Speech pathologists' experiences with stroke clinical practice guidelines and the barriers and facilitators influencing their use: a national descriptive study.

BACKGROUND: Communication and swallowing disorders are a common consequence of stroke. Clinical practice guidelines (CPGs) have been created to assist health professionals to put research evidence into clinical practice and can improve stroke care outcomes. However, CPGs are often not successfully implemented in clinical practice and research is needed to explore the factors that influence speech pathologists' implementation of stroke CPGs. This study aimed to describe speech pathologists' experiences and current use of guidelines, and to identify what factors influence speech pathologists' implementation of stroke CPGs. METHODS: Speech pathologists working in stroke rehabilitation who had used a stroke CPG were invited to complete a 39-item online survey. Content analysis and descriptive and inferential statistics were used to analyse the data. RESULTS: 320 participants from all states and territories of Australia were surveyed. Almost all speech pathologists had used a stroke CPG and had found the guideline "somewhat useful" or "very useful". Factors that speech pathologists perceived influenced CPG implementation included the: (a) guideline itself, (b) work environment, (c) aspects related to the speech pathologist themselves, (d) patient characteristics, and (e) types of implementation strategies provided. CONCLUSIONS: There are many different factors that can influence speech pathologists' implementation of CPGs. The factors that influenced the implementation of CPGs can be understood in terms of knowledge creation and implementation frameworks. Speech pathologists should continue to adapt the stroke CPG to their local work environment and evaluate their use. To enhance guideline implementation, they may benefit from a combination of educational meetings and resources, outreach visits, support from senior colleagues, and audit and feedback strategies.

Aubrey Leatham and the introduction of cardiac pacing to the UK.

In the early 1950s, Dr Aubrey Leatham established a cardiac unit at St. George's Hospital, Hyde Park Corner, London. He developed and taught the essential clinical skill of cardiac auscultation. Under his guidance a clinical department for the care of cardiac patients was developed and coupled to physiological academic research. He was a pioneer in cardiac pacing and, in 1961, Harold Siddons, O'Neal Humphries, and Aubrey Leatham implanted the first 'indwelling' pacemaker in the UK in a 65-year-old man with repeated Stokes-Adams attacks due to complete heart block. The nickel-cadmium 'accumulator', which powered the pacemaker, had to be recharged once a week.

A complicated chinese herbal medicine nephrotoxicity.

Chinese herbal medicine is widely used globally. In many instances, it is associated with severe adverse outcomes. We report case of a Chinese herbal nephropathy occurring in a 43-year-old woman showing renal impairment, metabolic acidosis, Stokes - Adams syndrome, hypernatremia, and hypokalemia, characteristics not usually encountered in published cases.

Paroxysmal Ventricular Standstill: A Rare Cardiac Manifestation of Syncope.

BACKGROUND Transient abrupt loss of consciousness due to sudden but pronounced decrease in cardiac output caused by a change in heart rate and rhythm is termed Stokes-Adams disease. Causes of Stokes-Adams syndrome are 1) transition from normal rhythm to high grade block, 2) slowing of idioventricular rhythm in the course of complete heart block, and 3) abnormal ventricular rhythm such as ventricular tachycardia and ventricular fibrillation. Paroxysmal ventricular standstill is one of the rarest causes of Stokes-Adams attack. It is well documented that some patients with a diagnosis of epilepsy actually have a cardiac cause for their convulsions. Brevity of these episodes sometimes makes diagnosis difficult. CASE REPORT We present a case of 40-year-old builder who was normally fit and healthy who developed paroxysmal ventricular standstill. He presented to the Emergency Department with multiple episodes of seizure-like activity. Blood tests which included antibody screen were normal except for hypophosphatemia. Computed tomography head scan was normal. He was commenced on intravenous phenytoin infusion which did not abort his seizure-like episodes. Eventually, ventricular standstill was recorded on cardiac monitoring. The seizure-like episodes were determined to be Stokes-Adams attacks. He underwent transcutaneous pacing and then transvenous pacing with eventual permanent pacemaker insertion. He did not have further episodes at yearly follow-up. CONCLUSIONS This case serves as a reminder of the diagnostic dilemma between syncope and seizures. Misdiagnosing cardiac dysrhythmia for epilepsy could lead to adverse consequences for the patient. It is incumbent upon the emergency physician to perform cardiac monitoring on all patients who present with syncope or convulsion in order that dysrhythmia is observed during such episode.

Empagliflozin and Cardiovascular and Kidney Outcomes across KDIGO Risk Categories: Post Hoc Analysis of a Randomized, Double-Blind, Placebo-Controlled, Multinational Trial.

BACKGROUND AND OBJECTIVES: In the Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG Outcome), empagliflozin, in addition to standard of care, significantly reduced risk of cardiovascular death by 38%, hospitalization for heart failure by 35%, and incident or worsening nephropathy by 39% compared with placebo in patients with type 2 diabetes and established cardiovascular disease. Using EMPA-REG Outcome data, we assessed whether the Kidney Disease Improving Global Outcomes (KDIGO) CKD classification had an influence on the treatment effect of empagliflozin. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Patients with type 2 diabetes, established atherosclerotic cardiovascular disease, and eGFR≥30 ml/min per 1.73 m2 at screening were randomized to receive empagliflozin 10 mg, empagliflozin 25 mg, or placebo once daily in addition to standard of care. Post hoc, we analyzed cardiovascular and kidney outcomes, and safety, using the two-dimensional KDIGO classification framework. RESULTS: Of 6952 patients with baseline eGFR and urinary albumin-creatinine ratio values, 47%, 29%, 15%, and 8% were classified into low, moderately increased, high, and very high KDIGO risk categories, respectively. Empagliflozin showed consistent risk reductions across KDIGO categories for cardiovascular outcomes (P values for treatment by subgroup interactions ranged from 0.26 to 0.85) and kidney outcomes (P values for treatment by subgroup interactions ranged from 0.16 to 0.60). In all KDIGO risk categories, placebo and empagliflozin had similar adverse event rates, the notable exception being genital infection events, which were more common with empagliflozin for each category. CONCLUSIONS: The observed effects of empagliflozin versus placebo on cardiovascular and kidney outcomes were consistent across the KDIGO risk categories, indicating that the effect of treatment benefit of empagliflozin was unaffected by baseline CKD status. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: EMPA-REG OUTCOME, NCT01131676.

Convulsive syncope: a condition to be differentiated from epilepsy.

The clinical presentation of epilepsy and syncope can be confusingly similar. We present a patient with reflex syncopal episodes that mimic seizures using video-EEG recordings. During the episodes, head/eye deviations, automatisms and dystonic movements, suggesting an epileptic seizure, were observed. The EEG revealed diffuse slow waves when the patient lost consciousness and complete cessation of the cerebral activity occurred when the dystonic movements started. On ECG recordings, bradycardia, followed by complete asystolia lasting for 40 seconds, was observed. We conclude that the differential diagnosis of epilepsy and syncope can be quite misleading and clinical features may not always be reliable. In cases where diagnosis is uncertain, circulatory and cardiac causes should always be kept in mind and video-EEG with simultaneous cardiac recordings are mandatory for accuracy of diagnosis.

Hemiblocks revisited.

The trifascicular nature of the intraventricular conduction system and the concept of trifascicular block and hemiblock were described by Rosenbaum and his coworkers in 1968. Since then, anatomic, pathological, electrophysiological, and clinical studies have confirmed the original description and scarce advances have been developed on the subject. In the present study, we attempt to review and redefine reliable criteria for the electrocardiographic and vectorcardiographic diagnosis of left anterior and posterior hemiblock. One of the most important problems related to hemiblocks is that they may simulate or conceal the electrocardiographic signs of myocardial infarction or myocardial ischemia and may mask or simulate ventricular hypertrophy. Illustrative examples of these associations are shown to help the interpretation of electrocardiograms. The incidence and prevalence of the hemiblocks is presented based on studies performed in hospital patients and general populations. One of the most common causes of hemiblocks is coronary artery disease, and there is a particularly frequent association between anteroseptal myocardial infarction and left anterior hemiblock. The second most important cause is arterial hypertension, followed by cardiomyopathies and Lev and Lenègre diseases. The hemiblocks may also occur in aortic heart disease and congenital cardiopathies. Left anterior hemiblock is more common in men and increases in frequency with advancing age. Evidence is presented regarding the relationship of spontaneous closure of ventricular septal defects, which may explain the finding of this and other conduction defects in young populations. Isolated left anterior hemiblock is a relatively frequent finding in subjects devoid of evidence of structural heart disease. Conversely, isolated left posterior hemiblock is a very rare finding; its prognostic significance is unknown and is commonly associated with right bundle-branch block. The most remarkable feature of this association is that the prognosis is much more serious with a great propensity to develop complete atrioventricular block and Adams-Stoke seizures.

Cardiac pacemaker treatment of heart block in Enugu a 5-year review.

BACKGROUND: Symptomatic heart block is a treatable cardiac cause of death which occurs globally. In Nigeria it is increasingly diagnosed and treated with permanent artificial cardiac pacemaker insertion and pulse generator implantation, sometimes after a period of misdiagnosis and inappropriate treatment. METHODS: Twenty-three patients who were diagnosed with symptomatic heart block and surgically treated with permanent artificial cardiac pacemaker in National Cardiothoracic Centre, Enugu, between April 2001 and March 2006 had their case notes retrospectively reviewed and information entered into a proforma. This was analyzed. Patients diagnosed with symptomatic heart block but not treated with artificial cardiac pacemaker insertion were excluded from the study. There were eight such patients who could not afford the cost of surgical treatment during the period under review. RESULTS: The mean age of the patients was 70 years and the commonest presentation was shortness of breath (100%). Hypertensive heart disease was present in 65% of the patients and a history of chronic chloroquine usage was positive in 73% of the patients. Predominant pretreatment pulse rate was in the range of 30-40 per minute (43%) while 21% of the patients had pulse rate below 30 per minute. These categories of patients commonly had Stoke-Adams syndrome. Sixty-seven per cent of the patients had predominantly systolic hypertension on admission and 16% had hypotension. Third degree heart block was present in 65% of the patients and 89% of all patients needed pre-pacing haemodynamic stabilization with positive inotropic/chronotropic drug(s). Treatment consisted of permanent endocardial pacing in 65% and epicardial pacing in 35% of the patients with equally good response in symptoms, haemodynamic parameters and electrocardiographic features. CONCLUSION: Permanent artificial cardiac pacing is, the reliable treatment of symptomatic heart block and should be included in the National Health Insurance Scheme list.

Unrecognized paroxysmal ventricular standstill masquerading as epilepsy: a Stokes-Adams attack.

Recognition of cardiac syncope masquerading as epilepsy may be difficult in the Emergency Department. We report a middle-aged man with recent onset convulsions who posed a diagnostic puzzle before it was found that he had paroxysmal ventricular standstill with complete atrioventricular block: he made a complete recovery after temporary pacemaker insertion. The main lessons from this case were (1) a convulsive seizure of only seconds duration and with an abrupt return of consciousness suggests syncope not epilepsy, (2) repeated, convulsive syncopes without provocation suggest cardiac syncope, (3) a 12-lead ECG should be recorded as soon as possible after such a series of episodes and should not be discontinued until an event is captured, and (4) Emergency Department clinicians should be familiar with any automatic gain on their ECG machine, lest fast, atrial activity be mistaken for narrow complex tachycardia. In summary, a good clinical history is of prime importance in differentiating convulsive syncope from epilepsy, and a simple, non-invasive cardiovascular evaluation may help to diagnose the condition as cardiac syncope.

Eponymous doctors associated with Edinburgh, Part 2--David Bruce, John Cheyne, William Stokes, Alexander Monro Secundus, Joseph Gamgee.

This, the second in a three-paper series with this title, looks at famous doctors who trained in Edinburgh and their eponyms. With one possible exception, none seems to have sought the eponym, nor awarded it to themselves, nor used it for self-promotion. Unlike those in the first paper, all eponyms in this paper are still in use and their brevity is in contrast to the lengthy description needed if the eponym is not used. Examples are Cheyne-Stokes respiration, Stokes-Adam attacks, Brucellosis and Gamgee dressing. Monro Secundus is included because of his vehement defence of his professional reputation and research findings when he suspected others of trying to detract credit from him, a characteristic seldom reported for the others.

[Morgagni-Adams-Stokes after adenosine injection in a patient with WPW syndrome--a case report]. / Zespól Morgagni-Adams-Stockesa po wstrzyknieciu adenozyny u pacjentki z zespolem WPW.

A case of a 16-year-old girl with left sided accessory pathway is presented. Following adenosine-induced termination of atrio-ventricular reentrant tachycardia the patient developed polymorphic ventricular tachycardia followed by preexcited atrial fibrillation with very rapid ventricular response and syncope. Arrhythmia was terminated by amiodarone infusion. Potential complications after adenosine injection are discussed.

Heart block and hyperthyroidism. Report of two cases.

In two patients with hyperthyroidism who had no signs of heart disease, first-degree heart block with tall and large P waves occurred. In one patient, a left bundle-branch block and transient complete heart block with Stokes-Adams episodes also occurred, although there was no verifiable evidence of acute inflammatory disease.

[Variant angina pectoris associated with Morgagni-Adams-Stokes syndrome--case report]. / Wazospastyczna postac dusznicy bolesnej z towarzyszacym zespolem Morgagniego- Adamsa-Stokesa--opis przypadku.

We report a case of Prinzmetal angina initially manifested with short losses of consciousness in a 55-year-old man hospitalized in the Department of Coronary Artery Disease, Institute of Cardiology, Jagiellonian University Medical College in Cracow. Clinical symptomatology of the presented case, causes and mechanism of loss of consciousness in variant angina as well as treatment methods are discussed.

Ventricular overdrive suppression of idioventricular rhythm in patients with complete heart block.

Idioventricular rate, QRS width, site of block and responses to ventricular overdrive pacing were studied in 29 patients with chronic complete heart block in an attempt to distinguish patients liable to syncopal attacks. Ten patients were asymptomatic, 5 gave a history of presyncope and 14 of syncope. Although the mean idioventricular rate of the 10 patients in the narrow QRS group (40.0 per min) was significantly faster than that of the 19 patients in the wide QRS group (35.5 per min; P less than 0.02), the rate did not distinguish symptomatic patients in either the narrow or the wide QRS groups. His bundle studies of the site of block were also unhelpful. Overdrive right ventricular pacing at increasing rates was used to assess ventricular escape times which were not significantly different in symptomatic and asymptomatic wide QRS patients. There was, however, a significant difference in the product of maximum ventricular escape time X overdrive cycle length between symptomatic and asymptomatic narrow QRS patients after 30 s overdrive (3.850+/-1.670 vs 1.070+/-0.475; P less than 0.01); 60 s overdrive (5.020+/-2.170 vs 1.240+/-0.515; P less than 0.01) and 120 s overdrive (6.040+/-2.900 vs 1.460+/-0.275; P less than 0.01) which may have clinical predictive values.

Effect of ventricular extrasystoles on idioventricular rhythm in patients with complete heart block.

Idioventricular rate, QRS width, site of block and responses to premature ventricular stimulation were studied in 23 patients with chronic complete heart block in an attempt to distinguish patients liable to syncopal attacks. Seven patients were asymptomatic, five gave a history of presyncope and 11 of syncope. Although the mean idioventricular rate of the nine patients in the narrow QRS group (39.7 per min) was significantly faster than that of the 14 patients in the wide QRS group (35.3 per min; P less than 0.05), the rate did not distinguish symptomatic patients within either the narrow or the wide QRS groups. His bundle studies of the site of block and the effect of single and paired right ventricular stimulation upon idioventricular rhythm were also unhelpful. The response of the return cycle to increasingly premature ventricular extrasystoles, however, proved more complex than was anticipated.

Emergency Physician Attitudes, Preferences, and Risk Tolerance for Stroke as a Potential Cause of Dizziness Symptoms.

INTRODUCTION: We evaluated emergency physicians' (EP) current perceptions, practice, and attitudes towards evaluating stroke as a cause of dizziness among emergency department patients. METHODS: We administered a survey to all EPs in a large integrated healthcare delivery system. The survey included clinical vignettes, perceived utility of historical and exam elements, attitudes about the value of and requisite post-test probability of a clinical prediction rule for dizziness. We calculated descriptive statistics and post-test probabilities for such a clinical prediction rule. RESULTS: The response rate was 68% (366/535). Respondents' median practice tenure was eight years (37% female, 92% emergency medicine board certified). Symptom quality and typical vascular risk factors increased suspicion for stroke as a cause of dizziness. Most respondents reported obtaining head computed tomography (CT) (74%). Nearly all respondents used and felt confident using cranial nerve and limb strength testing. A substantial minority of EPs used the Epley maneuver (49%) and HINTS (head-thrust test, gaze-evoked nystagmus, and skew deviation) testing (30%); however, few EPs reported confidence in these tests' bedside application (35% and 16%, respectively). Respondents favorably viewed applying a properly validated clinical prediction rule for assessment of immediate and 30-day stroke risk, but indicated it would have to reduce stroke risk to <0.5% to be clinically useful. CONCLUSION: EPs report relying on symptom quality, vascular risk factors, simple physical exam elements, and head CT to diagnose stroke as the cause of dizziness, but would find a validated clinical prediction rule for dizziness helpful. A clinical prediction rule would have to achieve a 0.5% post-test stroke probability for acceptability.

Arrhythmias and Stokes-Adams attacks in acute rheumatic fever.

In spite of general complacency about first-degree heart block in acute rheumatic fever, abnormal conduction with dysrhythmias, occasional complete heart block, and, rarely, Stokes-Adams attacks are important early signs of acute rheumatic fever and may precede other signs. Every person with episodic fainting is entitled to an ECG, and frequent ECGs are imperative in any case of rheumatic fever with signs of arrhythmias. Changing atrioventricular block necessitates continuous monitoring for dysrhythmias. A 13-year-old boy who appeared with Stokes-Adams attacks secondary to acute rheumatic fever was successfully treated by temporary pacing.

Adams-Stokes seizures due to ventricular tachydysrhythmias in patients with heart block: prevalence and problems of management.

One hundred and twelve patients with heart block and chronic tendency to syncope were ECG-monitored during syncope. Ventricular tachycardia and/or fibrillation (VT-VF) was observed as the cause of syncope in 11 patients: in 6 of 20 patients with chronic third degree A-V block, in 3 of 65 with paroxysmal A-V block and in 2 of 27 with S-A block. The R-R interval preceding the escape beat which initiated VT-VF varied between 1.2 and 2.2 seconds. The cerebral attacks were amenable to long-term pacemaker treatment. However, relapses of VT-VF were observed during pacing with a low rate of 55 per minute and during short interruptions in pacing, as produced by intermittent pacemaker failure or threshold determination. In one patient, supplementary treatment with a beta-blocking agent had to be given to suppress exercise-induced attacks of VT-VF after pacemaker implantation.

Unusually high pacemaker threshold in severe myxedema. Decrease with thyroid hormone therapy.

In a patient with myxedema and complete heart block, an usually high pacemaker threshold was observed initially during transvenous right ventricular endocardial pacing. The pacemaker threshold gradually decreased with thyroid replacement therapy, suggesting that the lack of thyroid hormone in some patients might increase the pacemaker threshold.