Fiddling with the pacemaker: Twiddler's syndrome in a Parkinsonian patient.

We describe the case report of an 86-year-old Afro-Caribbean Parkinsonian gentleman with intermittent Mobitz II heart block and syncope who received a DDD pacemaker. Due to Parkinson's syndrome, the patient rotated the atrial lead around the pacemaker, causing the famous "Twiddler's syndrome", a rare clinical issue which can easily be diagnosed with a simple chest X-ray.

Recommendations for transoesophageal echocardiography: update 2010.

Transoesophageal echocardiography (TOE) is a standard and indispensable technique in clinical practice. The present recommendations represent an update and extension of the recommendations published in 2001 by the Working Group on Echocardiography of the European Society of Cardiology. New developments covered include technical advances such as 3D transoesophageal echo as well as developing applications such as transoesophageal echo in aortic valve repair and in valvular interventions, as well as a full section on perioperative TOE.

Brain natriuretic peptide testing for angina in a rapid-access chest pain clinic.

BACKGROUND: Patients complaining of chest pain are frequently referred to secondary care, although the majority have pain of non-cardiac origin. AIM: To investigate whether B-type natriuretic peptide (BNP) levels are predictive of a diagnosis of non-cardiac pain. DESIGN: Cross-sectional study. METHODS: Consecutive patients (n = 296) presenting to a rapid-access chest pain clinic (RACPC) received the usual clinical assessment plus near-patient BNP testing, with the assessor blinded to the result. After clinical assessment (including exercise stress testing if clinically indicated), pain was diagnosed likely/definitely cardiac or non-cardiac. RESULTS: Median BNP was higher in those diagnosed with likely/definite cardiac chest pain (26.5 vs. 8 pg/ml) (p < 0.0001, Wilcoxon rank sum test). The odds ratio for cardiac pain in those with BNP <20 pg/ml was 0.25 (95%CI 0.14-0.47) (p < 0.0005); adjusting for age and sex reduced this to 0.41 (95%CI 0.20-0.83) (p = 0.01). The area under the curve (AUC) for the model including BNP, age and sex was 0.70. With BNP as a continuous variable, the AUC for the same model was 0.72. DISCUSSION: In typical patients presenting to a RACPC, those with a BNP < or =20 pg/ml were significantly less likely to be diagnosed with cardiac pain. Near-patient BNP testing may have a role as a 'rule out test' for angina in patients presenting to a RACPC.

Contemporary mortality due to acute myocardial infarction, unstable angina and exertional angina in a population in South East London.

BACKGROUND: Data on the contemporary mortality of coronary heart disease (CHD) are surprisingly sparse. AIM: To describe the contemporary mortality of all manifestations of CHD. DESIGN: Prospective follow-up of patients with a first presentation of CHD in a defined population. METHODS: We studied 537 patients with a first presentation of acute myocardial infarction, unstable angina or new exertional angina in Bromley Health Authority, London (population 295,000). Patients were prospectively monitored for cardiac and non-cardiac mortality for a median of 6 years. RESULTS: During a median 6 years follow-up, there were 88 (16%) deaths. Survival free from cardiac death was not significantly different between unstable angina (92%) and new exertional angina (94%), but was lower for acute myocardial infarction (84%). DISCUSSION: Mortality from CHD appears to be falling. However, efforts to prevent myocardial infarction should continue to be a priority, because on-going early mortality remains high. New exertional angina should be diagnosed and managed promptly, as its mortality is similar to that of unstable angina.

Usage of troponin in the real world: a lesson for the introduction of biochemical assays.

BACKGROUND: Studies have demonstrated economic and clinical effectiveness using troponin as a risk stratification tool in chest pain patients. Those with a positive result are investigated invasively, whilst those with a negative result and ECG are promptly mobilized, facilitating discharge. AIM: To determine whether our use of troponin I (cTnI) in routine clinical practice conforms to ideal standards. DESIGN: Audit study. METHODS: Data were collected from 93 laboratory request forms for cTnI measurement on 72 patients with matched available patient records. RESULTS: Eighty requests had no information regarding timing of blood sample in relation to the clinical event; 39% gave no clinical indication. Only 71% of results were available within 12 h. An admission diagnosis of acute coronary syndrome (ACS) was made in 25%. Fifteen had typical cardiac chest pain with a negative cTnI: 6 of these had an exercise treadmill test before discharge. Nine had a positive cTnI, but only two had coronary angiography. Of patients with negative cTnI and possible ACS, 84% were in hospital for >4 days. DISCUSSION: The introduction of troponin assays into widespread use requires careful assessment. cTnI requests and subsequent patient management remain below expected standards. Ideally, the laboratory should provide an accurate result within a reasonable time frame, while physicians need to request cTnI at a suitable time-point and use the result appropriately. Lessons from the introduction of cTnI measurement may be useful for the introduction of future new tests in other areas of cardiology and medicine.

Distortions of the Xanthophylls Caused by Interactions with Neighboring Pigments and the LHCII Protein Are Crucial for Studying Energy Transfer Pathways within the Complex.

It has been proposed that photoprotective non-photochemical quenching (NPQ) in higher plants arises from a conformational change in the antenna which alters pigment-pigment interactions. This brings about the formation of energy quenching "traps" that capture and dissipate excitation energy as heat. We have used the semiempirical AM1-CAS-CI method combined with the transition density cube (TDC) approach to model chlorophyll (Chl) to xanthophyll (Xanth) resonant Coulomb couplings in the crystal structure of LHCII. Due to its proposed role as the NPQ quenching site we have focused on lutein interactions and have explored how distortions to lutein conformation, as well as interpigment distances and relative orientations, affect this coupling. Our calculations indicate that distortions as well as Chl-lutein angle have a significant effect on coupling, whereas interpigment distances have a relatively minor effect. We therefore conclude that particular attention to the distortions of the Xanths should be given for calculation of energy transfer pathways and study of the NPQ mechanism.

A Rapid Access Heart Failure Clinic provides a prompt diagnosis and appropriate management of new heart failure presenting in the community.

BACKGROUND AND AIMS: The diagnosis of heart failure is an important clinical problem and yet reported diagnostic accuracy in primary care is less than 50%. We established a Rapid Access Heart Failure Clinic (RAHFC) in a district general hospital serving a population of 292,000 in SE London, UK, to diagnose and manage new cases of heart failure presenting for the first time in the community. METHODS: Patients with suspected new onset heart failure were referred by their Primary Care Physician without appointment for clinical assessment on the same or next working day. Assessment by a specialist registrar in cardiology included history, examination, chest X-ray, electrocardiogram (ECG) and echocardiogram. When a diagnosis of heart failure was made appropriate treatment, including angiotensin converting enzyme inhibitors (ACEI), was started. RESULTS: Over 15 months 383 patients were seen (0.4 cases/100,000 population/weekday) 178/383 (46%) were considered to have definite or possible heart failure at the initial assessment in the RAHFC. A normal ECG (negative predictive value 94%) and chest X-ray virtually excluded the diagnosis of heart failure. After subsequent specialist investigations and follow-up, including a trial of therapy where appropriate, 101/383 (26%) were finally diagnosed as clinical heart failure. ACEI therapy was commenced in 56/57 (98%) of patients in whom it was considered appropriate. CONCLUSION: The RAHFC provided rapid assessment, prompt diagnosis and early introduction of life prolonging therapy for patients presenting with suspected heart failure in the community.

Precise molecular weight determination of PCR products of the rRNA intergenic spacer region using electrospray quadrupole mass spectrometry for differentiation of B. subtilis and B. atrophaeus, closely related species of bacilli.

Assessment of 16S-23S rRNA intergenic spacer region (ISR) sequence variability is an important supplement to 16S rRNA sequencing for differentiating closely related bacterial species. Species differentiation can also be achieved by determination of approximate size of PCR (polymerase chain reaction) products of ISRs, based on their relative electrophoretic mobility on agarose gels. Closely-related species can have ISR PCR products that are similar in size. More precise molecular weight (M.W.) determination of these products might allow improved discrimination of such species. Electrospray quadrupole mass spectrometry (ESI-Q-MS) has the potential to provide such precision. For ESI-Q-MS analysis, size limitation of PCR products is currently limited to around 130 base pairs (bp). Bacillus subtilis and Bacillus atrophaeus are two closely related species with few distinguishing phenotypic characteristics. B. subtilis has recently been sub-divided into two subgroups, W23 (type strain, W23) and 168 (type strain, 168). PCR products amplified from the ISR including the 5' terminal end of the 23S rRNA and a conserved portion of the ISR were analyzed by ESI-Q-MS. A 119 or 120 bp PCR product was produced for B. atrophaeus strains. However, strains of B. subtilis subgroups W23 and 168 each produced 114 bp products. In summary, a mass spectrometry method was developed for differentiation of B. subtilis and B. atrophaeus. Also, the genetic similarity of B. subtilis subgroups W23 and 168 was confirmed. Accurate determination of the molecular weight of PCR products from the 16S-23S rRNA intergenic spacer region using electrospray quadrupole mass spectrometry has great potential as a general technique for characterizing closely related bacterial species.

Quantitative analysis of neutral and acidic sugars in whole bacterial cell hydrolysates using high-performance anion-exchange liquid chromatography-electrospray ionization tandem mass spectrometry.

A procedure for analysis of a mixture of neutral and acidic sugars in bacterial whole cell hydrolysates using high-performance anion-exchange liquid chromatography-electrospray ionization tandem mass spectrometry (HPAEC-ESI-MS-MS) is described. Certain bacteria (including bacilli), grown under phosphate-limited conditions, switch from producing a teichoic acid (containing ribitol) to a teichuronic acid (characterized by glucuronic acid content). Bacterial cells were hydrolyzed with sulfuric acid to release sugar monomers. The solution was neutralized by extraction with an organic base. Hydrophobic and cationic contaminants (including amino acids) were removed using C18 and SCX columns, respectively. HPAEC is well established as a high-resolution chromatographic technique, in conjunction with a pulsed amperometric detector. Alternatively, for more selective detection, sugars (as M-H- ions) were monitored using ESI-MS. In HPAEC, the mobile phase contains sodium hydroxide and sodium acetate, which are necessary for chromatographic separation of mixtures of neutral and acidic sugars. Elimination of this high ionic content prior to entry into the ESI ion source is vital to avoid compromising sensitivity. This was accomplished using an on-line suppressor and decreasing post-column flow-rates from 1 ml to 50 microliters/min. In the selected ion monitoring mode, background (from the complex sample matrix as well as the mobile phase) was eliminated, simplifying chromatograms. Sugar identification was achieved by MS-MS using collision-induced dissociation.

A critical evaluation of the NICE guidelines for post-myocardial infarction prophylaxis. National Institute for Clinical Excellence.

The UK National Institute for Clinical Excellence (NICE) has recently published guidelines on prophylaxis for patients who have experienced a myocardial infarction (MI). Based on a previously commissioned extensive review of the literature, the recommendations are antiplatelet therapy, beta-blockers and angiotensin converting enzyme inhibitors (ACEIs) for all patients; statins for those with hypercholesterolaemia; spironolactone for those with moderate-to-severe heart failure (HF); and insulin for those with diabetes. While there may be concerns about some of the details (eg., the possible adverse interaction between aspirin and ACEIs), comments on the use of statins for those with HF, the lack of advice on the choice of lipid-lowering therapy for those intolerent of statins, the dangers of spironolactone therapy and the practicality of intensive insulin treatment, the guidelines are firmly based on sound evidence of efficacy and cost effectiveness. The NICE guidelines should therefore stimulate the provision of resources to address the gap between current practice and these recommendations.

Rapid access cardiology--a nine year review.

BACKGROUND: Rapid access cardiology clinics provide a rapid assessment and evaluation of patients with suspected chest pain, heart failure or cardiac arrhythmia. Longitudinal data regarding the attendances and clinical diagnoses at rapid access clinics is lacking and may provide insight into their efficiency and role in providing a comprehensive referral service for primary care. METHODS: Data regarding total number of attendances and diagnoses were retrospectively analysed from databases collated by nurse specialists and physicians undertaking rapid access clinics at Charing Cross Hospital between April 2002 and March 2011. RESULTS: A total of 12 000 patients were seen over the 9-year time period. Demand for Rapid Access Chest Pain Clinic and Rapid Access Arrhythmia Clinic has shown a steady rise since 2007 whereas attendances at Rapid Access Heart Failure Clinic have remained constant. The proportion of patients diagnosed with significant cardiac disease across all rapid access clinics has not changed significantly. The most commonly diagnosed arrhythmia was atrial fibrillation (15% of all attendances). CONCLUSION: Referrals have increased to our service which suggests that demand for a rapid access cardiology service remains high and the proportion of patients diagnosed with significant cardiac disease has remained constant. Despite considerable motivation towards providing primary based care this has not occurred in our local area and we believe this shows that our model, based in secondary care to be both efficient and accessible to local GPs and patients.

A rapid access cardiology service for chest pain, heart failure and arrhythmias accurately diagnoses cardiac disease and identifies patients at high risk: a prospective cohort study.

OBJECTIVE: To conduct a one year follow up study of patients seen in a combined rapid access chest pain, arrhythmia and heart failure clinic. METHODS: Local general practitioners, accident and emergency department clinicians and other hospital clinicians were invited to refer patients with a new presentation of chest pain, palpitations and suspected cardiac-induced breathlessness to the rapid access cardiology clinics at Charing Cross Hospital, London, on a one-stop, no appointment basis. Consent to be followed up by a postal questionnaire one year later was sought from all patients attending between 1 November 2002 and 31 October 2003. RESULTS: 1223 patients were seen in the 12 month study period. 940 (77%) consented to one year follow up. 216 (23%) patients had a diagnosis of definite cardiac, 621 (66%) of not cardiac and 103 of possible cardiac disease (11%). 98% of patients diagnosed "not cardiac" did not receive a diagnosis of cardiac disease over the following 12 months. Of patients with diagnosed definite cardiac disease, one year cardiac mortality was 7 of 216 (3%), compared with an age- and sex-matched expected cardiac mortality of 0.9% (standardised mortality ratio 3.5, 95% confidence interval (CI) 1.4 to 7.2). For patients with an initial diagnosis of possible or not cardiac disease, cardiac mortality at one year was 0.3% compared with an expected cardiac mortality of 0.4% (standardised mortality ratio 0.8, 95% CI 0.1 to 2.8). CONCLUSIONS: A rapid access cardiology clinic accurately diagnoses and risk stratifies patients into those with cardiac disease at high risk of cardiac death and those without significant cardiac disease.

Echocardiographic features and brain natriuretic peptides in patients presenting with heart failure and preserved systolic function.

OBJECTIVE: To characterise patients who appear to fulfil the diagnosis of heart failure with preserved systolic function clinically, echocardiographically, and by concentrations of brain-type natriuretic peptide (BNP). METHODS: 102 new cases of heart failure were identified over 24 months in 213 patients referred to a rapid access heart failure clinic. Patients with heart failure and preserved systolic function with contemporary markers of diastolic function were assessed to evaluate their cardiac status further. RESULTS: Forty patients (39%) had an ejection fraction (EF) < 45% and 62 (61%) had an EF > or = 45%. Of these 62 patients, 30 (48%) fulfilled the case definition of diastolic heart failure. The remaining 32 (52%) had neither an EF < 45% nor abnormalities of diastolic function. Dobutamine stress echocardiography was performed on 26 (42%) patients with EF > or = 45%, which provided an alternative explanation for symptoms in 15 (58%) patients. Concentrations of BNP were higher in patients with diastolic abnormalities (mean (SEM) 101.4 (32.5) pg/ml v 58.4 (6.78) pg/ml, p = 0.042) and with no diastolic abnormalities (199 (37.9) pg/ml v 58.4 (6.78) pg/ml, p < 0.0001) than in patients with no heart failure. CONCLUSION: Among ambulatory patients presenting with suspected heart failure in the community 19% have systolic dysfunction, 14% have diastolic dysfunction, and 15% seemingly have heart failure with neither systolic nor diastolic dysfunction. A new understanding, including alternative parameters of diastolic function, seems to be necessary to classify patients with heart failure and preserved systolic function.

Social marketing of oral rehydration therapy and contraceptive in Egypt.

This article examines the antecedents, activities, results, and prospects for institutionalization of two large social marketing programs currently in operation in Egypt: the National Control of Diarrheal Diseases Project, which promotes oral rehydration therapy to treat diarrheal dehydration, and the Family of the Future, which is recognized as one of the most sophisticated and effective contraceptive social marketing programs operating today. This examination of two health-related social marketing programs operating simultaneously in the same country can highlight the factors that contribute to successful programs.

Properties of the genus Tatlockia. Differentiation of Tatlockia (Legionella) maceachernii and micdadei from each other and from other legionellae.

The biochemical reactions, carbohydrate content, and 16S-rRNA sequences of Tatlockia (Legionella) maceachernii and Tatlockia micdadei strains were studied. Except for catalase activity, Tatlockia strains were relatively inert in the biochemical tests commonly used in clinical laboratories. Phenotypically, the two Tatlockia species could be distinguished from other legionellae by the presence of yersiniose A, by their inability to hydrolyze hippurate or starch, by the absence of colony or media fluorescence, and by the absence of distinct browning of tyrosine-containing medium. These two species differed from one another by the production of acetoin by T. micdadei but not by T. maceachernii. Gelatinase activity, which had been reported in T. maceachernii, was observed in only one of the four strains studied. The 16S-rRNA sequences and carbohydrate profiles of T. maceachernii and T. micdadei were essentially identical. In preparing the RNA for study, it was noted that the 23S rRNA was fragmented in all T. maceachernii strains tested, while the 23S rRNA of T. micdadei strains was intact. Among the legionellae studied, T. maceachernii was most closely related to T. micdadei.

Application of numerical systematics to the phenotypic differentiation of legionellae.

A total of 163 strains, including 106 strains of Legionella pneumophila, 28 strains of Tatlockia micdadei, and 29 strains of other legionellae (including members of the proposed genus Fluoribacter), were studied. Ten tests which together could distinguish the genera previously proposed were identified. These tests included catalase-peroxidase, gelatinase, hippurate hydrolysis, starch hydrolysis, medium browning, acetoin production, oxidase, medium fluorescence, colony fluorescence, and the bromcresol purple spot test. T. micdadei strains were strongly catalase positive and bromcresol purple spot test positive and produced acetoin but otherwise were usually inert in the other tests. L. pneumophila and Fluoribacter species could usually be distinguished by strength of catalase activity, blue-white colony fluorescence (if present), and differences in frequency of hippurate hydrolysis, starch hydrolysis, yellow-green medium fluorescence, and, to a lesser extent, oxidase activity. With a simple algorithm and computer program, the overall accuracy was 98.8%.