Auscultating heart and breath sounds through patients’ gowns: who does this and does it matter?

Background Doctors are taught to auscultate with the stethoscope applied to the skin, but in practice may be seen applying the stethoscope to the gown. Objectives To determine how often doctors auscultate heart and breath sounds through patients’ gowns, and to assess the impact of this approach on the quality of the sounds heard. Methods A sample of doctors in the west of Scotland were sent an email in 2014 inviting them to answer an anonymous questionnaire about how they auscultated heart and breath sounds. Normal heart sounds from two subjects were recorded through skin, through skin and gown, and through skin, gown and dressing gown. These were played to doctors, unaware of the origin of each recording, who completed a questionnaire about the method and quality of the sounds they heard. Results 206 of 445 (46%) doctors completed the questionnaire. 124 (60%) stated that they listened to patients’ heart sounds, and 156 (76%) to patients’ breath sounds, through patients’ gowns. Trainees were more likely to do this compared with consultants (OR 3.39, 95% CI 1.74 to 6.65). Doctors of all grades considered this practice affected the quality of the sounds heard. 32 doctors listened to the recorded heart sounds. 23 of the 64 (36%) skin and 23 of the 64 (36%) gown recordings were identified. The majority of doctors (74%) could not differentiate between skin or gown recordings, but could tell them apart from the double layer recordings (p=0.02). Trainees were more likely to hear artefactual added sounds (p=0.04). Conclusions Many doctors listen to patients’ heart and breath sounds through hospital gowns, at least occasionally. In a short test, most doctors could not distinguish between sounds heard through a gown or skin. Further work is needed to determine the impact of this approach to auscultation on the identification of murmurs and added sounds

Cardioverting acute atrial fibrillation and the risk of thromboembolism: not all patients are created equal

Current guidelines support the well-established clinical practice that patients who present with atrial fibrillation (AF) of less than 48 hours duration should be considered for cardioversion, even in the absence of pre-existing anticoagulation. However, with increasing evidence that short runs of AF confer significant risk of stroke, on what evidence is this 48-hour rule based and is it time to adopt a new approach? We review existing evidence and suggest a novel approach to risk stratification in this setting. Overall, the risk of thromboembolism associated with acute cardioversion of patients with AF that is estimated to be of <48 hours duration is low. However, this risk varies widely depending on patient characteristics. From existing evidence, we show that using the CHA2DS2-VASc score may allow better selection of appropriate patients in order to prevent exposing specific patient groups to an unacceptably high risk of a potentially devastating complication

Vector-valued covariant differential operators for the M\"obius transformation

We obtain a family of functional identities satisfied by vector-valued functions of two variables and their geometric inversions. For this we introduce particular differential operators of arbitrary order attached to Gegenbauer polynomials. These differential operators are symmetry breaking for the pair of Lie groups $(SL(2,\mathbb C), SL(2,\mathbb R))$ that arise from conformal geometry.Comment: To appear in Springer Proceedings in Mathematics and Statistic

Sources of Social Capital for Malawi People Living With HIV.

With one of the highest rates of poverty and HIV in the world, Malawi faith-based organizations (FBOs), non-governmental organizations (NGOs), and community-based organizations (CBOs) are expected to provide tangible and emotional support to people living with HIV (PLWH). Using Lin's social capital theoretical approach, we examine the perspective of PLWH regarding the adequacy of support responses. Forty-six rural Malawi HIV+ adults provided interviews that were recorded digitally, translated, and transcribed by Malawi research assistants. Atlas.ti was used to organize the data and to aid in the analytic process. Participants expressed disappointment in the lack of resources that could be accessed through the FBOs although their expectations may have been unrealistic. Outcomes from accessing and mobilizing the FBO network were negative in terms of stigmatization by FBO leaders and members, whereas outcomes related to CBOs and NGOs were generally positive in terms of empowerment through HIV information and attendance at support groups

Chains of large gaps between primes

Let $p_n$ denote the $n$-th prime, and for any $k \geq 1$ and sufficiently large $X$, define the quantity $$G_k(X) := \max_{p_{n+k} \leq X} \min( p_{n+1}-p_n, \dots, p_{n+k}-p_{n+k-1} ),$$ which measures the occurrence of chains of $k$ consecutive large gaps of primes. Recently, with Green and Konyagin, the authors showed that $$G_1(X) \gg \frac{\log X \log \log X\log\log\log\log X}{\log \log \log X}$$ for sufficiently large $X$. In this note, we combine the arguments in that paper with the Maier matrix method to show that $$G_k(X) \gg \frac{1}{k^2} \frac{\log X \log \log X\log\log\log\log X}{\log \log \log X}$$ for any fixed $k$ and sufficiently large $X$. The implied constant is effective and independent of $k$.Comment: 16 pages, no figure