A crown-group cnidarian from the Ediacaran of Charnwood Forest, UK.

Cnidarians are a disparate and ancient phylum, encompassing corals and jellyfish, and occupy both the pelagic and benthic realms. They have a rich fossil record from the Phanerozoic eon lending insight into the early history of the group but, although cnidarians diverged from other animals in the Precambrian period, their record from the Ediacaran period (635-542 million years ago) is controversial. Here, we describe a new fossil cnidarian-Auroralumina attenboroughii gen. et sp. nov.-from the Ediacaran of Charnwood Forest (557-562 million years ago) that shows two bifurcating polyps enclosed in a rigid, polyhedral, organic skeleton with evidence of simple, densely packed tentacles. Auroralumina displays a suite of characters allying it to early medusozoans but shows others more typical of Anthozoa. Phylogenetic analyses recover Auroralumina as a stem-group medusozoan and, therefore, the oldest crown-group cnidarian. Auroralumina demonstrates both the establishment of the crown group of an animal phylum and the fixation of its body plan tens of millions of years before the Cambrian diversification of animal life.

Winning hearts and minds: ECG reporting in the first seizure clinic.

BACKGROUND AND AIMS: An electrocardiogram (ECG) is a mandatory test for anyone presenting with loss of consciousness. Many referrals to the first seizure clinic (FSC) are caused by syncope. We assessed the sensitivity of neurologists' ECG reporting in detecting rhythm abnormalities including some potentially life-threatening cardiac conditions. METHODS: We audited patients referred to a FSC in Glasgow over 4 years. All ECGs were interpreted by the attending neurologist as standard practice. Subsequently, two cardiologists reviewed the ECGs independently. RESULTS: Of 160 consecutive patients, 92 patients (58%) were diagnosed as having seizures, 43 (27%) as syncope, and 25 (16%) were unclassified. Twenty eight ECGs thought to be normal by the neurologist were considered abnormal by the cardiologist, including three with long corrected QT interval. The proportion of abnormal ECGs and disparity in reporting between neurologists and cardiologists persisted independent of the underlying diagnosis. CONCLUSION: Reporting of ECGs by non-cardiologists may not be adequately sensitive in picking up potentially life threatening cardiac conditions. Cardiologist input into FSCs is recommended to enhance the diagnostic yield.

Adopting seven-day working in practice: a report by the Royal College of Physicians and Surgeons of Glasgow.

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.

Limited clinical utility of CT coronary angiography in a district hospital setting.

BACKGROUND: Studies have demonstrated considerable accuracy of multi-slice CT coronary angiography (MSCT-CA) in comparison to invasive coronary angiography (I-CA) for evaluating coronary artery disease (CAD). The extent to which published MSCT-CA accuracy parameters are transferable to routine practice beyond high-volume tertiary centres is unknown. AIM: To determine the accuracy of MSCT-CA for the detection of CAD in a Scottish district general hospital. DESIGN: Prospective study of diagnostic accuracy. METHOD: One hundred patients with suspected CAD recruited from two Glasgow hospitals underwent both MSCT-CA (Philips Brilliance 40 × 0.625 collimation, 50-200 ms temporal resolution) and I-CA. Studies were reported by independent, blinded radiologists and cardiologists and compared using the AHA 15-segment model. RESULTS: Of 100 patients [55 male, 45 female, mean (SD) age 58.0 (10.7) years], 59 and 41% had low-intermediate and high pre-test probabilities of significant CAD, respectively. Mean (SD) heart rate during MSCT-CA was 68.8 (9.0) bpm. Fifty-seven per cent of patients had coronary artery calcification and 35% were obese. Patient prevalence of CAD was 38%. Per-patient sensitivity, specificity, positive and negative (NPV) predictive values for MSCT-CA were 92.1, 47.5, 52.2 and 90.6%, respectively. NPV was reduced to 75.0% in the high pre-test probability group. Specificity was compromised in patients with sub-optimally controlled heart rates, calcified arteries and elevated BMI. CONCLUSION: Forty-Slice MSCT-CA has a high NPV for ruling out significant CAD when performed in a district hospital setting in patients with low-intermediate pre-test probability and minimal arterial calcification. Specificity is compromised by clinically appropriate strategies for dealing with unevaluable studies. Effective heart rate control during MSCT-CA is imperative. National guidelines should be utilized to govern patient selection and direct MSCT-CA reporter training to ensure quality control.

Secondhand smoke exposure and survival following acute coronary syndrome: prospective cohort study of 1261 consecutive admissions among never-smokers.

OBJECTIVE: To determine whether exposure to secondhand smoke is associated with early prognosis following acute coronary syndrome. DESIGN, SETTING AND PARTICIPANTS: We interviewed consecutive patients admitted to nine Scottish hospitals over 23 months. Information was obtained, via questionnaire, on age, sex, smoking status, postcode of residence and admission serum cotinine concentration was measured. Follow-up data were obtained from routine hospital admission and death databases. RESULTS: Of the 5815 participants, 1261 were never-smokers. Within 30 days, 50 (4%) had died and 35 (3%) had a non-fatal myocardial infarction. All-cause deaths increased from 10 (2.1%) in those with cotinine < or =0.1 ng/ml to 22 (7.5%) in those with cotinine >0.9 ng/ml (chi(2) test for trend p<0.001). This persisted after adjustment for potential confounders (cotinine >0.9 ng/ml: adjusted OR 4.80, 95% CI 1.95 to 11.83, p = 0.003). The same dose response was observed for cardiovascular deaths and death or myocardial infarction. CONCLUSIONS: Secondhand smoke exposure is associated with worse early prognosis following acute coronary syndrome. Non-smokers need to be protected from the harmful effects of secondhand smoke.

The burden of atrial fibrillation in unselected acute medical admissions.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is of increasing prevalence. The presence of AF complicates the management of patients presenting as medical emergencies. OBJECTIVE: To assess the prevalence of AF and current investigation and management strategies in unselected acute medical admissions. DESIGN: Prospective survey of all acute medical admissions over 22 days. SETTING: Stobhill Hospital--district general hospital in north Glasgow. SUBJECTS: Five hundred and seven consecutive acute medical admissions. RESULTS: Of the 507 patients, 47 (9.3%) had AF. AF was a new diagnosis in five patients (11.0%). The most common presenting features were dyspnoea and chest pain. The principal underlying medical conditions were hypertension and ischaemic heart disease. AF was the primary reason for admission in six patients (12.8%) and a documented reason for admission in 11 patients (23.4%). Thyroid function tests were or had previously been performed in 45 patients (95.7%). Twenty-four patients (51.1%) underwent echocardiography or had done so previously. Twenty-two patients (46.8%) received anticoagulation with warfarin. Ten patients (21.3%) should have received warfarin by standard guidelines but did not. No patient received warfarin inappropriately. Rate control was used in 40 patients (85.1%). Rhythm control was attempted in four patients (8.5%). CONCLUSION: AF is common amongst emergency admissions to district general hospitals and has significant resource implications. Improvements are needed both in the use of echocardiography and in the administration of anticoagulant therapy.

Pericardiocentesis practice in the United Kingdom.

BACKGROUND: Pericardial effusions frequently present challenging clinical dilemmas. Whether or not to drain an effusion, and if so by what method, are two common decisions facing cardiologists. We performed a survey to evaluate pericardiocentesis practice in the United Kingdom (UK). METHODS: A total of 640 questionnaires were sent to all cardiologists in the UK Directory of Cardiology in March 2003. RESULTS: A total of 274 (43%) completed questionnaires were returned, 88% from consultants, equally distributed between tertiary referral centres and district general hospitals. More than 1500 procedures were performed, largely using a paraxiphoid approach (89%). Clinical tamponade was the commonest indication for pericardiocentesis (83%). However, the majority of respondents (69%) considered echocardiographic features alone an indication for pericardiocentesis, even in the absence of clinical tamponade. The commonest perceived indications for drainage were right ventricular diastolic collapse and right atrial collapse (69% and 33% of respondents respectively). For guidance, 82% use echocardiography, either alone or with fluoroscopy or the electrocardiogram (ECG) injury trace. 11% employ fluoroscopy alone or with the ECG injury trace. The remaining 11% stated that they would use the ECG injury trace alone or use no guidance. Using the ECG injury trace alone is said by the European Society of Cardiology (ESC) guidelines to offer an inadequate safeguard. Reported complications included ventricular puncture (n = 12, 0.8%) and hepatic damage (n = 4, 0.3%). CONCLUSION: Pericardiocentesis practice varies substantially in the UK. Many cardiologists would perform pericardiocentesis based on echocardiographic features alone. 11% of cardiologists use guidance that is considered inadequate by the ESC guidelines.

Key issues in the management of atrial fibrillation--protecting the patient and controlling the arrhythmia.

Atrial fibrillation (AF) is the most common sustained tachyarrhythmia and its prevalence is increasing. It is an independent risk factor for stroke and is associated with significant morbidity and mortality. AF currently accounts for 1% of NHS expenditure. The management of AF has a broad evidence base and both the American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) and the National Institute for Clinical Excellence (NICE) have recently published guidelines. Some controversy persists regarding stroke risk stratification and appropriate anticoagulation regimes although a general consensus is now emerging. Rate and rhythm control strategies have been shown to be comparable in terms of clinical outcomes. Current anti-arrhythmic drugs have limited efficacy and significant side-effect profiles. Electrophysiological and surgical interventions have a role in both strategies. This article broadly reviews the evidence for different management strategies in AF and presents a practical approach to treatment in light of the recently published national and international guidelines.

Prevalence and prognostic implications of electrocardiographic left ventricular hypertrophy in heart failure: evidence from the CHARM programme.

BACKGROUND: Electrocardiographic left ventricular hypertrophy (ECG LVH) is a powerful independent predictor of cardiovascular morbidity and mortality in hypertension. OBJECTIVE: To determine the contemporary prevalence and prognostic implications of ECG LVH in a broad spectrum of patients with heart failure with and without reduced left ventricular ejection fraction (LVEF). METHODS AND OUTCOME: The Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) programme randomised 7599 patients with symptomatic heart failure to receive candesartan or placebo. The primary outcome comprised cardiovascular death or hospital admission for worsening heart failure. The relative risk (RR) conveyed by ECG LVH compared with a normal ECG was examined in a Cox model, adjusting for as many as 31 covariates of prognostic importance. RESULTS: The prevalence of ECG LVH was similar in all three CHARM trials (Alternative, 15.4%; Added, 17.1%; Preserved, 14.7%; Overall, 15.7%) despite a more frequent history of hypertension in CHARM-Preserved. ECG LVH was an independent predictor of worse prognosis in CHARM-Overall. RR for the primary outcome was 1.27 (95% confidence interval (CI) 1.04 to 1.55, p = 0.018). The risk of secondary end points was also increased: cardiovascular death, 1.50 (95% CI 1.13 to 1.99, p = 0.005); hospitalisation due to heart failure, 1.19 (95% CI 0.94 to 1.50, p = 0.148); and composite major cardiovascular events, 1.35 (95% CI 1.12 to 1.62, p = 0.002). CONCLUSION: ECG LVH is similarly prevalent in patients with symptomatic heart failure regardless of LVEF. The simple clinical finding of ECG LVH was an independent predictor of a worse clinical outcome in a broad spectrum of patients with heart failure receiving extensive contemporary treatment. Candesartan had similar benefits in patients with and without ECG LVH.

WITHDRAWN: Secondary Harmonic Imaging Overestimates Left Ventricular Mass Compared to Fundamental Echocardiography.

The publisher regrets that this was an accidental duplication of an article that has already been published in Eur. J. Echocardiogr., 4 (2003) 178-181, . The duplicate article has therefore been withdrawn.

Plastic baton round injuries.

OBJECTIVES: To review the injuries resulting from a new plastic baton round. METHODS: Review of case notes of patients presenting with injuries caused by plastic baton rounds over a four month period in Northern Ireland. RESULTS: Twenty nine patients were identified, 28 with 30 injuries were included in the study. Eighty nine per cent were male; the average age was 24.3 years. Seven patients required admission. There were no fatalities. Five injuries were to the upper limbs and 16 to the lower limbs. Three patients sustained pulmonary contusions. There were no head injuries. CONCLUSIONS: Although the numbers in this study are small it should be noted that no patient suffered a face, neck, or head injury. This is in contrast with previous studies in which up to 41.4% of attendances were for face, neck, or head injuries. In this study there were seven injuries to the trunk. Of the 14 deaths attributable to plastic baton rounds in Northern Ireland, all have been the result of head or chest trauma. The use of plastic baton rounds has decreased and, while a reduction in head injuries is noted, potentially serious chest injuries are still occurring. It is vital that guidelines on firing are adhered to. A large proportion of people who have been struck by plastic baton rounds do not attend an accident and emergency department and therefore doctors must be aware of patients with potentially serious injuries presenting late.

Team triage improves emergency department efficiency.

OBJECTIVE: To see whether three hours of combined doctor and nurse triage would lead to earlier medical assessment and treatment and whether this benefit would carry on for the rest of the day when normal triage had resumed. METHOD: Eight days were randomly selected; four for team triage and four for the normal nurse led triage. Team triage was coordinated by a middle grade or consultant from 9 am to 12 noon. Times to triage, to see a doctor, radiology, admission, and discharge were recorded. No additional medical or nursing staff were used and staffing levels were similar each day. All patients including blue light emergencies and minor injuries were included. RESULTS: Median times were significantly reduced (p<0.05) during the intervention to triage (2 min v 7 min, p = 0. 029), to see a doctor (2 min v 32 min, p = 0.029), and to radiology (11.5 min v 44.5 min, p = 0.029). Waiting times at midday were longer for patients in the non-intervention group. More patients were seen and discharged within 20 minutes in the intervention group (18 of 95 (19%) v 2 of 69 (3%) p = 0.0043). No significant knock on effect was demonstrable for the remaining 21 hours after the intervention ceased. CONCLUSION: Three hours of combined doctor and nurse triage significantly reduces the time to medical assessment, radiology, and to discharge during the intervention period. Waiting times at midday were shorter in the triage group. There was no significant knock on effect the rest of the day.

Secondary harmonic imaging overestimates left ventricular mass compared to fundamental echocardiography.

AIMS: The significance of left ventricular hypertrophy in hypertension is well documented, being an independent risk factor for cardiovascular morbidity and mortality. Normal values for left ventricular mass and partition values for left ventricular hypertrophy come from measurements obtained by fundamental echocardiography. Secondary harmonic imaging improves definition of cardiac borders. We hypothesise that this overestimates left ventricular mass compared to fundamental imaging. METHODS AND RESULTS: Thirty patients had four parasternal long-axis M-modes performed, two using 1.7 mHz output frequency, receiving at two octaves higher and two using fixed frequency of 2.5 mHz (fundamental imaging). Absolute left ventricular mass and left ventricular mass index were calculated for each modality. Intra-observer variability was <7%. Range on fundamental imaging was 54-264 g/m2 compared to 80-293 g/m2 on secondary harmonic imaging. Mean left ventricular mass index for the group was 118 g/m2 (fundamental imaging) vs 147 g/m2, P<0.001. Twenty-nine of 30 patients had higher left ventricular mass index on secondary harmonic imaging compared to fundamental imaging. Left ventricular mass index was an average of 26% higher on secondary harmonic imaging, range (-7 to 65%) corresponding to average absolute left ventricular mass difference of 55 g. Eleven of 30 patients had left ventricular hypertrophy on fundamental imaging and 17/30 on secondary harmonic imaging. CONCLUSION: Secondary harmonic imaging overestimates left ventricular mass index compared to fundamental imaging. Normal left ventricular mass index range is based on equations using fundamental imaging measurements. Management decisions and prognostic implications made on the basis of raised left ventricular mass index using secondary harmonic imaging should be done so with caution.

Rapid access chest pain clinics--can they be justified?

Rapid access chest pain clinics are expanding across the country with marked resource implications despite a paucity of data regarding their efficacy. Early assessment of patients in this manner potentially delays review of patients referred via the traditional route. We conducted a prospective observational study of patients referred with chest pain to the Cardiology Outpatient Department over a four-week period in a District General Hospital to compare demographics and outcomes in patients referred to the rapid access with those referred to the general cardiology clinics. There were no significant differences in baseline demographics, exercise test result or clinic outcome. Both populations were low risk. Discussion is needed between primary and secondary care to achieve a consensus as to the purpose of a rapid access system and how best to utilise the service appropriately. Further studies are required to assess the efficacy and health economics of this system.

Two cases of biceps injury in bodybuilders with initially misleading presentation.

Two cases are reported of biceps injuries in body builders. In both cases the mechanism of injury is either unclear or initially misleading. One case went on to develop necrotising fasciitis, requiring extensive debridement after an initial diagnosis of a biceps haematoma. This report emphasises the difficulties inherent in differentiating necrotising and non-necrotising infections in the emergency department setting and highlights a subgroup of patients who may be at particular risk of delayed diagnosis.