The accuracy and interobserver agreement in detecting the 'gallop sounds' by cardiac auscultation

STUDY OBJECTIVES: To determine the observer accuracy and interobserver agreement in identifying S4 and S3 by cardiac auscultation and whether they improve with increasing observer experience. DESIGN: Prospective, blinded study. SETTING: Cardiology and general internal medicine wards in a university-affiliated teaching hospital. PATIENTS: Forty patients with a cardiac diagnosis and 6 patients without were studied. MEASUREMENTS AND RESULTS: Two cardiologists, one general internist, three senior and two junior postgraduate internal medicine trainees, blinded to the patients' characteristics, examined the patients and documented their findings on a questionnaire. Computerized phonocardiogram was obtained in all patients as a gold standard and was interpreted by a blinded, independent cardiologist. The mean positive predictive values for S4 and S3 were 51% (range, 24 to 100%) and 71% (range, 50 to 88%), respectively. The mean negative predictive values for S4 and S3 were 82% (range, 67 to 94%) and 64% (range, 56 to 85%), respectively. The overall interobserver agreements for detecting S4 was K = 0.05 (95% confidence interval [CI], 0.01 to 0.09) and S3 was K = 0.18 (95% CI, 0.13 to 0.24). There was no apparent trend in the accuracy or interobserver agreement with regard to the level of observer experience. CONCLUSION: The agreement between observers and the phonocardiographic gold standard in the correct identification of S4 and S3 was poor and the lack of agreement did not appear to be a function of the experience of the observers. The overall interobserver agreement for the detection of either S4 or S3 was little better than chance alone.     

Laparoscopic appendectomy and the management of gynecologic pathologic conditions found at laparoscopy for presumed appendicitis

A laparoscopic approach to patients with possible appendicitis has increased in popularity. In this article it is compared to the traditional open appendectomy, and the management of frequently found gynecologic pathology masquerading as appendicitis is described.     

Letter recognition reveals pathways of second-order and third-order motion

How are second-order (texture-defined) and third-order (pattern-tracking) motions processed in our brains? As shown here in the context of an ambiguous motion task involving a nominal second-order stimuli first devised by Werkhoven et al., [Werkhoven, P., Sperling, G. & Chubb, C. (1993) Vision Res. 33, 463-485.], the observers fell into two distinct groups based on the direction of perceived motion. The differences were interpreted in terms of the algorithms used to extract motion: one group by using a second-order motion process and the other by using a third-order motion process. This was investigated further using a dual-task paradigm in which the interference between two tasks indicated the nature of processing involved. Observers who used third-order motion processing experienced interference with letter recognition and a more severe interference in dual third-order motion tasks. Observers who used second-order motion processing experienced interference with another second-order motion detection but not with letter recognition. Insofar as task interference implies the need for attention, the complex interference effects and the apparently paradoxical interference effects of second-order motion perception imply that there are multiple forms of attention. Whether two tasks interfere depends on whether they require the same form of attention. Insofar as spatio-temporal processing is assumed to be carried out in the dorsal stream and pattern recognition in the ventral stream, the interference patterns suggest that second-order motion may be computed entirely in the dorsal stream, and third-order motion may involve two computational processes, one of which shares computational resources with the letter recognition task in the ventral stream.     

Self-association of disulfide-dimerized melittin analogues

Two cysteine substitutions of bee venom melittin have been synthesized to investigate the effects of disulfide cross-linking on the self-association properties of the peptide in solution. K23C melittin (mltK23C) was designed to link nonpolar surfaces of the amphipathic melittin helix on the basis of the close juxtaposition of pairs of K23 side chains in the crystal of the native melittin tetramer. K23Q/Q25C melittin (mltQ25C) was designed to link the polar surfaces of the peptide such that self-association in membrane bound states might be stabilized. The mltK23C disulfide dimer, (mltK23C)2, is highly structured at low pH under conditions where native melittin, and the mltK23C monomer, are unstructured. High-resolution NMR, circular dichroism, and fluorescence spectroscopy established that (mltK23C)2 is a helical monomer (pseudodimer) with stable helical segments between residues 2-13 and 15-25. Although the symmetrical nature of the pseudodimer prevented high-resolution structure determination, analysis of calculated hydrogen bond lengths, chemical shifts, near-UV circular dichroism, and urea denaturation demonstrated similarities with alpha-helical coiled coils and with the structure of native melittin in methanol. Stopped flow fluorescence showed that (mltK23C)2 underwent pH- and divalent anion-linked dimerization to a melittin-like pseudotetramer, indicating that a pair of disulfide bonds could be accommodated in a structure similar to the native melittin crystal structure. Despite incorporation of two disulfide bonds into the melittin tetramer, the folding free energy (DeltaGw) of [(mltK23C)2]2 was similar to that for the native melittin tetramer under the condition used. Incorporation of a disulfide bond on the polar helix face in melittin did not stabilize helical structure in the absence of self-association. Instead, this molecule underwent pH- and divalent anion-linked self-association to an ill-defined aggregate which precipitated.