Medical mortality in an emergency department in Nigeria: the transition is obvious!

INTRODUCTION: The emergency department (ED), a major entry point into the hospital, provides an insight to the type of cases seen, the quality of care and mortality spectrum in a health institution. We aim to identify the spectrum of medical causes of mortality in our ED, the demographic pattern and duration of stay before death. METHOD: This is a retrospective study that looked at medical mortality in the ED from January 2004 to December 2009. We obtained data on the demographics and causes of death from the medical records and case notes of the deceased. RESULTS: A total of 16587 patients were admitted during the period under review, of these 1262 (7.61%) died in the ED. The male to female ratio was 1.58:1.0 [772 males (61.2%), and 489 females (38.8%)]. Mortality was highest among the 20-45 years age range, followed by 46-65 years, >65 years and < 20 years in decreasing frequency [589(46.7%), 421(33.4%), 186 (14.8%) and 66(5.2%) respectively]. The three most common causes of death were stroke 315(25%), HIV related illnesses 126(10.0%), and heart failure 123(9.7%). Most deaths occurred less than 24hours of admission, 550(43.6%), followed by one day (36.0%) and two days (10.8%) post admissions respectively. CONCLUSION: The commonest cause of death in the ED was stroke. The burden of death was highest in the younger age group, with most occurring less than 24 hours of admission.

Clinical and echocardiographic correlates of pulmonary hypertension among heart failure patients in Lagos, south-western Nigeria.

BACKGROUND: Pulmonary hypertension (PH) is very prevalent among heart failure (HF) subjects and is now recognised as an independent predictor of poor prognosis. There is a paucity of data in our environment about the frequency and correlates of PH in HF. We aimed to determine the frequency of PH in HF patients in an academic hospital and assess its correlates using echocardiography. METHODS: A total of 219 heart failure patients in NYHA functional class II to IV, and without co-morbidities that could cause PH, were consecutively recruited. Demographic, clinical and echocardiographic data were obtained from all subjects. RESULTS: The frequency of PH was 38.8%, using an estimated pulmonary artery systolic pressure (PASP) cut-off value of > 36 mmHg. HF subjects with PH tended to be male with a worse NYHA functional class compared with subjects without PH. HF subjects with PH also had significantly higher left ventricular (LV) filling pressures (higher left atrial volume index and E/e' ratio), more severe mitral regurgitation (MR), poorer LV systolic function, and worse parameters of right ventricular (RV) structure and function compared with those without PH. Echocardiographic variables that correlated significantly with PASP include LV filling pressures (p < 0.001 for all), mitral regurgitant volume (r = 0.269, p < 0.001) and LV ejection fraction (r = -0.239, p > 0.001). On multivariate analysis, the left atrial volume index and E/e' ratio were independently associated with PASP. CONCLUSIONS: PH is common among HF subjects in our environment and is associated with higher LV filling pressure, more severe MR, poorer LV systolic function and worse RV remodelling. Routine screening for PH among HF patients is recommended for better risk stratification and management.

Clinical usefulness of a timed overnight (8 hours) Urine Albumin (microalbumin) excretion in monitor-ing treatment in benign essential hypertension.

AIMS AND OBJECTIVES: This research aims to establish the usefulness of timed over- night (8 hours) Urine Albumin(microalbumin) Excretion (UAE), in monitoring therapy in Nigerian patients with benign essential hypertension. SUBJECTS AND METHODS: The study population comprised 40 normotensives/controls, (23 males and 17 females) aged between 20-70 years, with a mean blood pressure 116/75mmHg, 30 well-controlled hypertensive patients, diastolic BP <100mmHg or MAP (mean arterial pressure) = 110mmHg and 30 poorly controlled hypertensive patients, diastolic blood pressure > 100mmHg or MAP >110mmHg.Urine albumin(microalbumin) was determined on the 8 hours overnight urine samples by ELISA method using kit from Randox Laboratories Limited, N.Ireland Cat No. MA 1410. UAE was calculated from the urine albumin concentration, urine volume and collection time. The intra assay precision was determined by running 20 replicates of two kit controls in a single batch. The coefficient of variation was 6.6% at 10.70mg/L and 4.3% at 51.20mg/L. RESULTS: The average UAE in the three groups were as follows: 12:22 +/-4.65ug/ min, 21.50 +/- 10.5ug/min and 30.10 +/- 24.25 ug/min in the control, well controlled and poorly controlled groups respectively, 12.5% of normotensive subjects, 40% of well controlled and 56.7% of poorly controlled patients were found to have microalbuminuria.The UAE increased significantly with the severity of hypertension (r = 0.32, p<0.001 for control) r = 0.38, p<00.05 for controlled and r = 0.49 p<0.05 for poorly controlled. CONCLUSION: A timed overnight (8 hours) Urinary UAE is a preferred alternative to cumbersome 24 hours urine collection for monitoring response to treatment in Nigerian patients with benign essential hypertension.

Impact of prehypertension on left ventricular mass and QT dispersion in adult black Nigerians.

BACKGROUND: Prehypertension has been associated with target-organ damage. This study sought to determine the impact of prehypertension (PHT) on QT dispersion and left ventricular hypertrophy (LVH) in adult black Nigerians. METHODS: One hundred and one subjects with office blood pressure (BP) < 140/90 mmHg were categorised according to their office BP into normotensive (normal BP < 120/80 mmHg, n = 57) and prehypertensive (prehypertensive BP 120-139/80-89 mmHg, n = 44) groups. Echocardiography and electrocardiography (ECG) were performed on the subjects. RESULTS: Thirty-four males aged 53.65 ± 16.33 years and 67 females aged 52.42 ± 12.00 years were studied. The mean QT interval dispersion (QT(d)) of the normotensive (38.96 ± 11.06 ms) and prehypertensive (38.41 ± 11.81 ms) groups were similar (p = 0.81). Prehypertensive subjects had higher left ventricular mass (LVM) (165.75 ± 33.21 vs 144.54 ± 35.55 g, p = 0.024), left ventricular mass index 1 (LVMI-1) (91.65 ± 16.84 vs 80.45 ± 18.65 g/m(2), p = 0.021) and left ventricular mass index 2 (LVMI-2) (54.96 ± 10.84 vs 47.51 ± 12.00 g/m(2.7), p = 0.017). QT(d) was independent of echocardiographic and electrocardiographic LVH (p > 0.05). CONCLUSIONS: Compared with normotension, prehypertension is associated with higher LVM but similar QT(d). This suggests that structural remodelling precedes electrical remodelling in prehypertension.

QT dispersion in hypertensive Nigerians with and without left ventricular hypertrophy.

BACKGROUND: Increased QT dispersion (QTd) has been implicated as a marker of arrhythmogenesis and cardiac death. Paucity of literature on QTd in Nigeria necessitated an inquiry into QTd in adult hypertensive population. This study sought to: (i) compare the QTd values of adult hypertensive subjects with age and sex matched normotensive subjects and (ii)examine the relationship between QTd and left ventricular hypertrophy (LVH). STUDY DESIGN: One hundred and fifty-one hypertensive patients and 101 age and sex-matched controls were recruited into this study. A resting 12- lead ECG was obtained from all subjects for determination of QTd and ECG LVH using Sokolow Lyon (SL) and Araoye's codes. Echocardiographic LVH was determined for 60 hypertensive subjects and 60 age/sex matched controls. RESULTS: Hypertensive subjects had higher mean QTd than the controls (65.6 ± 28.1 ms vs 38.7 ± 11.3 ms, p< 0.0001). QTd of hypertensives with ECG LVH was significantly higher than those without ECG LVH (Araoye: 71.5 ± 22.0 ms vs 62.2 ± 24.1 ms, p = 0.02, SL; 72.0 ± 24.4 ms vs 61.6 ± 23.1 ms p = 0.009). Similarly the QTd of hypertensives with echocardiographic LVH (72.6 ± 21.3 ms) was higher than those without (60.1 ± 22.2 ms) but did not achieve statistical significance (p = 0.085). CONCLUSIONS: Hypertension with or without ECG LVH is associated with significantly increased QTd. Echo-cardiographic LVH is associated with a non significant increase in QTd in hypertensive subjects.

QT Dispersion in Healthy Adult Nigerians.

BACKGROUND: Increase in QT dispersion (QTd) is associated with an increased risk of cardiovascular morbidity and mortality. OBJECTIVES: This study sought to (i) determine the mean QTd and (ii) characterise QTd in a healthy Nigerian population. METHODS: One hundred healthy Nigerian adults were studied. Healthy status of the subjects was determined by history and physical examination. A resting 12- lead ECG was obtained from all subjects for determination of QTc, QTd and ECG left ventricular hypertrophy (LVH) using Sokolow Lyon (SL) and Araoye's codes. Echocardiography was used to determine LV systolic function, LVM and LVMI for 60 subjects. RESULTS: The QTd ranged from 15-70ms with a mean value of 38.5 ± 11.2ms. QTd was independent of age (p = 0.86), sex (p = 0.97), heart rate (p = 0.22), blood pressure (p > 0.05), BMI (p = 0.81), QTc (p = 0.41), LVH (ECG and echo) and LV systolic function (p > 0.05). CONCLUSION: QT dispersion is independent of demographic parameters, LV systolic function and LV hypertrophy in healthy adult Nigerians.

Therapeutic Effects of Exercise Training On Selected Cardio-Pulmonary Parameters and Body Composition of Nigerians with Chronic Heart Failure (A Preliminary Study).

BACKGROUND: The use of exercise training in the management of individuals with chronic heart failure has not been widely accepted by health care providers especially in Sub-Saharan Africa because of the possibility that the failing hearts may have a negative response to the increased workload and stress of exercise. OBJECTIVE: The study aimed to evaluate the effects of exercise training (ET) on selected cardio-respiratory and body composition variables of Nigerians with chronic heart failure (CHF). METHODS: Thirty two Nigerians with CHF (male - 17), aged 30 to 71 years, mean age 54.2 ± 1.9 years and New York Heart Association Functional Class (NYHA) II-III recruited from Cardiology Clinic of Lagos University Teaching Hospital Nigeria participated in the study. They were randomized into exercise (EG) and control groups (CG). Exercise group performed 12-weeks of aerobic and resistance training for 60 minutes, three sessions per week. Selected cardio-respiratory and body composition variables were measured pre and post intervention in both groups. Data was analyzed using SPSS-17 package. Level of significance was set at 0.05. RESULTS: There was no significant difference in the measured variables between the groups at baseline (p > 0.05). Significant improvement was seen in EG in all the measured variables except the systolic (p = 0.29) and diastolic blood pressure (p = 0.45). No adverse effect was observed during the exercise training. No significant improvement was observed in the control group (p > 0.05). CONCLUSION: Exercise training may improve cardiorespiratory and body composition variables in patients with chronic heart failure.

Blood pressure, heart rate, cardiovascular reflexes and electrocardiographic changes in some hypertensive Nigerians.

The effects of hypertension on resting and reflex cardiovascular function were investigated in this study.  Blood pressure, heart rate and electrocardiogram were recorded in male and female control subjects and hypertensive Nigerian patients.  Blood pressure was measured, using the sphygmomanometer/auscultatory method.  Heart rate was determined from palpating the radial pulse or from the resting electrocardiograph. The systolic and diastolic blood pressures were high in the hypertensive patient (160.90 + 2.06 mmHg and 110.8 + 1.95 mmHg respectively compared with control subjects (119.3 + 2.05 and 73.58 + 1.09mmHg).  Pulse pressure and mean arterial pressures were also higher in the hypertensive patients.  Heart rate was higher in the hypertensive compared to the control groups (86.93 + 2.83 cf 71 + 1.35 beats per minute).  ECG analysis showed that the intervals were lower in the controls than in the hypertensive group except for PR intervals (0.21 + 0.01 cf 0.23 + 0.01 sec).  The amplitude of the waves was also lower in the control group than the hypertensive group. Cardiovascular response to exercise assessed from the post-exercise recovery graph showed that the aggregate recovery (6min after) was lower in the hypertensive subjects (22% cf 28%) than in controls.  This suggests that the baroreflex sensitivity was higher in the control than in the hypertensive subjects. Results from this study suggest that in hypertension there may be increased heart rate, altered electrocardiograph readings indicating ventricular hypertrophy and delay in ventricular conduction.  In hypertension baroreflex sensitivity may be reduced.

Echocardiographic patterns in treatment-naïve HIV-positive patients in Lagos, south-west Nigeria.

INTRODUCTION: Cardiovascular abnormalities are common in HIV-infected patients, although often clinically quiescent. This study sought to identify by echocardiography early abnormalities in treatment-naïve patients. METHODS: One hundred patients and 50 controls with no known traditional risk factors for cardiovascular disease were recruited for the study. The cases and controls were matched for age, gender and body mass index. Both groups had clinical and echocardiographic evaluation for cardiac abnormalities, and CD4 count was measured in all patients. RESULTS: The cases comprised 57 females (57.0%) and 43 males (43.0%), while the controls were 28 females (56.0%) and 22 males (44.0%) (χ(2) = 0.01; p = 0.913). The mean age of the cases was 33.2 ± 7.7, while that of the controls was 31.7 ± 9.7 (t = 1.02; p = 0.31). Echocardiographic abnormalities were significantly more common in the cases than the controls (78 vs 16%; p = 0.000), including systolic dysfunction (30 vs 8%; p = 0.024) and diastolic dysfunction (32 vs 8%; p = 0.002). Other abnormalities noted in the cases were pericardial effusion in 47% (χ(2) = 32.10; p = 0.000) and dilated cardiomyopathy in 5% (five); none of the controls had either complication. One patient each had aortic root dilatation, mitral valve prolapse and isolated right heart dilatation and dysfunction. CONCLUSION: Cardiac abnormalities are more common in HIV-infected people than in normal controls. A careful initial and periodic cardiac evaluation to detect early involvement of the heart in the HIV disease is recommended.

Diagnostic usefulness of N-terminal pro-brain natriuretic peptide among children with heart failure in a tertiary hospital in Lagos, Nigeria.

BACKGROUND: N-terminal pro-brain natriuretic peptide (NTproBNP) is useful in the diagnosis and management of adult patients with heart failure. OBJECTIVE: The objective of the study was to determine the usefulness of NT-proBNP in diagnosing congestive heart failure (CHF) in children and its correlation with left ventricular ejection fraction (LVEF) and clinical heart failure score. METHODS: Plasma NT-proBNP was measured in 28 children with CHF and age matched controls. Heart failure assessment was done using modified Ross score and all had echocardiography done. RESULTS: Mean plasma NT-proBNP of children with CHF (377.86±1026.49pg/mL) was significantly higher than that of controls (353.61±328.50 pg/mL) (p<0.001). A plasma NT-pro BNP of 951pg/mL was used as the cut off value for heart failure. The sensitivity, specificity, negative and positive predictive values were 57%, 96%, 69% and 94% respectively. NT-pro BNP levels showed a high positive correlation with the modified Ross score (r= 0.502; p<0.001) but low correlation with LVEF (r= -0.137; p>0.3). CONCLUSION: Our findings indicate that measuring NT-pro BNP may be useful as a diagnostic tool in congestive cardiac failure in children. The fact that its levels also correlated positively with modified Ross score thereby objectively determining severity of heart failure suggests that this biomarker may also be useful as an evaluation tool in congestive cardiac failure in children.

Evaluation of haemodynamic changes in hypertensive patients during tooth extraction under local anaesthesia.

OBJECTIVE: This study was conducted to determine the changes in blood pressure and the pulse rate of patients with controlled hypertension having dental extraction under local anaesthesia utilizing 2% lignocaine with adrenaline, and to evaluate whether these changes in blood pressure were are attributable to addition of adrenaline. METHODS: This prospective study was carried out in 33 consecutive hypertensive patients who presented at the exodontia clinic of the Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos, from December 2004 to August 2005 for intra-alveolar tooth extraction. Patients were randomly allocated to two groups according to the type of anaesthetic solution employed. Group A had tooth extraction done under 2% lignocaine with 1:80 000 adrenaline while group B had tooth extraction done under 2% lignocaine without vasoconstrictor (plain lignocaine). One tooth was extracted from each patient. Blood pressure and pulse rate measurements were recorded in the waiting room before surgery, in the surgery after local anaesthetic injection, during tooth extraction and 15 minutes after tooth extraction. RESULTS: The sample consisted of 20 females and 13 males age range 24 to 75 years (mean +/- SD = 50.1 +/- 11.7 years). There was no statistically significant difference between the systolic and diastolic blood pressure and pulse rate in the two groups after administration of local anaesthesia. However the highest alteration in parameters was observed during tooth extraction in the two groups. CONCLUSION: The haemodynamic changes induced by injecting 2% lignocaine with adrenaline in patients with controlled hypertension during tooth extraction is within normal range and is not different from that induced by 2% lignocaine without adrenaline. We consider it essential that all precautions to prevent inadvertent intravascular injection be undertaken by the care provider.

Primary open angle glaucoma and intraocular pressure in patients with systemic hypertension.

OBJECTIVE: To investigate the association between Primary Open Angle Glaucoma (POAG), Intraocular Pressure (IOP) and systemic hypertension. DESIGN: Cross-sectional, convenient and controlled study. SETTING: Eye Clinic of the Lagos University Teaching hospital, Idi-Araba, Lagos, Nigeria. SUBJECTS: Consecutive newpatients with documented history of hypertension medication of over three months and current attendees at hypertension clinic of the same hospital were enrolled into the study. RESULTS: A total of 150 hypertensive patients and 50 age-sex matched controls were studied. Age range of hypertensives was 34-54 years and controls 31-71 years. The mean age for hypertensive group was 56 years (+/- 12.95) and controls 54.76 years (+/- 9.65) p > 0.1. The mean IOP was 28.45 mmHg (+/- 10.3) in hypertensive group and 15.2 mmHg (+/- 5.09) in controls (P < 0.001). POAG was present in 58 (38.7%) of the hypertensive patients whilst only nine (18.0%) had POAG in control group (p < 0.01 odds ratio: 22). lOP > 21 mmHg was found in 28 (18.7) of hypertensive group and two (4.0%) of the control (p < 0.01 odds ratio 4.7). CONCLUSION: Systemic hypertension showed a modest positive association with elevated intraocular pressure. The strong relationship with IOP in part supports the association with POAG.

Trends in acute emergency room hypertension related deaths: an autopsy study.

INTRODUCTION: Hypertension is associated with increased morbidity and mortality. Paradigm shift and novel drugs that go beyond blood pressure control have debuted in the last decade globally and in Nigeria. The study therefore proposed to investigate the effect of the above if any on hypertension related acute deaths in patients admitted to the emergency room of the Lagos University Teaching Hospital. METHOD: Autopsy reports for bodies deposited from the medical emergency room (ER) were reviewed. Details of the time of admission, time of death and blood pressure status prior to the event were obtained. Subjects were batched into two groups 1982 1991 and 1992 2001 based on periods of paradigm shift in hypertension diagnosis and management. RESULT: There were 297 hypertension related deaths but 252 were analyzed. There were 168 (66.7%) males and 84 (33.3%) females (M:F 2:1) and mean age was 47.33 +/- 12.18 years (14-85 yr). Two thirds of the subjects (65.5%) were = 50 yrs of age. The mean duration of admission was 5.88 +/- 6.41 hours. One third (35.3%) died within an hour of admission. The commonest causes of death were stroke (52.8%) and heart failure 103 (40.9%). Intra-cerebral hemorrhage was the commonest type of stroke seen, 69 (52.3%). There were fewer cases of acute deaths in the second decade under review 95 (37.7%) vs. 157 (62.3%), p = 0.02 and strokes during this period, 47 (49.47) Vs 86 (54.78), p = 0.06. CONCLUSION: There is a trend towards reduction of hypertension related acute deaths. However stroke remains a major cause of acute hypertensive death and the patients are still dying young.

Perception of Nigerian internal medicine residents on the diagnosis and management of heart failure.

AIM: To evaluate the perception of internal medicine residents on diagnosis and management of heart failure in Nigeria. METHOD: A modified version of the Euro-F study questionnaire was administered to internal medicine residents (IMRs) from Nigeria who were attending the pre part I Fellowship examination of the Faculty of Internal Medicine of the National Postgraduate Medical College. Responses were compared with data from the Nigerian primary physicians (PCP) survey and the Euro-HF study. RESULTS: The commonest symptoms used by the IMRs in heart failure diagnosis were exertional dyspnoea 68.85%(42), pedal oedema 63.93%(39) and orthopnoea 50.82%(31), while the signs included elevated jugular venous pressure 50.82%(31), basal crepitations 47.50%(29) and a gallop heart rhythm 39.34%(24). Categorisation using the Framingham criteria for diagnosis showed that 52% of the IMRs knew three or more major signs of heart failure. The IMRs use of investigations in diagnosing heart failure was fair to good and was significantly higher than results from the Euro-F study and the primary care physicians (PCPs) in Lagos study; echocardiogram, (p=0.007and <0.00001); electrocardiogram, (p= 0.0002 and p=0.001); chest x-ray (p=0.05 and 0.5) respectively. However the mean proportion of IMRs that would rely on investigation to make a diagnosis was significantly lower than in the Euro-F study (p=0.0001) and in the PCPs (p = 0.02). Although the mean proportion of the IMRs patients using ACE-inhibitors was significantly higher than in the Euro-F survey (p<0.001) and the PCPs (p <0.00001), majority (93.94%) of the IMRs were using less than half the trial doses for treatment. On the other hand, the knowledge of survival benefits with the use of b-blockers was very poor in the all the groups, p>0.05. CONCLUSION: A substantial knowledge gap still exists among the IMRs as regards the diagnosis and management of heart failure and this need to be addressed by the trainers.

Comparative study of the effect of tocotrienols and -tocopherol on fasting serum lipid profiles in patients with mild hypercholesterolaemia: a preliminary report.

OBJECTIVES: Hypercholesterolaemia is a risk factor for cardiovascular diseases. Tocotrienols reportedly possess hypocholesterolaemic activity. This study examined the effect of tocotrienols (T3) in TOCOVIDTM Suprabio TM on serum lipids. Patients and Methods :A randomised (2:1), open-label study of patients with mild hypercholesterolaemia (= 5.18mmol/L to <7.77mmol/L) and one additional cardiovascular risk factor was carried out. Subjects received either tocotrienols (as TOCOVIDTM Suprabio TM ) (n=28) or vitamin E (a-tocopherol) 500mg daily (n=16). Fasting lipids were compared at baseline and after 4 weeks therapy. RESULTS: Following 4 weeks therapy, mean +/- SD total cholesterol declined significantly in the tocotrienol group (from 6.10+/-0.66 to 5.47+/-1.16; P=0.02) compared to the a-tocopherol group (from 5.92+/-0.52 to 5.47+/-0.76; P>0.05). Mean LDL-C levels (mmol/L) were also significantly reduced in the tocotrienol group (3.82+/-0.85 to 3.24+/-1.26; P=0.04), but not in those on a-tocopherol (3.84+/-0.75 to 3.28+/-0.94; P>0.05). There were no significant changes in HDL-C and triglycerides in both groups. The tocotrienol group experienced a net decline in TG (7.1+/-31.4 %; P>0.05) while the a-tocopherol group had a net increase at week 4 (38.6+/-61.7%; P>0.05). CONCLUSION: The study adds to existing evidence of the favourable effect of tocotrienols on total cholesterol and LDL-C. However, the results need further evaluation.

Clinical and echocardiographic assessment of Nigerian patients seen at the Lagos University Teaching Hospital with features of mitral valve prolapse.

In a 3-year prospective echocardiographic study of patients with clinical features of mitral valve prolapse who presented to the cardiology clinic of the medical out patients clinic of the Lagos University Teaching Hospital comprising of sixty-two patients. The most common complaints found were vague chest discomfort (42%) and chest pain. (28%) Their mean body mass index was 20.8 +/- 5.56 Kg/m2. The most common auscultatory sign was apical clicks (8%). Hypertension (12%) was the most common clinical association while the anterior leaflet (87%) was more affected. Mitral regurgitation was present in 35.7% of cases, which were mostly mild in severity (93%). There were statistical differences in the chamber and wall dimension measurements of those with isolated mitral valve prolapse when compared with those associated with other clinical conditions. (p < 0.05). Subjects with isolated mitral valve prolapse were found to have significant differences in the echocardiographic measurements when compared with those with coexisting diseases suggesting that mitral valve prolapse is a relatively benign condition except coexisting with other conditions like hypertension, valvular defects and obesity. These associated conditions tended to increase cardiac risk.

The examination of the jugular venous pressure (JVP): variation of technique amongst Nigerian resident doctors.

Resident doctors in Internal Medicine Faculty and General Medical Practice from accredited residency programmes from all over Nigeria were surveyed to investigate the existence of variation in the technique of clinical examination. Using a 10 item self administered questionnaire, the doctors were required to answer questions to test knowledge and skill of examining the jugular venous pressure. Data from 70 Internal Medicine (IMR) and 30 General Medical Practice Residents (GMP) were analysed. For both groups, years of post medical graduation and period spent in residency programme were comparable. On methodology of examination of JVP, there was significant inter- and intra group variation. Sixty per cent (60%) of IMR and only 10% of family practice doctors will use the internal jugular vein alone for assessment, whilst a comparable proportion (30% of IMR and 25% of GMP) will use both internal and external jugular veins. Whilst the sternal angle was the choice of reference point in the majority (87% of IMR versus 80% of GMP), the patient placement angle of 45 degrees was 93% for IMR and 100% for GMP. No respondent chose 60 degrees. Only 40% of both IMR and GMP will always use confirmatory maneuvers, especially the hepatojugular reflux. No GMP doctor and 25% of internal medicine will sometimes use posture and respiratory maneuvers to enhance their clinical decisions. Only 33% IMR and 40% of GMP indicated a correct value and/or unit of measurement for normal jugular venous pressure (JVP). Comparing the internal medicine and General Medical Practice Residents, there was marked inter- and intra-group variation, with more variation noted amongst the IMR. Most importantly, less than 50% of residents knew the correct value of an abnormal JVP. This variability of methodology and poor knowledge will impact on performance in the residency programme, patient care and medical education.