clínico de um bovino com essa patologia. Para se chegar a um diagnóstico conclusivo, deve-se conhecer a fundo os sinais clínicos, além dos métodos de diagnóstico para confirmação, tendo como técnica preconizada a auscultação com percussão do 9º ao 12º espaço intercostal, onde pode ser auscultado um tilintar metálico, quando ainda houver dúvidas, realiza-se a laparotomia exploratória, confirmando ou não a suspeita. Tendo o diagnóstico conclusivo desta patologia, é realizado o tratamento, que pode ser terapêutico, intervenção física por rolamento ou intervenção cirúrgica.

This study aimed to report a case of a case of left abomasum displacement in cattle. The displacement of abomasum is a multifactorial pathology which affects cattle of high milk production and may occur due to a diet associated with erratic management or even by the birthing mechanism, that is, factors that are linked directly to the accumulation of gas or abomasal hypomotility. This illness can generate different kinds of economic losses to the producers due to a fall in milk production and expenses with treatments. In that case, the objective with this job is to review the importance of the displacement of abomasum to the left and report the clinic case of a bovine with this pathology. To reach a conclusive diagnosis, the clinical signs should be thoroughly known, beyond the methods of diagnosis to confirmation, having as characteristic technique, the auscultation, with percussion from the ninth to the twelfth intercostal space where it can be auscultated a metallic tinkling. When there are still doubts, is performed an exploratory laparotomy, then having the confirmation. When having the conclusive diagnosis of this pathology is performed the treatment, being therapeutic, physical intervention by rolling or chirurgical intervention.

Deslocamento de abomaso à esquerda em bovino: relato de caso / Displacement of abomaso to the left in bovine: case of report

O trabalho objetivou relatar um caso um caso de deslocamento de abomaso à esquerda em bovino. O deslocamento de abomaso é uma patologia multifatorial, que afeta principalmente bovinos de alta produção leiteira, podendo ocorrer por uma dieta associada a um manejo errático ou até mesmo pelo desencadeamento do parto, ou seja, fatores que estão ligados ao acúmulo de gás e/ou hipomotilidade abomasal. Essa enfermidade pode gerar diversos prejuízos econômicos aos produtores, devido à queda na produção leite e gastos com o tratamento, diante disso, é importante revisar a importância do deslocamento de abomaso à esquerda e relatar o caso clínico de um bovino com essa patologia. Para se chegar a um diagnóstico conclusivo, deve-se conhecer a fundo os sinais clínicos, além dos métodos de diagnóstico para confirmação, tendo como técnica preconizada a auscultação com percussão do 9º ao 12º espaço intercostal, onde pode ser auscultado um tilintar metálico, quando ainda houver dúvidas, realiza-se a laparotomia exploratória, confirmando ou não a suspeita. Tendo o diagnóstico conclusivo desta patologia, é realizado o tratamento, que pode ser terapêutico, intervenção física por rolamento ou intervenção cirúrgica.(AU)

This study aimed to report a case of a case of left abomasum displacement in cattle. The displacement of abomasum is a multifactorial pathology which affects cattle of high milk production and may occur due to a diet associated with erratic management or even by the birthing mechanism, that is, factors that are linked directly to the accumulation of gas or abomasal hypomotility. This illness can generate different kinds of economic losses to the producers due to a fall in milk production and expenses with treatments. In that case, the objective with this job is to review the importance of the displacement of abomasum to the left and report the clinic case of a bovine with this pathology. To reach a conclusive diagnosis, the clinical signs should be thoroughly known, beyond the methods of diagnosis to confirmation, having as characteristic technique, the auscultation, with percussion from the ninth to the twelfth intercostal space where it can be auscultated a metallic tinkling. When there are still doubts, is performed an exploratory laparotomy, then having the confirmation. When having the conclusive diagnosis of this pathology is performed the treatment, being therapeutic, physical intervention by rolling or chirurgical intervention.(AU)

Role of the physical examination in the determination of etiology of ischemic stroke.

The actual investigation of the body of a patient by the clinician in search for the signs of the disease beginning with the primary vital signs and continues with the careful and attentive observation of the patient. This article reviews the key findings in the physical examination of patients with ischemic stroke that have the potential to indicate the etiology of the infarct and to help to choose the use of ancillary tests. Through a systematic search of articles published in English related to the physical examination of patients with stroke, we identified key findings in the vital signs and classic components of the physical exam (appearance of the patient, auscultation, and eye examination) that have shown clinical significance when determining ischemic stroke etiology. We further suggest that the prompt identification of such findings can translate into better use of diagnostic tools and selection of ancillary confirmatory tests, thus, reducing the time to etiology based treatment and secondary prevention of ischemic stroke. in this manuscript, we aim to show that even though nowadays the clinical skills tend to be overlooked due to the overreliance on technology, the physical exam continues to be a valuable tool in the clinician armamentarium when facing the challenge of a patient with ischemic stroke.

Heart Rate Determination in Newborns at Risk for Resuscitation in a Low-Resource Setting: A Randomized Controlled Trial.

OBJECTIVE: To compare 2 different methods (auscultation with a stethoscope and umbilical cord palpation) of heart rate (HR) estimation in newborns at risk for resuscitation in a low-resource setting. STUDY DESIGN: Sixty newborns at risk for resuscitation born at the St. Luke Catholic Hospital in Wolisso (Ethiopia) were randomized to HR assessment by auscultation using a stethoscope or umbilical cord palpation. HR was assessed at 60, 90, 120 seconds, and 5 minutes of life. The primary outcome was the agreement of HR obtained by auscultation or palpation compared with the HR determined by electrocardiogram. RESULTS: Mean difference between auscultation using a stethoscope and electrocardiogram was -13 bpm, -4 bpm, -6 bpm, and -10 bpm at 60, 90, 120 seconds, and at 5 minutes of life. Mean difference between palpation and electrocardiogram of was -20 bpm, -25 bpm, -23 bpm, and -31 bpm at 60, 90, 120 seconds, and at 5 minutes of life. The magnitude of the difference between auscultation and electrocardiogram was lower than that between palpation and electrocardiogram over time (P = .007). HR range was correctly identified in 14 out of 16 measurements (87%) with HR <100 bpm. CONCLUSION: HR assessment by auscultation was more accurate compared with cord palpation, but both may provide adequate clinical information to healthcare providers in terms of HR ranges. The clinical advantage of providing a stethoscope in low-resource settings remains to be established. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03854435.

Concordance in Discriminating Recordings of Different Lung Sounds Between Physiotherapists.

BACKGROUND: Auscultation is a fundamental part of the physical examination, but its utility has been questioned due to the low inter-rater concordance. We therefore sought to evaluate the concordance of the discrimination of lung sound recordings between experienced physiotherapists. METHODS: Lung sound recordings were selected and validated by an expert panel when Fleiss κ concordance was > 0.75. Eleven recordings were played for subject recognition using a portable computer in their workplace. Results were analyzed using Fleiss κ when looking for concordance between physiotherapists. Univariate regression was performed to determine if there was an association with clinical training, years of experience, academic accomplishment, or university affiliation. RESULTS: Sixty-nine physiotherapists with a median of 4 years of working experience (interquartile range 2-6 y) completed the study. There was moderate concordance (κ = 0.562; 95% CI 0.462-0.605) for overall lung sound recording discrimination. For continuous and noncontinuous lung sound recordings, discrimination concordance was substantial (κ = 0.63 and κ = 0.76, respectively). A bivariate analysis revealed that years of experience presented an inverse association with stridor recognition. CONCLUSIONS: Concordance between physiotherapists in discriminating recorded lung sounds was moderate. The ability to recognize stridor was inversely associated with years of work experience.

[Lung auscultation in the 21th century]. / La auscultación pulmonar en el siglo 21.

Lung auscultation is an essential part of the physical examination for diagnosing respiratory diseases. The terminology standardization for lung sounds, in addition to advances in their analysis through new technologies, have improved the use of this technique. However, traditional auscultation has been questioned due to the limited concordance among health professionals. Despite the revolu tionary use of new diagnostic tools of imaging and lung function tests allowing diagnostic accuracy in respiratory diseases, no technology can replace lung auscultation to guide the diagnostic process. Lung auscultation allows identifying those patients who may benefit from a specific test. Moreover, this technique can be performed many times to make clinical decisions, and often with no need for- complicated and sometimes unavailable tests. This review describes the current state-of-the-art of lung auscultation and its efficacy based on the current respiratory sound terminology. In addition, it describes the main evidence on respiratory sound concordance studies among health professionals and its objective analysis through new technology.

Análise da concordância da ausculta epigástrica e mensuração do pH na confirmação do posicionamento de sonda nasoenteral / Analysis of epigastric auscultation agreement and pH measurement in the confirmation of nasoenteral tube placement

Justificativa: A sonda nasoenteral é a principal via de escolha para administração de nutrição enteral, líquidos e medicamentos diretamente no trato gastrointestinal. A inserção da sonda naosoenteral às cegas, à beira leito, é um procedimento comum nas instituições de saúde. A confirmação do seu correto posicionamento pode evitar eventos adversos graves, principalmente, os respiratórios. Embora o exame de raios X seja o método de primeira linha para confirmar o posicionamento das sondas nasoenterais, existem restrições quanto ao seu uso. Dentre os métodos clínicos não radiológicos, a ausculta epigástrica é a mais utilizada. Contudo, evidências científicas disponíveis a contraindicam. A mensuração do pH do aspirado gástrico é o método não radiográfico mais recomendado na literatura internacional por apresentar alta sensibilidade, apesar das suas limitações. A partir do exposto, observou-se, no hospital participante deste estudo, práticas não baseadas nas melhores evidências científicas para confirmar o posicionamento de sondas nasoenterais recém inseridas às cegas, à beira leito. A ausculta epigástrica é o método mais utilizado na instituição, seguida pelo exame de raios X. Objetivo: avaliar a concordância entre os métodos clínicos (ausculta epigástrica e mensuração do pH) na confirmação do posicionamento de sonda nasoenteral. Método: estudo transversal realizado em um hospital privado de médio porte do interior do estado de São Paulo. Participaram 49 pacientes que foram submetidos a 90 procedimentos de inserção e confirmação do posicionamento da sonda. Os métodos clínicos foram realizados na seguinte ordem: ausculta epigástrica e mensuração do pH. Em seguida, todos os pacientes foram submetidos ao exame de raios X. Os dados foram coletados por meio de dispositivo móvel e foram inseridos na plataforma on-line Survey Monkey®. Variáveis demográficas, clínicas e terapêuticas foram obtidas do prontuário médico. Foram avaliados parâmetros de sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo. A concordância, entre os métodos clínicos e o resultado do exame de raios X, foi analisada por meio da estatística AC1, desenvolvida por Gwet. Resultados: A maioria dos pacientes foi do sexo feminino (67,3%), idosa (95,9%), com média de 82 anos de idade, branca (93,8%), aposentada (95,9%) e procedente do estado de São Paulo. O diagnóstico mais frequente, segundo a Classificação Internacional de Doenças (CID-10), foi a colocação de sonda gástrica ou duodenal, e a indicação principal foi a disfagia, seguida de inapetência. Todas as sondas inseridas eram de fino calibre, medidas para serem posicionadas no intestino. A ausculta epigástrica foi o método que apresentou maior sensibilidade (100,0%), porém menor especificidade (2,0%). A ausculta sugeriu que a sonda estava no estômago, quando de fato estava posicionada no intestino, em 51,1%. Ainda, em 2,2%, a ausculta foi positiva para posição gástrica. Contudo, a extremidade distal estava posicionada na junção esofagogástrica. A mensuração do pH apresentou sensibilidade menor (63,0%) que a ausculta, porém, maior especificidade (58%). Entretanto o valor é considerado regular. Ademais, o valor preditivo positivo da mensuração do pH foi de 55% e o negativo, de 66%. Não houve concordância entre a ausculta epigástrica e o exame de raios X (AC1 = 0,109; p = 0,372) e entre o método de mensuração do pH e o exame de raios X (AC1 = 0,206; p = 0,066). Conclusão: Os métodos clínicos avaliados, neste estudo, apresentaram limitações importantes que podem expor os pacientes a riscos. A ausculta epigástrica deve ser abolida da prática clínica e o exame de raios X permanece o método de primeira linha na confirmação do posicionamento de sondas nasoenterais recém inseridas às cegas, à beira leito. Implicações para a prática: Espera-se que os resultados deste estudo possam ser utilizados pelas lideranças do hospital e incorporados ao protocolo institucional para reduzir os riscos relacionados ao mau posicionamento de sondas nasoenterais.

Justification: The nasoenteral tube is the main passage of choice to nutrition management of enteral nutrition, liquids and medication straight to gastrointestinal tract. The blindly insertion of nasoenteral tube at the bedside is an ordinary procedure in health institutions. The confirmation of its correct positioning may prevent adverse events especially respiratory ones. Although the X-ray examination is the first-line method to confirm the placement of nasoenteral tubes, there are restrictions on their use. Among the non-radiological clinical methods, epigastric auscultation is the most used. However, available scientific evidences contraindicate it. The measurement of the gastric aspirated is the non-radiographic method most recommended in the international literature because of its high sensitivity, despite its limitations. From the above, it was observed in the hospital participating in this study, practices non based in the best scientific evidences to confirm the positioning of nasoenteral tubes recently inserted blindly at the bedside. The epigastric auscultation is the most used method in the institution, followed by the X-ray examination. Objective: to evaluate the agreement between the clinical methods (epigastric auscultation and pH measurement) in the confirmation of the nasoenteral tube placement. Method: cross-sectional study carried out in a medium-sized private hospital in the interior of the state of São Paulo. Forty-nine patients who were submitted to ninety insertion procedures and confirmation of tube placement. The clinical methods were performed in the following order: epigastric auscultation and pH measurement. Next, all the patients were submitted to X-ray examination. The data were collected through a mobile device and were inserted in the on-line platform Survey Monkey ®. Demografic, clinical and therapeutic variables were obtained from medical records. Sensitivity, specificity, positive and negative predictive values parameters were evaluated. The agreement of clinical methods and the result of the X-ray examination was analyzed through the AC1 statistics developed by Gwet. Results: most of the patients were female (67.3%), elderly (95.5%), with an average of 82 years old, white (93.8%), retired (95.9%) and from the State of São Paulo. The most frequent diagnosis, according to International Classification of Diseases (ICD10), was the gastric or duodenal tube placement, and the main indication was dysphagia, followed by inappetence. All the tubes inserted were fine caliber, measured to be placed in the intestine. The epigastric auscultation was the method with highest sensitivity (100.0%), but the lowest specificity (2.0%). The auscultation suggested the tube was in the stomach, when in fact was placed in the intestine, at 51.1%. Still, at 2.2% auscultation was positive for gastric position. However, the distal was placed at the esophagogastric junction. The pH measurement was less sensitive (63.0%) than auscultation, but more specific (58%). However, the value is considered regular. Moreover, the positive predictive value of the pH measurement was 55% and the negative, 66%. There was no agreement between epigastric auscultation and X-ray examination (AC1 = 0,109; p = 0,372) and between the pH measurement method and X-ray examination (AC1 = 0,206; p = 0,066). Conclusion: The clinical methods evaluated in this study presented important limitations that can expose patients to risks. The epigastric auscultation should be abolished from clinical practice and X-ray examination remains the first-line method in confirmation of tube placement of newly-inserted nasoenteral tubes blindly at the bedside. Implication for practice: It is hoped that the results of this study can be used by hospital leadership and incorporated to institutional protocol to reduce the risks related to the wrong position of nasoenteral tubes.

Auscultação dos sons da deglutição de crianças com bronquiolite / Auscultation of swallowing sounds of children with bronchiolitis

RESUMO Objetivo verificar as características acústicas dos sons de deglutição de lactentes com bronquiolite. Métodos estudo retrospectivo por análise de banco de dados aprovado pelo CEP sob o número 1499.911. Os sinais acústicos foram coletados por meio dos estetoscópios eletrônicos da marca Littmann®, modelo 4100. A amostra foi composta por sons da deglutição de lactentes com diagnóstico de bronquiolite viral aguda, internados em um hospital infantil do Sul do país. Os sons armazenados em arquivo digital foram abertos e rodados no software Deglutisom®, sendo verificados e confirmados por dois avaliadores independentes. Estabeleceu-se o pico de frequência, intensidade e intervalos de deglutição. Resultados a amostra de sons da deglutição de 22 crianças, sendo 31,8% do gênero feminino e 68,2% do masculino, apresentou mediana de idade de 81 dias. Encontrou-se diferença entre as características acústicas da deglutição comparadas ao gênero, com maior número de deglutições no gênero feminino (p=0,033). Não houve associação entre as variáveis pico de frequência (m=744 Hz), intensidade (m=52 dB) e tempo de deglutição (5,3s). Conclusão as características acústicas da deglutição da auscultação cervical de lactentes com bronquiolite, analisadas neste estudo, são de pico de frequência grave, intensidade forte, média de duas deglutições por sucção e tempo de deglutição de 5,3 s, havendo diferença entre os gêneros, em relação ao número de deglutições, maior no feminino.

ABSTRACT Purpose To verify the acoustic characteristics of swallowing noise in an infant with bronchiolitis. Methods A retrospective study was performed by database analysis approved by the ERC under the number 1499.911; the acoustic signals were collected through Littmann® model 4100 electronic stethoscopes. The sample was composed of a bank of infants swallowing sounds, diagnosed with acute viral bronchiolitis, children under 12 months-old, hospitalized in a children's hospital in the south of the Country. The sound file storage was opened, and it was rotated in the Deglutisom® software, being verified and confirmed by two independent judges. The peak of frequency, intensity, and swallowing intervals were established. Results The sample totalized a group of 22 babies, 31.8% of the female gender, and 68. 2% of males with a median age of 81 days. There was a difference between the acoustic characteristics of swallowing compared to the gender, regarding the number of swallows, with the highest number of swallows in the female gender (p=0.033). There was no association between the peak frequency (m=744 Hz), intensity (m=52 dB), and swallowing time (5.3s). Conclusion The acoustic characteristics of cervical auscultation swallowing of Infants with bronchiolitis are bass frequency peak, a strong intensity, a mean of two swallows, and a swallowing time of 5.3 s, with the difference between genders concerning the number of swallows, highest in the female.

Blood pressure measurement by oscillometric and auscultatory methods in normotensive pregnant women.

OBJECTIVE: to compare blood pressure values obtained by auscultatory and oscillometric methods in different gestational periods, considering cuff width. METHOD: it is a cross-sectional and quasi-experimental study approved by the Research Ethics Committee. The sample consisted of 108 low-risk pregnant women. Blood pressure measurements were performed in gestational periods of 10-14, 19-22 and 27-30 weeks. RESULTS: The oscillometric device presented values similar to the auscultatory method in systolic blood pressure, but overestimated diastolic blood pressure. Underestimation of blood pressure occurred when using the standard width cuff rather than the correct width cuff in both measuring methods. CONCLUSION: Verification of brachial circumference and use of adequate cuffs in both methods are indispensable to obtain reliable blood pressure values in pregnant women. We recommend performance of additional studies to evaluate diastolic blood pressure overestimation by the Microlife 3BTO-A.