JAGS
NOVEMBER 2015–VOL. 63, NO. 11
LETTERS TO THE EDITOR
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REFERENCES 1. Del Rio C, Anneesh AK, Mehta G et al. Ebola hemorrhagic fever in 2014: The tale of an evolving epidemic. Ann Intern Med 2014;161:746–748. 2. Dowell CF. Ebola hemorrhagic fever: Why were children spared? Pediatr Infect Dis J 1996;15:189–191. 3. Odden MC, Coxson PG, Moran A et al. The impact of the ageing population on coronary heart disease in the United States. Am J Med 2011;124:827–833. 4. Libow LS, Neufeld R, Olson E et al. Sequential outbreak of influenza A and B in a nursing home: Efficacy of vaccine and amantadine. J Am Geriatr Soc 1996;44:1153–1157. 5. Aylward B, Barboza P, Bawo L et al. Ebola virus disease in West Africa— the first 9 months of the epidemic and forward projections. N Engl J Med 2014;371:1481–1495. 6. Mumps Epidemiology and Prevention of Vaccine-Preventable Diseases. CDC [on-line]. Available at http://www.cdc.gov/vaccines/pubs/pinkbook/mumps.html Accessed March 30, 2015. 7. Weiler C. Acute Poliomyelitis, Epidemiology Medscape [on-line]. Available at http://emedicine.medscape.com/article/306440-overview#a0199. Accessed March 30, 2015. 8. WHO. Fig. 1. Further Efforts Needed to Achieve Measles Elimination in Germany. [on-line] Available at http://www.who.int/bulletin/volumes/87/2/ 07–050187/en/ Accessed March 24, 2015. 9. Chickenpox (Varicella Zoster Infection). Department of Health [on-line] Available at https://www.health.ny.gov/diseases/communicable/chickenpox/fact_sheet.htm Accessed March 30, 2015. 10. Encephalitis In-Depth Report. New York Times [on-line]. Available at http://www.nytimes.com/health/guides/disease/encephalitis/print.html. Accessed March 23, 2015. 11. West Nile Virus Activity 2007. CDC [on-line]. Available at http:// www.cdc.gov/mmwr/preview/mmwrhtml/mm5726a2.htm. Accessed March 23, 2015.
IMPROVING THE QUALITY OF AUSCULTATION FOR INDIVIDUALS WITH CACHEXIA To the Editor: Physical examination of patients with cachexia, in particular auscultation of the heart and lungs, is challenging for clinicians. This is partly caused by the prominence of bones as muscle and fatty tissue are lost, creating an uneven surface for the diaphragm of the stethoscope. This makes it challenging to adequately discern heart and lung sounds, and introduces adventitious sounds. Faced with the necessity of listening to the heart and lungs of individuals with cachexia as optimally as possible, the authors have developed a novel way of transmitting sounds from the body to the stethoscope. This technique capitalizes on the fact that liquids are excellent acoustic transmitters and that bags of solute (e.g., normal saline) are malleable and can be easily apposed to irregular surfaces. As demonstrated in Figure 1, a 50-mL bag of solute can be interposed between the individual’s chest and the stethoscope, offering greater contact between them. This technique provides an excellent yet simple means of transmitting the heart and lung sounds. Although this technique has not been formally studied, the authors have used it innumerable times and found it clinically useful. The bag serves as a surprisingly good acoustic window, provided that any air in the bag has been completely removed. Two limitations must be mentioned regarding this device. The first is that the size of the bag may prevent precise location of a particular sound, but with the use of a smaller bag (25 or 50 mL as opposed to 100 mL), discrete sounds can be readily located. The second limitation is that the bag constitutes another focus for potential transmission
Figure 1. Cross-section of the chest of an individual with cachexia, with prominent ribs and depressions created by loss of muscle and fatty tissue. (A) Sound transmission is impaired. (B) Addition of auscultation aid allows for better transmission.
of nosocomial infections. This can be resolved by washing the bag itself with an antimicrobial agent, as one would with the stethoscope. The maker of a normal saline solution confirmed that repetitive washing of a bag with such solution posed no health threat (personal correspondence). In summary, the device described in this article may help clinicians in their assessment of individuals with cachexia, as it has helped the authors multiple times in the past. It is not only widely available, but also safe and inexpensive, making it a perfect adjunct to difficult auscultation in individuals with cachexia. Lucas B. Chartier, MD, CM, MPH Emergency Department, University Health Network, Toronto, Ontario, Canada Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada Michael J. Bonnycastle, MD, CM Division of Geriatrics, St. Mary’s Hospital, Montreal, Quebec, Canada Division of Geriatric Medicine, McGill University, Montreal, Quebec, Canada
ACKNOWLEDGMENT Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Chartier, Bonnycastle: first draft of manuscript, revision of manuscript. Both authors approved the final version. Sponsor’s Role: N/A.
COMMENT ON “DEVELOPMENT AND VALIDATION OF THE GERIATRIC IN-HOSPITAL NURSING CARE QUESTIONNAIRE” To the Editor: Attitudes and perceptions of nurses are thought to influence the quality of care of the growing number of older hospitalized adults. We read with interest
NOVEMBER 2015–VOL. 63, NO. 11
LETTERS TO THE EDITOR
2441
REFERENCES 1. Del Rio C, Anneesh AK, Mehta G et al. Ebola hemorrhagic fever in 2014: The tale of an evolving epidemic. Ann Intern Med 2014;161:746–748. 2. Dowell CF. Ebola hemorrhagic fever: Why were children spared? Pediatr Infect Dis J 1996;15:189–191. 3. Odden MC, Coxson PG, Moran A et al. The impact of the ageing population on coronary heart disease in the United States. Am J Med 2011;124:827–833. 4. Libow LS, Neufeld R, Olson E et al. Sequential outbreak of influenza A and B in a nursing home: Efficacy of vaccine and amantadine. J Am Geriatr Soc 1996;44:1153–1157. 5. Aylward B, Barboza P, Bawo L et al. Ebola virus disease in West Africa— the first 9 months of the epidemic and forward projections. N Engl J Med 2014;371:1481–1495. 6. Mumps Epidemiology and Prevention of Vaccine-Preventable Diseases. CDC [on-line]. Available at http://www.cdc.gov/vaccines/pubs/pinkbook/mumps.html Accessed March 30, 2015. 7. Weiler C. Acute Poliomyelitis, Epidemiology Medscape [on-line]. Available at http://emedicine.medscape.com/article/306440-overview#a0199. Accessed March 30, 2015. 8. WHO. Fig. 1. Further Efforts Needed to Achieve Measles Elimination in Germany. [on-line] Available at http://www.who.int/bulletin/volumes/87/2/ 07–050187/en/ Accessed March 24, 2015. 9. Chickenpox (Varicella Zoster Infection). Department of Health [on-line] Available at https://www.health.ny.gov/diseases/communicable/chickenpox/fact_sheet.htm Accessed March 30, 2015. 10. Encephalitis In-Depth Report. New York Times [on-line]. Available at http://www.nytimes.com/health/guides/disease/encephalitis/print.html. Accessed March 23, 2015. 11. West Nile Virus Activity 2007. CDC [on-line]. Available at http:// www.cdc.gov/mmwr/preview/mmwrhtml/mm5726a2.htm. Accessed March 23, 2015.
IMPROVING THE QUALITY OF AUSCULTATION FOR INDIVIDUALS WITH CACHEXIA To the Editor: Physical examination of patients with cachexia, in particular auscultation of the heart and lungs, is challenging for clinicians. This is partly caused by the prominence of bones as muscle and fatty tissue are lost, creating an uneven surface for the diaphragm of the stethoscope. This makes it challenging to adequately discern heart and lung sounds, and introduces adventitious sounds. Faced with the necessity of listening to the heart and lungs of individuals with cachexia as optimally as possible, the authors have developed a novel way of transmitting sounds from the body to the stethoscope. This technique capitalizes on the fact that liquids are excellent acoustic transmitters and that bags of solute (e.g., normal saline) are malleable and can be easily apposed to irregular surfaces. As demonstrated in Figure 1, a 50-mL bag of solute can be interposed between the individual’s chest and the stethoscope, offering greater contact between them. This technique provides an excellent yet simple means of transmitting the heart and lung sounds. Although this technique has not been formally studied, the authors have used it innumerable times and found it clinically useful. The bag serves as a surprisingly good acoustic window, provided that any air in the bag has been completely removed. Two limitations must be mentioned regarding this device. The first is that the size of the bag may prevent precise location of a particular sound, but with the use of a smaller bag (25 or 50 mL as opposed to 100 mL), discrete sounds can be readily located. The second limitation is that the bag constitutes another focus for potential transmission
Figure 1. Cross-section of the chest of an individual with cachexia, with prominent ribs and depressions created by loss of muscle and fatty tissue. (A) Sound transmission is impaired. (B) Addition of auscultation aid allows for better transmission.
of nosocomial infections. This can be resolved by washing the bag itself with an antimicrobial agent, as one would with the stethoscope. The maker of a normal saline solution confirmed that repetitive washing of a bag with such solution posed no health threat (personal correspondence). In summary, the device described in this article may help clinicians in their assessment of individuals with cachexia, as it has helped the authors multiple times in the past. It is not only widely available, but also safe and inexpensive, making it a perfect adjunct to difficult auscultation in individuals with cachexia. Lucas B. Chartier, MD, CM, MPH Emergency Department, University Health Network, Toronto, Ontario, Canada Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada Michael J. Bonnycastle, MD, CM Division of Geriatrics, St. Mary’s Hospital, Montreal, Quebec, Canada Division of Geriatric Medicine, McGill University, Montreal, Quebec, Canada
ACKNOWLEDGMENT Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Chartier, Bonnycastle: first draft of manuscript, revision of manuscript. Both authors approved the final version. Sponsor’s Role: N/A.
COMMENT ON “DEVELOPMENT AND VALIDATION OF THE GERIATRIC IN-HOSPITAL NURSING CARE QUESTIONNAIRE” To the Editor: Attitudes and perceptions of nurses are thought to influence the quality of care of the growing number of older hospitalized adults. We read with interest
