ABSTRACT
Postural changes in 258 patients with pulmonary arteriovenous malformations (PAVMs) reviewed between 2005 and 2013 were evaluated prospectively using validated pulse oximetry methods. Of the 257 completing the test, 75 (29%) demonstrated orthodeoxia with an oxygen saturation fall of at least 2% on standing. None described platypnoea (dyspnoea on standing). The heart rate was consistently higher in the erect posture: 74 (29%) had a postural orthostatic tachycardia of ≥20â min(-1), and in 25 (10%) this exceeded 30â min(-1). Orthostatic tachycardia was more pronounced in PAVM patients than controls without orthodeoxia (age-adjusted coefficient 5.5 (95% CIs 2.6, 8.4) min(-1), p<0.001). For PAVM patients, the age-adjusted pulse rise was 0.79â min(-1) greater for every 1% greater drop in oxygen saturation on standing (p<0.001). In contrast to the postural orthostatic tachycardia syndrome, in this population, there was a trend for more pronounced orthostatic tachycardia to be associated with better exercise tolerance.
Subject(s)
Arteriovenous Fistula/complications , Heart Rate/physiology , Posture , Pulmonary Artery/abnormalities , Pulmonary Veins/abnormalities , Tachycardia/etiology , Adolescent , Adult , Aged , Aged, 80 and over , Arteriovenous Fistula/diagnosis , Arteriovenous Fistula/physiopathology , Female , Follow-Up Studies , Humans , Male , Middle Aged , Oximetry , Prospective Studies , Pulmonary Artery/physiopathology , Pulmonary Veins/physiopathology , Tachycardia/diagnosis , Tachycardia/physiopathology , Time Factors , Young AdultABSTRACT
Following induction of general anaesthesia for emergency caesarean section the trachea could not be intubated, and ventilation was established only following two cricothyroidotomies. The baby was delivered unimpaired, and tracheostomy subsequently performed. On the intensive care unit, maternal cardiorespiratory variables were satisfactory, although surgical emphysema of the face and neck became apparent. Increasing abdominal distension was relieved by suction to a pelvic drain. Radiographs revealed bilateral pneumothoraces, pneumomediastinum and pneumoperitoneum, which were resolved by intrapleural drainage.
ABSTRACT
We describe a 'one-stop' cholesterol clinic implementing a regime based on the Scandinavian Simvastatin Survival Study (4S) in patients with established coronary heart disease in a district general hospital. The clinic has been established in collaboration with the cardiac rehabilitation centre. It was commissioned as an audit project by the purchasing authority, Walsall Health, a need having been shown in a previous audit. In the new clinic, audit is inbuilt, rather than being carried out as a separate retrospective exercise, and undertaken prospectively for all patients. Central to this is a database, used for routine correspondence and administration, as well as monitoring outcome. This application of information technology has improved clinical practice. Attendance at the clinic has been excellent. Half the consultations have resulted in therapeutic interventions, many of which may otherwise have been missed. Over 50% of patients were eligible for lipid-lowering medication under the protocol. Cholesterol targets based on 4S were achieved but with much lower drug doses, which may have major cost implications. Cholesterol levels measured within 24 hours of admission for myocardial infarction were poor predictors of results obtained after convalescence. After the clinic visit, most patients were taking aspirin plus one or two other secondary prevention treatments. Guidelines have been issued to primary care. Future plans for audit links with general practitioners, integration of the metabolic and cardiological assessment of survivors of myocardial infarction, and for long-term monitoring of clinical events in treated patients are discussed.
Subject(s)
Anticholesteremic Agents/therapeutic use , Cholesterol/blood , Coronary Disease/blood , Evidence-Based Medicine , Outpatient Clinics, Hospital , Aged , Coronary Disease/prevention & control , England , Female , Humans , Hypercholesterolemia/diagnosis , Hypercholesterolemia/drug therapy , Long-Term Care/organization & administration , Male , Medical Audit/organization & administration , Middle Aged , Myocardial Infarction/blood , Patient Care Team/organization & administration , Risk FactorsABSTRACT
We report a prospective double-blind trial of the efficacy of a single epidural dose of buprenorphine on pain after spinal decompression. Postoperative pain was assessed by a linear analogue pain chart and by the additional requirement for analgesia. The patients receiving buprenorphine were significantly more comfortable (p less than 0.005) and required less analgesia in the first 12 hours after operation (p less than 0.05) than the control group. This simple procedure is recommended as an effective and safe method of reducing pain.
