AIMS To compare the success rate for transthoracic direct current cardioversion (DCC) of atrial fibrillation (AF) with antero-posterior (AP) and antero-apical (AA) electrode positions using an impedance compensated biphasic (ICB) waveform. METHODS AND RESULTS Three-hundred and seven patients [mean age 66 (SD+/-13), 195 male] with AF were recruited in three centres. Patients were randomized to an AA (n=150) or AP (n=144) pad position. Thirteen patients with implanted pacemakers were defaulted to the AP pad position. Cardioversion was performed using an ICB waveform with a 70, 100, 150, and 200 J energy selection protocol. If the fourth shock was unsuccessful, the pads were crossed over to the alternative position for a final 200 J shock. Shock 1 was successful in 54/150 (36%) AA and 45/144 (31%) AP patients, whereas success was achieved by shock 2 in 99/150 (66%) AA and 74/144 (51%) AP, by shock 3 in 123/150 (82%) AA and 109/144 (76%) AP, and by shock 4 in 143/150 (95%) AA and 127/144 (88%) AP and after cross-over in 144/150 (96%) AA and 135/144 (94%) AP. Overall success rate was higher than expected at 95%. Pad position was not associated significantly with success. There was a trend towards an improved outcome with the AA configuration (P=0.05). CONCLUSION The influence of pad position for DCC of AF may be less pertinent with ICB waveforms than with monophasic waveforms.

We describe a 62-year-old woman in whom systemic lupus erythematosus presented as life-threatening effuso-constrictive pericarditis. Surgical drainage of the pericardium was required and the patient made a satisfactory recovery. At six-months follow-up, while taking hydroxychloroquine and a non-steroidal anti-inflammatory agent, she remains well.

Objectives. The purpose of this study was to assess the efficacy of 150 mg of aspirin plus 100 mg of alteplase, administered as two intravenous bolus injections of 50 mg each given 30 min apart, and followed by intravenous heparin, on infarct-related coronary artery patency (Thrombolysis in Myocardial Infarction [TIMI] flow grade 3).Background. Previous workers have shown in animals that reducing the duration of an infusion of recombinant tissue-type plasminogen activator increases the initial rate of thrombolysis, resulting in high early infarct-related coronary artery patency rates. The logical progression of this idea is bolus administration.Methods. Consecutive patients presenting up to 6 h from the onset of symptoms were recruited for the study. Angiography was performed at 60 and 90 min after the first bolus and between 19 to 48 h after study entry. Patients were followed up for 1 month.Results. At 60 min, angiography revealed infarct-related coronary artery patency of TIMI flow grade 3 in 55 (86%) of 64 patients (95% confidence interval [CI] 75% to 93%) and TIMI flow grade 2 or 3 in 58 (91%) of 64 patients (95% CI 81% to 97%). At 90 min, infarct-related artery patency of TIMI flow grade 3 was achieved in 74 (88%) of 84 patients (95% CI 79% to 94%) and TIMI How grade 2 or 3 in 78 (93%) of 84 patients (95% CI 85% to 97%). Two patients (2.4%) had early angiographic reocclusion whereas 10 (11.9%) had late reinfarction. Bleeding episodes were mostly minor, and there was no cerebrovascular bleeding. Five patients (6.0%) died within 1 month of the acute myocardial infarction.Conclusions. In 84 patients with acute myocardial infarction, administration of 100 mg of double-bolus (2 x 50 mg) alteplase, aspirin and heparin is associated with remarkably high early infarct-related coronary artery patency rates (TIMI flow grade 3) of 86% and 88%, respectively, at 60 and 90 min.

Objective-To assess the safety and value of an exercise electrocardiography service for the diagnosis of suspected ischaemic heart disease to which general practitioners have direct access.Design-Direct access to a hospital exercise electrocardiography service was offered on a trial basis to 122 general practitioners in a defined urban area. Maximal exercise tests were performed according to the modified Bruce protocol and the results were despatched promptly to the referring doctors who were responsible for the subsequent management of their patients.Setting-All general practices in north and west Belfast (combined list size about 180 000) and the regional medical cardiology centre.

Three dimensional body surface maps provide more information on the gee-spatial distribution of cardiac elactrieal activity.It is hypo thesised that this information could facilitate the diagnosis of acute MI in early cases where standard methods are equivocal.To date these techniques have been confined to the laboratory and have yet to find clinical application.An important first step is the assessment of their diagnostic value among patients with established MI.All 82 consecutive patients admitted to the RVH cardiac unit with first presentation ofchastpaln suggestive of MI were mapped at 24 hours using a Corazonix BSM-32 predieter which measured QRS and STT iso-lntegrals using 32 leads.Of the 82 patients, 57 (69.5%) had an initial diagnostic ECG with subsequent confirmatory enzyme elevation.A further 25 (30.5%)presented with nondiagnostic ECG f'mdings.Fifteen of this group had an MI as confirmed by an increase in cardiac enzymes.For comparative purposes, 54 consols were recruited and mapped, all with normal ECG and no IHD risk factors.A series of discriminant function analyses were performed to assess sensitivity and specificity.Using a subset of the 32 QRS and the 32 STT iso-integralmeasurements, selected by a stepwise forward algorithm, a sensitivity of 94.7% (54/57) and a specificity of 90.7% (49/54) was obtained.When all measurements were analysed together, better results were obtained: sensitivity 10070 (57]57) and specificity 96.3 (42/ 54).In further multivariate analysis, map topography differed significantly (p<< 0.01) between males and females.Separating the data according to sex and using all QRS and sTr iso-integral measurements, 100% specificity and sensitivity resulted.Despite these findings, each of the derived discriminam functions had difficulty in classifying the 25 cases belonging to the possible MI group.The best results obtainable were: a sensitivity of 60% and a specificity of 60%.This suggests that further analysis is required to identify the topography of these patients.

A 39-year-old patient in her eleventh pregnancy was admitted to the obstetric unit of another hospital at 34 weeks gestation with nausea, vomiting and malaise for two weeks, and jaundice for two days before admission. Although there was no -previous history of pre eclampsia, hypertension (170/100mmHg) and mild oedema had been noted at 30 weeks for which she was treated with labetolol, chlorthalidone and diazepam. The day following her admission she became confused and unresponsive. Intrauterine death occurred and she was transferred to this hospital.

Six patients with histologically proven HBsAg-negative chronic active hepatitis (CAH), who were initially treated successfully with prednisolone with or without azathioprine, developed unacceptable adverse effects due to prednisolone. In all six patients the liver disease relapsed on reduction of the prednisolone dose and they subsequently entered a trial of low dose d-penicillamine, Two of the patients required early withdrawal of d-penicillamine and a third patient, who had a good clinical and biochemical response initially, developed heavy proteinuria at 14 months. In the remainder, d-penicillamine was well tolerated and the liver disease satisfactorily controlled permitting reduction of the prednisolone dose to 2.5 mg daily. We conclude that in this subgroup of patients with HBsAg-negative CAH and major prednisolone-induced adverse effects, d-penicidamine is an effective alternative therapy although side effects are common.

We report a case of malignant melanoma in which the presenting feature was melanuria. Melanuria should be considered in the differential diagnosis of any patient presenting with dark urine.