Suspected cardiac syncope in elderly patients: use of the 12-lead electrocardiogram to select patients for holter monitoring.

BACKGROUND: Results of 24-hour Holter monitoring in elderly patients are often unhelpful, since the prevalence of asymptomatic arrhythmias increases and their prognostic significance is unclear. We investigated the value of the resting electrocardiogram (ECG) in predicting significant findings on 24-hour Holter recordings in those suspected of having cardiac syncope. OBJECTIVE: To see whether the resting 12-lead ECG can be used as a screening tool to select elderly patients suspected of having cardiac syncope for 24-hour ECG monitoring. METHOD: Comparison of resting 12-lead ECGs and 24-hour Holter tapes in 145 consecutive elderly outpatients suspected of having a cardiac cause for falls, dizziness, or syncope. RESULTS: Four of 30 normal ECGs (13%) showed an abnormality on Holter monitoring as compared with 55 of the 115 abnormal ECGs (47.8%; chi = 11.7143, p < 0.005). In the 'normal' group the 4 abnormal Holter recordings all showed short runs of supraventricular tachycardia, and no intervention resulted. The 115 abnormal resting ECGs showed either ischaemia (n = 27), dysrhythmia (n = 28), sinus bradycardia (n = 22), or conduction defects (n = 38). The 55 of these which showed abnormalities on Holter recordings occurred mostly where the resting ECG showed dysrhythmia (n = 14/28; 50%), bradycardia (n = 19/22; 86.4%), and conduction defect (n = 17/38; 44.7%). Seven patients had complete heart block on Holter, and all had conduction defects on resting ECG (p < 0.0004). Fifteen patients had pauses of longer than 3 s on Holter; all had conduction defect, bradycardia, or dysrhythmias on resting ECG (p < 0.0045). Sixteen patients were paced because of complete heart block or pauses on Holter recordings, and all had either bradycardia or conduction defects on resting ECG, resulting in complete resolution of their symptoms. CONCLUSIONS: Patients with suspected cardiac syncope and normal resting ECGs are unlikely to reveal significant abnormalities on single 24-hour Holter monitoring. Cardiac event recorder or prolonged Holter monitoring may be required in patients with strong clinical history. Those with abnormal ECGs, in particular sinus bradycardia and conduction defects, are highly likely to have significant abnormalities on 24-hour ECG monitoring.

Screening for acute myocardial infarction in elderly patients with collapse, confusion and falls.

Falls, collapse and confusion are frequent causes of admission to hospital in the elderly, and myocardial infarction (MI) can present atypically. The study was designed to assess the incidence of MI in this group of patients and provide information on the value of screening methods. A total of 142 elderly patients with a mean age of 83 years (range 76-99) were admitted with unexplained collapse, confusion or falls. Serial ECGs and cardiac enzymes were performed. Eighty-two patients (59%) had normal ECGs; of these, 80 (98%) had normal or non-significantly elevated cardiac enzymes; 72/108 patients without chest pain had normal ECGs compared with 10/32 who had chest pain (p < 0.01). Cardiac enzymes were elevated in 5/108 without chest pain and 10/32 with chest pain (p < 0.01). Thirty-two (23%) had chest pain, 14 (10%) had an acute MI. In those presenting with chest pain, 32% had an MI, compared with only 1.9% of those without chest pain (p < 0.01); 18% of patients with an initially abnormal ECG had an MI compared with only 5% of those with a normal ECG (p = 0.02). None of the patients with a normal ECG who were free of chest pain were subsequently proven to have an MI. Cardiac enzymes are often non-specifically elevated in this group of patients due to muscle injury. The incidence of MI is low in patients without chest pain and we would not advocate routine screening with serial cardiac enzymes, unless there is chest pain or an abnormal 12-lead ECG on admission.

Effects of bekh-k-karafs (apium graveolens linn) root on central nervous systme.

Bekh-e-Karafs has been reported to be effective in a number of ailments in Unani system of medicine. The aqueous extract of the drug was screened for C.N.S. depressant, anti-convulsant and analgesic activities. The central depressant and analgesic activities of the drug were found to be significant while anti-convulsant activity was found to be insignificant. The results are reported here.

A prospective study of dysplasia and carcinoma in the rectal biopsies and rectal stump of eight patients following ileorectal anastomosis in ulcerative colitis.

The present study concerns eight patients with ulcerative colitis treated by total colectomy and ileorectal anastomosis and subjected to follow-up rectal biopsies who later developed precancer (two cases) or carcinoma in the retained rectum. We report the results of the biopsies and the detailed mapping of lesions in the resected rectal stump to highlight certain features which may lead to increased detection rate of early malignancy. Two groups of patients emerged. Group A: in all four cases the follow-up biopsies showed increasing severity of dysplasia; altered mucin secretion with predominance of sialomucins was seen in the biopsies even in the absence of inflammation or dysplasia; the biopsy findings (morphological and secretory) mirrored those observed in the rectal stump; in three, the lesions were villous polypoid growths, of which two were invasive carcinomas. Group B: in none of the cases was dysplasia seen in the biopsies and mucus secretion was normal; similar features were seen in the rectal stump; all had invasive carcinoma of which three were flat ulcerated lesions. The different behaviour of carcinoma in the two groups almost certainly reflects the different tumour phenotype characteristics and this is a matter for further study. From the practical point of view we emphasize the risk of relying on biopsy evidence of dysplasia alone as an indicator of malignancy and the need for additional immunological or histochemical tests to assess the individual risk of cancer in colitis.

The effect of secoverine hydrochloride on stimulated sigmoid motility: a double-blind, placebo controlled cross-over study in irritable bowel syndrome.

The effect of oral secoverine hydrochloride on neostigmine-stimulated sigmoid motility in 12 patients with irritable bowel syndrome was studied in a double-blind placebo-controlled cross-over study. Both spontaneous and stimulated motor activity were significantly reduced by the compound in comparison with placebo. The most sensitive indices were the frequency of wave activity, maximum amplitude and motility index. Two patients reported mild dizziness after secoverine.

Sialomucins in the assessment of dysplasia and cancer-risk patients with ulcerative colitis treated with colectomy and ileo-rectal anastomosis.

The clinical notes and histology of 374 patients treated by colectomy and ileo-rectal anastomosis for ulcerative colitis were reviewed. Only those with definite diagnosis of ulcerative colitis and follow-up rectal biopsies were included (171 cases). Morphology and patterns of mucin secretion were investigated to assess whether abnormal mucin with predominance of sialomucins is a useful indicator of malignancy-risk. Carcinoma has developed in six patients and 'precancer' in seven. The results show coexistence of dysplasia and sialomucin even in the absence of inflammation in all but three biopsies; in contrast the presence of both dysplasia and normal mucin profile was found in less than 1%. A significant correlation was noted between an inflamed mucosa and the development of cancer or precancer, the presence of sialomucins and the appearance of dysplasia. Sialomucins showed a greater sensitivity in detecting cancer than dysplasia (75% versus 30%). However, dysplasia was notably more specific (94% compared with 50%), hence its greater predictive value as indicator of malignancy (50% as against 15% for a positive sialomucin result). Mucin stains on routine fixed paraffin-embedded tissue provide a simple screening method to sharpen the assessment of dysplasia and cancer-risk in patients with ulcerative colitis despite the limitations referred to above. The lack of definite evidence of dysplasia in four patients who developed malignancy without premalignant changes in the rectal biopsies emphasises the need for frequent multiple biopsies in patients with an ileo-rectal anastomosis for ulcerative colitis.

Mucin secretion in inflammatory bowel disease: correlation with disease activity and dysplasia.

When rectal biopsies from 65 patients with ulcerative colitis and 20 patients with Crohn's disease was stained for mucins, an abnormal pattern (excess of sialomucins) was seen in about half of them. This is in contrast with 65 cases of non-specific proctitis where the mucin pattern of rectal biopsies was normal in all except one case. The abnormal mucin secretion in patients with ulcerative colitis was apparently related to the activity, duration, and extent of the disease. All biopsies with dysplasia showed predominant sialomucin staining except one. All biopsies showing sialomucins during remission also had dysplasia, while during active disease a number of biopsies had increased sialomucins without the evidence of dysplasia. It is not known if such cases will subsequently develop morphological atypia.

Morphological and mucus secretion criteria for differential diagnosis of solitary ulcer syndrome and non-specific proctitis.

Over a four-year period 21 cases of solitary ulcer syndrome (SUS) were studied for their clinical, histological, and mucus secretion patterns and compared with histological and mucus secretion patterns of 78 cases of non-specific proctitis collected over the same period. Normal mucus composition was found in non-specific proctitis while abnormalities of mucins with predominance of sialomucins were associated with SUS. Although histology remains the most important investigation in the diagnosis of SUS, mucin changes provide valuable additional evidence.