Is Mobitz type I atrioventricular block benign in adults?

OBJECTIVE: To assess the need for pacing in adults with chronic Mobitz type I second degree atrioventricular block (Mobitz I). DESIGN: Prospective study. SETTING: District general hospital. PATIENTS: 147 subjects aged > or = 20 years (age cohorts 20-44, 45-64, 65-79, and > or = 80) with chronic Mobitz I without second degree Mobitz II or third degree (higher degree) block on entry, seen from 1968 to 1993 and followed up to 30 June 1997. Sixty four had organic heart disease. The presence of symptomatic bradycardia was defined as highly likely in 47 patients (class 1); probable in 14 (class 2); and absent in 86 (class 3). INTERVENTIONS: Pacemakers were implanted in 90 patients for the following indications: symptoms in 74 and prophylaxis in 16. MAIN OUTCOME MEASURES: The main outcome measure was death, with conduction deterioration to higher degree block or symptomatic bradycardia the alternative measure. RESULTS: Five year survival to death was reduced in unpaced patients relative to that expected for the normal population (overall mean (SD) 53.5 (6.7)% v 68.6%, p < 0.001; class 3, 54.4 (7.3)% v 70.1%, p < 0.001). Paced patients fared better than unpaced (overall (mean (SD) five year survival 76.3 (4.5)% v 53.5 (6.7)%, p = 0.0014; class 3, 87.2 (5.4)% v 54.4 (7.3)%, p = 0.020; and organic heart disease, 68.2 (7.6)% v 44.0 (9.9)%, p < or = 0.0014). There were no deaths in the < 45 cohort. Survival to first outcome (main or alternative) was further reduced to 31.7 (5.0)% in 102 patients unpaced initially and 34.2 (5.7)% in class 3. Only the 20-44 cohort and patients with sinus arrhythmia had > 50% survival. CONCLUSION: Mobitz I block is not usually benign in patients > or = 45 years of age. Pacemaker implantation should be considered, even in the absence of symptomatic bradycardia or organic heart disease.

Is the radiation of chest pain a useful indicator of myocardial infarction? A prospective study of 541 patients.

In recent years it has been claimed that in those presenting with chest pain, the extent of pain radiation may be predictive of MI and that women's and men's pattern of pain radiation differs. This prospective study therefore investigated whether there were differences in pain radiation between those with and without MI and according to gender. Patients (n = 541) presenting to a CCU with an episode of chest pain were asked to indicate on a body map the region of pain radiation they experienced at the time of symptom onset. As expected, radiation to the left and/or to right shoulder/arm was significantly higher in the MI group. Women with MI experienced more chest pain radiating to the right arm/shoulder (P = 0.0005), upper right region (P = 0.0006) and arm/shoulder than those without MI. Additionally, women with MI also described more pain radiation in the front neck (P = 0.015) area, and the right shoulder/arm (P = 0.02) than their male counterparts. A third of these women also experienced more pain radiating to the back (P = 0.005). The premise of greater chest pain distribution amongst those with an MI could not be confirmed. Nevertheless, the study identified significant differences amongst women with MI, the discussion analyses the implications for practice.

¿Pueden ser útiles los descriptores verbales específicos para diferenciar a los pacientes con o sin infarto agudo de miocardio? resultados de un estudio de dos años / Can specific verbal descriptors be useful in differentiating those with and without MI? Findings from a two-year study

Este artículo presenta los resultados de un estudio de 2 años, realizado en una unidad coronaria de 11 camas situada en un hospital del suroeste de Inglaterra. El objetivo del estudio era explorar las diferencias entre los descriptores verbales utilizados por pacientes con y sin infarto agudo de miocardio (IAM), para determinar su contribución en la valoración de pacientes con sospecha de IAM. Además, el estudio analizaba si existían diferencias entre las palabras utilizadas por los varones y las mujeres con IAM para describir los síntomas de dolor torácico. Todos los pacientes ingresados con un episodio de dolor torácico se seleccionaban para participar en el estudio, siempre que: hubieran estado sin dolor 24 h después del ingreso, fueran mayores de 18 años y hablaran inglés. La muestra incluyó 266 pacientes con IAM y 275 sin IAM. A todos los pacientes se les ofreció una lista de 12 palabras sensoriales y 10 afectivas, validadas en investigaciones anteriores. Los resultados sugieren que hay poca diferencia entre las palabras utilizadas por los pacientes con o sin IAM para describir su dolor torácico, lo que puede confirmar la complejidad para obtener un diagnóstico diferencial exacto. Sin embargo, hay algunas diferencias claras entre el vocabulario utilizado por los varones y las mujeres con IAM, las mujeres se expresaban con un lenguaje más emotivo que los varones, refiriendo su dolor torácico en términos de estar "asustadas" (p < 0,05) y "aterradas" (21,1 por ciento frente a 12,1 por ciento). La discusión presenta los aspectos metodológicos y posibles implicaciones para la práctica en el futuro (AU)

[Can specific verbal descriptors be useful in differentiating those with and without MI? Findings from a two-year study]. / Pueden ser útiles los descriptores verbales específicos para diferenciar a los pacientes con o sin infarto agudo de miocardio? Resultados de un estudio de dos años.

This paper discusses the findings of a two-year study, which was based in an eleven-bedded coronary care unit in the South-West of England. The study aimed to explore the difference between the verbal descriptors used by those with and without MI in order to determine their contribution in assessing patients with a suspected MI. The study also examined whether any differences existed between the words men and women with MI used to describe their chest pain symptoms. All patients admitted with an episode of chest pain were eligible to participate providing that they were pain-free at 24 hours after admission, were over 18 years of age and could speak English. The sample comprised of 266 patients with MI and 275 without MI. All patients were offered a menu of 12 sensory and 10 effective words, which had been validated in previous research. The results suggest that there is little difference in the words patients with and without MI use to describe their chest pain and this may reinforce the complexity in obtaining an accurate differential diagnosis. However, there are some clear differences in the vocabulary of men and women with MI. Women with MI appeared to report more emotive language than men and expressed their chest pain in terms of being "frightened" (p < 0.05) and "terrified" (21.1 % vs 12.1 %). The discussion will examine the methodological issues and possible practice implications for the future.

Are manual gestures, verbal descriptors and pain radiation as reported by patients reliable indicators of myocardial infarction? Preliminary findings and implications.

Patients experiencing an episode of acute chest pain need to be assessed promptly and effectively to ensure optimal management. The aim of this study was to investigate whether there were specific aspects of patients' symptom reports which could be viewed as additional indicators of myocardial infarction (MI) and contribute to the assessment process. The sample consisted of 267 patients who presented with an episode of acute chest pain. Methods of data collection were based on, or modified from, previous studies which had investigated the use of manual gestures, choice of verbal descriptors and extent of pain radiation in patients with and without MI. To determine whether these variables were of significance in the diagnosis, the responses of those with (n = 118) and without MI (n = 149) were compared. The results suggest that it is currently impossible to draw any conclusions as to whether the variables studied can be judged as reliable indicators of MI. The findings indicate that there are some differences between the groups particularly in the language used. Moreover, women with MI characterized their symptoms through stronger emotive words such as 'worrying' (P = 0.014) 'frightening' and 'intolerable' and also differed from their male counterparts in their reports regarding pain radiation. Implications for practice and for research are discussed.

Cytotoxic activity of Propionibacterium acnes and other skin organisms.

Culture supernatants from four species of skin micro-organisms were tested against VERO (monkey kidney cells) and skin fibroblasts for cytotoxic activity. Cytotoxic activity was produced by the three species of Propionibacterium tested (P. acnes, P. avidum and P. granulosum), and this activity was highest when cultures were grown in the presence of glucose. In contrast, Staphylococcus epidermidis was devoid of cytotoxic activity whether grown in the presence of glucose or not. The agent responsible for the cytotoxic activity was heat stable, of low molecular weight and removable from supernatants by ether extraction. These properties, coupled with the finding that the levels of cytotoxicity are directly proportional to the concentrations of propionate measured in samples, suggests that propionate is the agent responsible for the cytotoxicity of the culture supernatants. Pure propionate and the salts of other carboxylic acids (CI to C5) were tested at the same concentrations and showed different degrees of cytotoxicity depending on their chain length. Propionate may have an important role in the aetiology of the disease acne vulgaris.

Survival in second degree atrioventricular block.

Two hundred and 14 patients with chronic second degree heart block were seen and followed up in the Devon Heart Block and Bradycardia Survey between 1968 and 1982. The patients were divided into three groups according to the type of block. In group 1 there were 77 patients with Mobitz type I block (mean age 69 years), in group 2, 86 patients with Mobitz type II block (mean age 74 years), and in group 3, 51 with 2:1 or 3:1 block (mean age 75 years). The five year survival was similar in all groups, being 57%, 61%, and 53% in groups 1, 2, and 3 respectively. The presence or absence of bundle branch block did not appear to influence prognosis. In particular, patients in group 1 without bundle branch block did not fare any better than those in group 2 both with and without bundle branch block. One hundred and three of the patients were fitted with pacemakers, the proportion being greatest in group 2. In each group a significantly larger number of paced patients survived than unpaced. The five year survival for all the paced patients in the study was 78% compared with 41% for the unpaced. Since the paced patients were slightly younger than the unpaced two age matched groups of 74 patients each were selected from the paced and unpaced patients, but the five year survival of those paced was still significantly better. It is concluded that in the patients in the present study chronic Mobitz type I block has a similar prognosis to that of Mobitz type II block. Unpaced patients with both types did very badly, whereas those fitted with pacemakers had a five year survival similar to that expected for the normal population. These results refute the benign reputation of chronic Mobitz type I block and imply that patients with this condition should be considered for pacemaker implantation on similar criteria to those adopted for patients with higher degrees of block.

Depression following childbirth--a search for predictive signs.

Potential risk factors for depression after childbirth were correlated with 13 symptoms of depression in a sample of 618 women from 64 general practitioners.Eight significant predictive factors were identified. The most important were stress after the confinement, depression during pregnancy, a severe attack of the ;five-day blues', a history of previous puerperal depression and previous miscarriage.

Fitting hearing aids: the effects of method of instruction.

An experiment was conducted to examine the effect of teaching method, age and sex on older people's ability to fit their hearing aids. Four methods of teaching were examined, three of which used visual material developed in conjunction with the Exeter College of Art. As a result of the experiment self-instruction is the method recommended for use at Hearing Aid Centres as it reduces instructor time, leads to greater success and naturally differentiates those who are having substantial difficulty from those who manage. It can both save technician time and reveal those on whom they need to concentrate their effort. In this way it is evidently the most efficient.

Survival in sinoatrial disorder (sick-sinus syndrome).

A total of 381 patients with established (156) or potential (225) sinoatrial dysfunction were included in a 10-year prospective survey to determine the course of the disease and the benefits of pacing. With the exclusion of nine patients who were lost to follow-up, 61 were fitted with pacemakers. The overall survival of patients with established and potential dysfunction was similar and apparently indistinguishable from that of the normal population. Pacemaker implantation had little discernible effect on mortality though it reduced some incapacitating symptoms. These findings suggest that sinoatrial dysfunction is a relatively benign condition. Hence pacing should probably not be adopted as a routing measure but be reserved for patients with troublesome symptoms.

Out-patient physiotherapy: patterns of provision.

A total of 1014 physiotherapy out-patients and their therapists were interviewed at 10 hospitals in Oxfordshire and Devonshire, including a District General Hospital, a Geriatric, and a sample of associated Community Hospitals in each of the two regions. Over 70% of these patients were suffering from long-term disabilities. The proportion of this type of patient varied between the hospital types, and this variation was similar in the two regions. The overall frequencies with which the different physiotherapy treatments were employed were, for the most part, similar in all departments regardless of hospital type or regions involved. Exercises and heat were the predominant treatments everywhere. The standard frequency of attendance was twice or three times a week. One third of the patients used hospital transport; most patients attended a hospital reasonably close to their homes.

Problems with handling the BE10 series hearing aids among elderly people.

Seven items of activity related to patients' ability to handle behind-the-ear hearing aids (BE11/12) were investigated to establish the effects of age, sex and functional disability. One hundred and thirty-six patients were examined; all were first-time users of hearing aids. Over two-fifths of the sample had problems with manipulating the volume control and over a third had difficulty with inserting the earmould and changing the battery. For both men and women, the difficulties with the volume control and earmould were significantly associated with functional disability. Difficulties with these tasks were also significantly related to age and sex. Patients aged 75 years of age or more had greater difficulties than those who were younger and women had more difficulty than men.

A comparison of trainee and trainer clinical experience.

The results are presented of a survey comparing patients seen in the surgery by trainer and trainee during a six-month attachment.STATISTICALLY SIGNIFICANT DIFFERENCES WERE SHOWN AS FOLLOWS: the trainee saw a younger group of patients, a higher proportion of whom were male; the trainee saw fewer musculoskeletal disorders, fewer gynaecological disorders, and gave less contraceptive care. He saw more acute respiratory tract infections. Despite there being no direction of trainee workload, some of the difference in clinical workload significantly altered over a six-month period. However, trainee and trainer experience of many clinical conditions was not significantly different.We suggest that trainees and trainers should agree at the start of a traineeship on the aspects of clinical care in which experience should be obtained. Regular monitoring of the trainee's clinical workload would then enable deficiencies to be identified and corrected by direction of appropriate patients to the trainee.

Evaluation of follow-up services for elderly people prescribed hearing aids: report of a pilot project.

The first stage of a programme to determine the effectiveness of different types of follow-up service for elderly people prescribed hearing aids is described. Follow-up sessions of two hours each were held at fortnightly intervals and were given to groups comprising six patients. Three treatments were compared, one consisting of two follow-up sessions, the second of four sessions, and the third none (the control group). Two groups received each treatment. The results failed to demonstrate any advantage from the treatments. The men, who were more handicapped by their hearing loss, did better than women and there was a predominance of men in the control groups. The necessity of some follow-up service was demonstrated since a substantial proportion of patients were not utilising their aids satisfactorily at six months after issue and had problems which were then resolved. Any follow-up programme must concentrate very heavily on basic handling and maintenance of the aid, for most of the difficulties experienced were with these.