Delay in presentation of patients with acute stroke to hospital in Oxford.

We identified prospectively all patients (181 patients, 183 episodes) admitted to hospital in Oxford with acute stroke from 1 January to 30 June 1997. Data were inadequate in 30, leaving 153 episodes in 151 patients (63 men, 90 women). Structured interviews were used to investigate the timing of events preceding admission. Most strokes (91%) occurred at home, and 36% of patients were alone. After a median delay of 15 min, 56% called a GP (median 30 min response), 41% an ambulance (median 48 min to admission), and 3% went directly to A&E. Median time from hospital admission to doctor assessment was 69 min. Factors reducing delay were: initially calling an ambulance rather than a GP (p < 0.0001); onset not at home (p < 0.001); symptoms improving between onset and admission (p < 0.002); and altered consciousness (p < 0.002). The stroke was not recognized by 44% of patients, but no significant delay resulted. Overall, 31% were admitted within 3 h of onset, 46% within 6 h. Initial contact with the GP is a major determinant of delay. If acute therapies for stroke become available, GPs should be the primary targets for an educational initiative.

Guillain-Barré syndrome in Oxfordshire: clinical features in relation to age.

We have examined the clinical features of Guillain-Barré syndrome (GBS) in a UK series with a valid epidemiological base, studying cases from a geographically-defined population using enhanced data from the Oxford record linkage study and applying standard diagnostic criteria. Clinical features in patients aged > or = 60 years were compared with those aged 20-59 years. Cranial nerve involvement was found less often in old than in young adults (6/21 vs 27/41, chi 2 p < 0.02). Old patients more frequently had other diagnoses accompanying GBS (10/21 vs 3/41, p < 0.001). There were no significant differences between old and young in: occurrence or type of preceding illness; site of symptoms at onset; severity of maximal neurological impairment; sphincter dysfunction or any autonomic involvement; requirement for artificial ventilation; case fatality rate; proportion of patients with no residual disability at or before 12 months from onset; mean duration from onset to maximal neurological impairment, from onset to first signs of recovery, and from maximal neurological impairment to recovery ('plateau time'). The variety and severity of clinical features of Guillain-Barré syndrome are similar in old and young adults.

Age-specific incidence of Guillain-Barré syndrome in Oxfordshire.

The epidemiology of Guillain-Barré syndrome was examined in a population-based retrospective study using defined diagnostic criteria and linked hospital records. Between 1974 and 1986 there were 72 incident cases, giving a crude annual incidence rate (95 per cent confidence interval) of 1.1 per 100,000 persons per year (0.8-1.4). Age-adjusted incidence rates were insignificantly higher for women, 1.23 (0.8-1.6), than for men, 1.0 (0.6-1.3). After infancy, rates increased with age, and remained high in the over-75 age group. These variations in incidence were not explained by variations in severity. There was evidence of an increase in rates over the period surveyed. Rates tended to be higher in the winter and early spring. The incidence of Guillain-Barré syndrome in the elderly has been underestimated in the past, and this study shows no evidence of a previously reported bimodal distribution of age-specific incidence in adult life.

Perimenopausal risk of falling and incidence of distal forearm fracture.

A postal survey of 2000 women and 2000 men sampled from the electoral roll in Oxford was undertaken to ascertain whether changes with age in the risk of falling might explain the stepwise increases in age specific incidence rates of distal forearm fracture which occur in women at around the age of 50. Corrected response rates were 83% for women and 72% for men. In women, but not in men, there was a rise in the risk of falling from 45 years, peaking in the 55-59 year age group, and sinking to a nadir at ages 70-74. In both sexes rates rose in extreme old age. These variations were not attributable to preferential response from people who had suffered a fracture. It is concluded that changes in the risk of falling interact with osteoporosis to produce a perimenopausal rise in the incidence of forearm fractures and contribute to the fluctuations in incidence of these fractures in old age.

Transvenous pacemaker electrodes placed unintentionally in the left ventricle: three cases.

Three patients are described in whom pacemaker electrodes were unintentionally placed within the left ventricle, followed by considerable delay before the error was recognized. In two cases temporary pacemaker wires were inserted into the subclavian artery and passed along a retrograde course. One patient required urgent surgery for acute arterial obstruction on removal of the wire. In the third case, a permanent wire was inserted correctly into a vein but traversed the atrial septum, probably via a patent foramen ovale, to enter the left ventricle. Twelve lead electrocardiograms in all three patients showed paced complexes with right bundle branch block configuration. This appearance should raise suspicion that the pacemaker electrode might be in the left ventricle, in which case its position should be defined by chest radiographs (including a lateral view) and echocardiography.

A comparison of the long-term effects of sotalol and atenolol on QT interval and arrhythmias after myocardial infarction.

In order to dissociate the Class III effects of sotalol on QT interval and arrhythmias from those of chronic beta-receptor blockade, we compared the effects of sotalol 160 mg b.d. and atenolol 50 mg b.d. in a double-blind crossover study of 103 patients followed for one year after discharge following acute myocardial infarction. Sotalol caused a highly significant lengthening of the absolute and corrected QT (QTc) interval over atenolol which was apparent by day 6 and persisted unchanged throughout the follow-up period. The increase in QT interval averaged 43 ms (9%). Sotalol blunted the increase in ventricular premature beat frequency on ambulatory monitoring which occurred with atenolol, although direct comparison of arrhythmia frequency between the groups receiving atenolol and sotalol revealed no significant difference. Marked lengthening of QTc interval (greater than 500 ms) was observed on 29 occasions in patients receiving sotalol, most commonly at day 6, but no episodes of polymorphic ventricular tachycardia were recorded. The Class III action of sotalol persists over and above any response to beta-blockade during a one-year follow-up period. In a population with a low incidence of spontaneous arrhythmias, however, there was only a modest difference in antiarrhythmic efficacy between atenolol and sotalol. Episodes of marked lengthening of QT interval induced by sotalol in the absence of other adverse factors need not be arrhythmogenic.

An outbreak of Q fever affecting postal workers in Oxfordshire.

Twenty-five people in Oxfordshire were found to have had clinical illness due to Q fever in the 3 months from April to June 1983. Twelve cases were diagnosed through the routine laboratory diagnostic service. Five of these were postmen, four of whom worked in a sorting office where an outbreak of illness similar to influenza had been noted by the Occupational Health Nurse. Thirteen cases were diagnosed by active case-finding in this sorting office but investigation failed to define the source of the outbreak. Nine of the 18 postal workers were found to have antibodies to phase I Coxiella burnetii antigen. The significance of these antibodies is discussed. Surveillance for over 2 years has not revealed anyone with symptoms or signs suggestive of chronic Q fever. An outbreak of Q fever among postal workers has not previously been described. We recommend continued surveillance for this enigmatic condition.

Comparison of inhaled and intravenous terbutaline in acute severe asthma.

In patients with acute severe asthma, 5 mg of terbutaline by inhalation and 500 microgram intravenously in divided doses both produced equally effective but not maximal bronchodilatation. There was no difference in the production of side-effects. These results support the view that inhaled therapy can be as effective in patients with acute severe asthma as injected treatment. In view of the risks of intravenous treatment, especially using high doses, inhaled bronchodilator therapy would seem advisable as initial treatment.