Electrophysiology in a district general hospital.

OBJECTIVE--To investigate the feasibility of performing electrophysiological studies at a district general hospital and to evaluate the importance of such studies in the management of patients with suspected arrhythmias. DESIGN--Retrospective study of patients having had electrophysiological studies during a three year period. SETTING--District general hospital. SUBJECTS--93 patients (50 men, 43 women, mean age 45.9 years) with suspected arrhythmias. RESULTS--The patients were divided into two groups according to symptoms. Group 1 (34 patients) presented with syncope. Group 2 (59 patients) presented with palpitation. All had previously undergone non-invasive investigations. All had had multiple hospital admissions and outpatient attendances. In group 1 nine patients with no documented arrhythmias had inducible ventricular tachycardia and three of six with suspected bradyarrhythmias had ventricular tachycardia. Fourteen patients had suspected ventricular arrhythmias before electrophysiological studies, which were confirmed in all, four receiving automatic implantable cardioverter defibrillators. Electrophysiological studies were used to guide drug treatment in all patients. Group 2 consisted of 32 patients with reentrant supraventricular tachycardia and 15 with ventricular tachycardia; 12 had no documented arrhythmias. In those with supraventricular tachycardia, accessory pathways were identified in all. In 23 patients drug treatment (guided by electrophysiological studies) was successful. In nine, drug treatment guided by electrophysiological studies were ineffective and radiofrequency ablation was successful. In 15 patients with ventricular tachycardia and palpitations, 10 had their drugs changed after electrophysiological studies and their ventricular tachycardia was suppressed. In five patients electrophysiological studies showed that ventricular tachycardia was unsuppressed and they were referred for an operation or implantation of an automatic cardioverter defibrillator. In 12 patients with no documented arrhythmias electrophysiological studies identified significant arrhythmias in six. There were no complications. CONCLUSIONS--Diagnostic electrophysiological studies can safely and effectively be performed in a district general hospital. These studies are especially effective in investigating patients with syncope, and also provide a strategy for future arrhythmia management.     

Endoscopic biliary stenting in a district general hospital.

During a 48 month period to December 1990, 367 patients, median age 75 years, with obstructive jaundice caused by common bile duct stones (201), malignant biliary obstruction (148), and benign biliary strictures (18), underwent therapeutic endoscopic retrograde cholangiopancreatography. Endoscopic biliary stenting and drainage was achieved in 343 of 367 patients attempted (93%), seven patients requiring a combined percutaneous endoscopic approach. Endoscopic stenting failed in 24 patients because of malignant duodenal infiltration (10), Billroth 2 gastrectomy (6), tight and extensive biliary strictures (6), peripapillary diverticulum (1), and technical failure (1). Prolonged follow up was available in 91% (311 of 343). The 30 day mortality was 5% (17 of 343), which included two procedure related deaths (0.6%) from fulminant pancreatitis and major sphincterotomy site bleeding. Early complications occurred in 14% (48 of 343) and late complications occurred in 11.9% (35 of 294) patients, as of the original 343, 17 had died within 30 days and another 32 were lost to follow up. Eighty patients with incomplete bile duct clearance and eight patients with benign biliary strictures had biliary stents inserted for 12-48 months (median 30). Endoscopic biliary stenting services are necessary in a district general hospital with technical success, death and morbidity rates comparable to other studies.     

Recognition of alcoholic liver disease in a district general hospital.

Two-hundred-and-two patients with alcoholic liver disease whose investigations included a liver biopsy were seen in a district general hospital over a seven year period. Thirty-five percent presented with general gastrointestinal symptoms rather than with overt liver disease or previously recognised excess consumption of alcohol. Recognition of the alcohol problem was assisted by the finding of a raised mean corpuscular volume (MCV) and/or gammaglutamyl transpeptidase (GGTP). The use of these methods of detection is discussed in relation to the rapid rise in alcohol consumption in the United Kingdom, and the high mortality of cirrhosis reported from special centres. Twnety-two per cent of the patients were found to have an established cirrhosis, and there was some evidence that the women were more susceptible to some of the toxic effects of alcohol. Early detection can be enhanced by a high level of suspicion, wider recognition of the significance of a high MCV, and the greater use of GGTP estimations.     

Treatment of atrial fibrillation

Atrial fibrillation is a common and in most patients recurrent arrhythmia. Atrial fibrillation can increase mortality and causes at times severe symptoms in affected patients. Timely initiation of sustained oral anticoagulation is indicated in patients with atrial fibrillation at risk for stroke to prevent thromboembolic complications. Patients at risk for stroke can be identified by clinical characteristics using validated score systems, e.g., the CHADS(2) score or the Framingham score. Drugs that slow AV nodal conduction can improve symptoms associated with high ventricular rate. Cardioversion can acutely terminate atrial fibrillation in almost all patients, but many patients suffer from recurrent atrial fibrillation. The prevention of arrhythmia recurrences ("rhythm control therapy") is indicated in patients with severe arrhythmia-related symptoms. Antiarrhythmic drugs can approximately double the maintenance rate of sinus rhythm. Other drugs that were not primarily developed as antiarrhythmic agents, e.g., ACE inhibitors, sartans, and possibly statins, can further improve maintenance of sinus rhythm in selected patient groups. Catheter-based isolation of the pulmonary veins is a recently developed intervention that can cure some forms of atrial fibrillation. It is likely that a multimodal therapeutic approach will in the future allow rhythm control therapy to become more effective.     

心房颤动的治疗

<正>心房颤动是临床上最常见的一种心律失常,其患病率与发病率均随年龄增长逐步增加,40岁以上男性和女性的心房颤动患病终生风险分别为26%和23%[1]。心房颤动是由遗传因素、自主神经系统、炎症系统及内分泌系统共同作用所致的进行性疾病。在心电图上表现为正常的P波消失,代之以波幅不等、形态各异、间隔不齐的连续小锯齿波,频率在350-600次/min。这种持续紊乱的电活动会引起心房收缩功能下降,心排出量下降超过15%;会使心房局部     

Sputum microbiology in a district general hospital. The role of Branhamella catarrhalis

Evidence is presented that supports the view that Branhamella catarrhalis has a pathogenic role in chronic chest disease, similar in many respects to Haemophilus influenzae. It was isolated from 4% of sputum specimens (compared to 10% for Haemophilus influenzae). Fifty-three per cent produced beta-lactamase, and all were resistant to trimethoprim. The relevance of these findings to antibiotic treatment is discussed.     

Audit of HIV partner notification in a district general hospital

We evaluated partner notification for HIV in a district general hospital over a two-year period. The majority of current partners were notified and 60% were found to be HIV-positive. No previous partners were successfully notified. We make recommendations intended to improve the rate of notification and testing.     

Ibutilide: efficacy and safety in atrial fibrillation and atrial flutter in a general cardiology practice.

BACKGROUND: Published experience with ibutilide (IB) in randomized clinical trials reveals that conversion to sinus rhythm (SR) occurs in 31% of patients with atrial fibrillation (AF) and in 63% of patients with atrial flutter. HYPOTHESIS: The study was undertaken to test the efficacy and safety of IB in patients with AF and with atrial flutter and to compare them with those reported in previous studies. METHODS: In a general cardiology practice, 54 consecutive patients with AF or atrial flutter, no contraindication to IB, and a normal QTc interval, were treated with intravenous IB (0.4-2.0 mg). Duration of arrhythmia, left atrial (LA) size, ejection fraction (EF), time to conversion, QTc interval, and adverse drug events were determined. Patients were observed for a minimum of 6 h. Successful cardioversion was defined as arrhythmia termination within 6 h. RESULTS: Twenty-four of 34 (70.6%) patients with AF and 15 of 20 (75%) patients with atrial flutter converted to SR. Conversion of AF to SR was more likely to occur if duration of AF was approximately 96 h compared with > 96 h (81 vs. 17%, respectively; p = 0.006). The mean time to arrhythmia termination was 68.8 min. Left atrial size, determined by echocardiogram, was 44 +/- 13 mm in 43 patients. Patients with LA size approximately 45 mm had a conversion rate of 55% in both AF and flutter, compared with a conversion rate of 72% in patients with LA size < 45 mm. Ejection fraction was not a predictor of drug success. The QTc intervals were significantly prolonged after IB administration, with a mean change of 47.1 ms for successfully treated patients. Sustained polymorphic ventricular tachycardia occurred in one patient within 1 min of IB infusion, requiring electrical cardioversion to SR. This patient's serum electrolytes and QTc interval were normal prior to IB infusion; however, the QTc increased by 160 ms (from 387 to 547 ms) during drug infusion. No systemic or pulmonary emboli occurred. CONCLUSION: The efficacy of IB for conversion of AF to SR in this prospective observational study was considerably better than previously reported. Duration of AF remains an important predictor of conversion to SR. Complications are rare and without long-term adverse effects.     

Laparoscopic splenectomy: single-centre experience of a district general hospital

We report the results of 20 consecutive laparoscopic splenectomies performed on haematology patients for a number of indications. Our series includes patients up to 77 years of age at the time of surgery and removal of spleens weighing up to 3530 g. The most significant benefit is the early rate of discharge post-operatively (median 2 d); however, there is a risk of conversion to open laparotomy (in this series 3/20, 15%). We show that laparoscopic splenectomy can be offered as a therapeutic option to patients unfit for conventional laparotomy and that even large and bulky spleens can be removed safely using this approach.     

心房纤颤的药物治疗

心房纤颤(简称房颤)是临床最常见的心律失常[1].尽管近年来,在房颤的非药物治疗方面取得了令人瞩目的进展,但目前药物治疗仍然是房颤患者最常规的治疗选择.房颤的药物治疗在恰当的抗凝基础上可分为:心律控制和心率控制.     

Methotrexate for Crohn's disease: experience in a district general hospital

Controlled trials have demonstrated the efficacy of methotrexate (MTX) in the induction and maintenance of remission in patients with luminal Crohn's disease, but its use outside of specialist centres remains limited. We present a case series of 24 patients treated with parenteral MTX in a district general hospital. Patients received an induction course of 25 mg weekly for 16 weeks, followed by maintenance doses of 15 mg weekly. Nineteen patients achieved remission during the induction period. Of these, 10 were maintained in remission for more than 12 months. In total, there were six relapses within 1 year and five drug withdrawals due to side effects during the observation period. Of the six relapses, three required surgical intervention (with two of these re-starting methotrexate postoperatively) and three were recommenced on maintenance MTX after a short period at an increased dose. Our results are similar to outcomes achieved in large, randomized, controlled trials and indicate that MTX can be used safely and effectively for the treatment of refractory Crohn's disease in the district general hospital setting.     

Treatment of atrial fibrillation with an implantable atrial defibrillator--long term results.

OBJECTIVES: To evaluate the long-term outcome with an implantable atrial defibrillator (IAD) in patients with recurrent atrial fibrillation (AF). BACKGROUND: Maintenance of sinus rhythm using repeated internal cardioversion shocks has been shown to be effective and safe in short-term studies but long term follow-up is unknown. METHODS: Since 1995, 136 patients (30 women) with symptomatic, drug-refractory atrial fibrillation were implanted with an IAD (METRIX, InControl). This analysis was performed after a median of 40 (range 7-66) months after implantation. RESULTS: In 26 patients, the programmed mode was not documented during last follow-up, four patients had died. Of the remaining 106 patients (mean age 58+/-10, range 34 - 79 years), 39 were actively delivering therapy with the device, in 14 patients the device was used to monitor the arrhythmia but no shocks were delivered, and in 53 patients it was turned off or explanted. Increases in defibrillation thresholds (n=7), patient intolerance of multiple cardioversion shocks (n=15), and significant bradycardia requiring dual-chamber pacing (n=12) were the main reasons for discontinuation of therapy in addition to battery depletion (n=19). After explantation, efforts to maintain sinus rhythm were continued in 17 patients whereas rate control was attempted in 36 patients. CONCLUSIONS: A strategy of maintaining sinus rhythm long-term with an IAD is feasible in a proportion of patients. However, patient selection is critical, and technical improvements (i.e. higher shock energies, dual-chamber pacing and additional preventive and anti-tachycardia pacing algorithms) are required to increase the number of patients having long term benefit, and frequent arrhythmia recurrences and patient intolerance to repeated cardioversion shocks remain a major limitation.     

Predictors of risk in patients with unstable angina admitted to a district general hospital.

OBJECTIVE--To observe the long-term prognosis of patients with unstable angina and select simple criteria to identify high and low risk subgroups. DESIGN--A six month prospective survey with three year follow up. SETTING--One eleven bed coronary care unit. PATIENTS--All patients admitted with chest pain in whom no infarct was confirmed by subsequent electrocardiographic or enzyme changes and for whom no alternative cause of chest pain was found were studied. Unstable angina was also diagnosed if there was evidence of myocardial ischaemia in the form of previous effort angina, previous myocardial infarction, or if transient electrocardiographic changes accompanied the pain. When none of the above were present, chest pain without a known cause, was diagnosed. INTERVENTIONS--No routine intervention. Angiography and revascularisation for persistent symptoms despite medical treatment. OUTCOME MEASURES--Death or non-fatal infarction. RESULTS--In the 141 patients with unstable angina there were eight deaths and five non-fatal infarctions during the first eight weeks. Symptoms of increasing angina before admission were similar in all three groups and did not help predict early complications. Recurrence of pain in hospital, a rise in cardiac enzymes to less than twice the upper limit of normal, and transient electrocardiographic changes were all associated with an increased risk of early events. The presence of either abnormal enzyme activity or more than five episodes of pain in hospital identified a group of 49 in whom 11 of the 13 early events occurred. After three years, 29 of the 141 patients had died and eight had had infarctions (overall event rate 26%). Seventeen had undergone revascularisation (12%) and 51 (36%) were on antianginal treatment. Thirty six (26%) were still alive, without new myocardial infarction, and were free of angina. In the 29 patients with chest pain without a known cause there were no early events and only one non-fatal infarction during the three year follow up. CONCLUSION--When patients are admitted to the coronary care unit with chest pain not due to myocardial infarction, the history, electrocardiography and measurement of cardiac enzymes are sufficient to identify high and low risk subgroups.     

Predictors of risk in patients with unstable angina admitted to a district general hospital.

OBJECTIVE--To observe the long-term prognosis of patients with unstable angina and select simple criteria to identify high and low risk subgroups. DESIGN--A six month prospective survey with three year follow up. SETTING--One eleven bed coronary care unit. PATIENTS--All patients admitted with chest pain in whom no infarct was confirmed by subsequent electrocardiographic or enzyme changes and for whom no alternative cause of chest pain was found were studied. Unstable angina was also diagnosed if there was evidence of myocardial ischaemia in the form of previous effort angina, previous myocardial infarction, or if transient electrocardiographic changes accompanied the pain. When none of the above were present, chest pain without a known cause, was diagnosed. INTERVENTIONS--No routine intervention. Angiography and revascularisation for persistent symptoms despite medical treatment. OUTCOME MEASURES--Death or non-fatal infarction. RESULTS--In the 141 patients with unstable angina there were eight deaths and five non-fatal infarctions during the first eight weeks. Symptoms of increasing angina before admission were similar in all three groups and did not help predict early complications. Recurrence of pain in hospital, a rise in cardiac enzymes to less than twice the upper limit of normal, and transient electrocardiographic changes were all associated with an increased risk of early events. The presence of either abnormal enzyme activity or more than five episodes of pain in hospital identified a group of 49 in whom 11 of the 13 early events occurred. After three years, 29 of the 141 patients had died and eight had had infarctions (overall event rate 26%). Seventeen had undergone revascularisation (12%) and 51 (36%) were on antianginal treatment. Thirty six (26%) were still alive, without new myocardial infarction, and were free of angina. In the 29 patients with chest pain without a known cause there were no early events and only one non-fatal infarction during the three year follow up. CONCLUSION--When patients are admitted to the coronary care unit with chest pain not due to myocardial infarction, the history, electrocardiography and measurement of cardiac enzymes are sufficient to identify high and low risk subgroups.