Following the UK Academy of Medical Royal Colleges Report on seven day consultant present care, the Royal College of Physicians and Surgeons of Glasgow held a symposium to explore clinicians' views on the ways in which clinical care should best be enhanced outside 'normal' working hours. In addition, a survey of members and fellows was undertaken to identify the tests which would make the greatest impact on care out of hours. Key messages were: (a) that seven-day consultant delivered care would not achieve the desired benefit to patient care if introduced in isolation from other inter-relating factors. These include alternatives to hospital admission, enhanced nursing support, increased junior medical, pharmacy, social care and ambulance availability and greater access to selected diagnostic services; (b) that the care of hospital inpatients is a service which is one part of the totality of secondary care provision. Any significant change in the deployment of staff for inpatient care must be carefully managed so as not to result in a reduced quality of care provided by the rest of the system.

Diplopia and gaze palsies are extremely disabling and distressing problems, especially in patients with significant cardiac co-morbidity. A case of Parinaud syndrome and oculomotor nerve palsy following coronary angiography (CA) is reported. These neuro-ophthalmic complications are not previously documented in the literature in association with CA. The case raises awareness of potential ocular motility deficits that may occur following CA. Potential risk factors during CA are analysed and the mechanisms of the embolic pathway are discussed.

Atrial fibrillation (AF) is a common arrhythmia associated with increased morbidity and mortality. Current practice aims to restore sinus rhythm (SR), although the question of whether rate or rhythm control is the optimal approach for these patients remains unanswered. The most established method of restoring SR in patients with AF of duration greater than 48 hours is external direct-current cardioversion (DCC). This is a descriptive paper summarising how we utilised the hospital's day surgery unit for the provision of DCC for patients with AF in order to provide a more efficient service and allow an increased number of procedures to be conducted. We describe the reasons for setting up the service and the methods involved. We also summarise the advantages associated with this new system.

Hypertension is one of the major risk factors for coronary artery disease. This risk is considerably magnified by the presence of left ventricular hypertrophy. The likeliest dominant factor in this increased risk is myocardial ischaemia, the recognition of which is of key importance. Antihypertensive agents ideally should also protect against occurrence of the clinical syndromes associated with coronary artery disease.

BACKGROUND:Electrocardiography is the fundamental investigation for decision making regarding thrombolytic treatment in acute myocardial infarction (MI). Increasing the accuracy of ECG analysis by input from consultant staff may assist in management decisions in patients with suspected MI.AIMS:To evaluate a system whereby out of hours ECGs can be faxed to the consultant to aid in decision making regarding thrombolytic treatment.METHODS:112 patients with suspected MI were assessed on admission by the senior house officer (SHO) who faxed to a cardiology consultant the ECG trace and a predesigned form with information on: clinical assessment of the patient; interpretation of the ECG; and views regarding administration of thrombolytic treatment including choice of agent. The consultant reviewed the information and communicated his views to the SHO. Subsequent diagnosis was recorded in all patients and the forms were analysed in regard to areas of agreement and disagreement between the SHO and the consultant.RESULTS:A diagnosis of MI was confirmed in 52 of the 112 patients (46.4%). The consultant agreed with the SHO's decision on thrombolysis in 98 patients (87.5%). The reason for disagreement in the remaining 14 patients (12.5%) was SHO misinterpretation of the ECG (10 patients) and clinical assessment (four patients). Eight patients were saved unnecessary thrombolytic treatment and four received it when they otherwise would not have. Additionally the choice of thrombolytic agent was changed in six patients from streptokinase to tissue plasminogen activator.CONCLUSION:The use of fax machine assists in decision making with regard to thrombolytic treatment and provides support to junior doctors in what can be a difficult, yet critical decision.

The exact mechanisms for thrombus formation in patients with valvular heart disease have not been clearly defined. Abnormalities in plasma coagulation factors indicative of a prothrombotic state may in part account for the risk of stroke and thromboembolism in such patients. The aim of this study was, therefore, to determine the effects of mitral regurgitation (MR) and aortic stenosis (AS) on plasma fibrinogen or fibrin D-dimer levels as indices of a thrombogenic (or prothrombotic) state. A total of 25 patients with valve disease in sinus rhythm were studied: 12 patients (all women; mean age fifty-five years, sem 3.3) with MR; and 13 patients (7 men, 6 women; mean age fifty-seven years, sem 3.5) with AS were studied. Patients with MR had a median plasma fibrinogen that was significantly elevated when compared with female population values (median difference 0.62 g/L; 95% confidence intervals (CI) 0.27 to 1.05, P = 0.0016). However, these patients had a median plasma fibrin D-dimer that was lower than that for population controls (median difference 21 ng/mL; 95% CI 0 to 38, P = 0.05). Patients with aortic valve disease had a median plasma fibrinogen that was significantly increased when compared with population controls (median (continued on next page) difference 0.82 g/L; 95% CI 0.34 to 1.24, P = 0.001). These patients had a plasma fibrin D-dimer level that was similar to population values (median difference 3 ng/mL; 95% CI -25 to 22, P = 0.80). Patients with MR or AS have higher plasma fibrinogen levels when compared with "normal" population values, suggesting possible hemorheologic abnormalities in these patients. Subjects with MR had lower plasma fibrin D-dimer levels, suggesting lesser intravascular clotting, consistent with clinical echocardiographic studies. Subjects with AS had plasma fibrin D-dimer levels similar to the "normal" population values, suggestive of a different pathophysiological mechanism for thromboembolism. These findings add to an improved understanding of the relationship between clinical observations and the signif icance of plasma fibrinogen and fibrin D-dimer levels in thrombogenesis.

Myocardial infarction remains the single most common cause of death in patients with essential hypertension. This becomes particularly evident when the hypertension is associated with left ventricular hypertrophy. To combat the continuing high mortality from myocardial infarction in hypertensive heart disease, however, all aspects of the relationship must be studied. Thus, addressing the interface from an epidemiological standpoint as well as from a pathological point is critical and progress in these areas as well as in areas of management are ultimately likely to lead to a fall in morbidity and mortality from ischemic heart disease in patients with hypertension.

EDITOR, - We appreciate the interest shown in our article on the treatment of suspected myocardial infarction in the community.1 Alastair D Short and Barbara West report that only 20% of general practitioners …

Use ofaspirin by general practitioners in suspected acute myocardial infarction

Conference Abstract| February 01 1994 Does Endothelial Dysfunction Contribute to Thrombogenesis in Patients with Chronic Atrial Fibrillation? GYH Lip; GYH Lip 1Department of Cardiology, University Department of Medicine. Royal Infirmary, Glasgow, Scotland Search for other works by this author on: This Site PubMed Google Scholar D Smith; D Smith *Department of Haematology, University Department of Medicine. Royal Infirmary, Glasgow, Scotland Search for other works by this author on: This Site PubMed Google Scholar GDO Lowe; GDO Lowe **Department of Stobhill Hospital, University Department of Medicine. Royal Infirmary, Glasgow, Scotland Search for other works by this author on: This Site PubMed Google Scholar F G Dunn F G Dunn 1Department of Cardiology, University Department of Medicine. Royal Infirmary, Glasgow, Scotland Search for other works by this author on: This Site PubMed Google Scholar Clin Sci (Lond) (1994) 86 (s30): 34P. https://doi.org/10.1042/cs086034Pa Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Cite Icon Cite Get Permissions Citation GYH Lip, D Smith, GDO Lowe, F G Dunn; Does Endothelial Dysfunction Contribute to Thrombogenesis in Patients with Chronic Atrial Fibrillation?. Clin Sci (Lond) 1 February 1994; 86 (s30): 34P. doi: https://doi.org/10.1042/cs086034Pa Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll JournalsClinical Science Search Advanced Search This content is only available as a PDF. © 1994 The Biochemical Society and the Medical Research Society1994 Article PDF first page preview Close Modal You do not currently have access to this content.

the asthmatic patients would need to be sampled, at random. The chart may seem counterintuitive in that the sample required to estimate '-r=0 1 is smaller than that required to estimate 'rr= 0 5 and yet one would expect a larger sample to be needed to estimate a smaller proportion. This arises because the variance of an estimated proportion is largest at 7r=0 5. The width of the confidence interval, however, is fixed at 0 05, and so if aT=0 1 the allowable error is 50% of the estimate whereas if IT=0 5 the allowable error is only 10% of the estimate. The formula given by Machin and Campbell should be used for confidence intervals with other widths.2 This formula should not be used to test hypotheses. For example, to test the hypothesis that 50% of asthmatic patients had had their peak flow recorded in the past year one would use conventional tables, as described by Daly, in which the concept of the power of the test is also involved.'

Cardiac glycosides are unusual in having a narrow therapeutic range, which is idiosyncratic to the individual. In view of this it is perhaps not surprising that toxicity is a common occurrence, being reported in up to 35% of digitalized patients.' There are several mechanisms which can lead to this problem. Firstly, digoxin is excreted mainly by the kidneys, and therefore, any impairment ofrenal function may lead to higher than expected plasma concentrations. Congestive cardiac failure, renal failure and advanced age can also cause toxicity by reducing the volume of distribution of the drug. Concomitant electrolyte imbalance, notably hypokalaemia, hypomagnesaemia and hypercalcaemia can potentiate digoxin toxicity. Approximately 30% of digoxin is plasma protein bound and thus certain other drugs such as amiodarone and calcium antagonists can lead to higher than expected plasma concentrations. Lastly, several clinical conditions such as hypothyroidism, chronic lung disease and cardiac amyloid are associated with an abnormally high myocardial sensitivity to digoxin. Despite all of this, however, there is often still no clear relationship between these factors and manifest toxicity.

An unusual complication after aortocoronary bypass grafting (CABG) is described in which a false aneurysm of the saphenous vein graft to the right coronary artery (RCA) developed and caused profuse intermittent bleeding through the sternotomy wound. The aetiology of this condition is uncertain but it could occur whenever a suture line is present especially in the presence of infection. The diagnosis was made non-invasively by a contrast enhanced computed tomogram and was subsequently confirmed by selective coronary bypass angiography. The pseudoaneurysm was successfully obliterated by coil embolisation of the right coronary graft, which stopped the bleeding immediately and was followed by rapid wound healing.

One hundred and eleven patients over the age of 65 years who underwent coronary artery bypass grafting in Glasgow between 1980 and 1985 were compared with 548 younger patients, who had coronary artery bypass surgery over a similar period of time. The elderly group had a higher prevalence of females, pre-operative unstable angina, left main coronary artery disease and depressed left ventricular function. There were no significant differences between the two groups in operative morbidity or mortality and angina was abolished or improved in 93% of the elderly patients at follow-up. Coronary artery surgery has an important role in the management of angina in elderly patients.

after thrombolytic treatment. Thesum ofthe(E)STsegmentareainleads showing STsegmentelevation inthe12 lead electrocardiogram atpresentation was used asanindex ofpotential myocardial injury (initial ischaemic index). Theevolved infarct size at48hwas assessed bya QRS scoring system.Two groupsofpatients, bothadmitted withanterior myocardial infarction within 6hofonset,were studied. Group1 (n= 35)received analgesia onlyandgroup 2(n= 33)received thrombolytic treatmenteither bytheintracoronary (streptokinase, n = 13)orintravenous route(anistreplase, n = 20). Reperfusion wasassessed angiographically. Themean (SDpotential infarct size assessed bytheinitial ischaemic index was similar inboth groups(group 1, STarea= 115(60) MM2and group2 = 126(77mm2).TheQRS scorerepresenting evolved infarct size was significantly lower inthetreated group (4-1 (2-5)) thaningroup 1(7-8 (2-6)). The95%confidence intervals forQRS scoresbased ontheadmission ESTareafrompatients withsuccessful reperfusion were applied toa third setofpatients (n= 22)totesttheability oftheadmission ST area(myocardial injury) to predict theQRS scoreaccurately . Whilepatients withsuccessful reperfusion hadsignificantly lower QRSscoresthanthose whodidnot(45(3- 1)v9-3(3-4)), thewideconfidence intervals caused byinter-individual variability precluded an accurateprediction oftheQRS scoreinan individual fromtheISTareaattimeofpresentation. There was no difference ininfarct size inpatients treated early (<3h)(QRSscore4-2(28)) orlater (3-6h)(4-1 (2-1)). Thisstudyprovides evidence thatsequential electrocardiographic changes are reducedin patients withanterior myocardial infarction whoachieve reperfusion after thrombolytic treatment andthat this benefit isshownwith treatmentgiven up tosixhours after infarct onset.Nonetheless, therelation between theinitial ischaemic index andtheevolved QRS scorehaswideconfidence intervals, reflecting inter-individual variability, anddoes notallow theprediction ofaQRS scorein anindividual patient.

It has previously been suggested that amiodarone, used widely to treat refractory cardiac arrhythmias, may induce glucose intolerance. In view of this, we have undertaken a prospective study in a group of 10 patients with normal glucose tolerance profiles requiring amiodarone therapy for control of supraventricular or ventricular dysrhythmias. The patients were followed for a total of 9 months, and glucose tolerance tests and glycosylated haemoglobin were done at 3 monthly intervals in all patients.