Clinical articles

The European Working Time Directive (EWTD) ensures doctors do not work excessive hours. On 1st August 2004, junior doctors were no longer excluded from the EWTD and their working hours were limited by law to 58 hours per week. By 2009, this will be reduced to 48 hours. Although benefits include improved patient care,1 the EWTD has implications for service provision and specialist registrar (SpR) training.

Complications of arterial access are an important cause of morbidity following percutaneous coronary intervention. Recently published data suggest a rate of around 3.5% of major vascular complications. We present an audit of vascular access site complications in a single centre over a 12-month period. Overall complication rates were low (1.2%) in a centre whose default strategy following femoral artery access is arterial closure using the Perclose™ device. Specific problems using the Starclose™ device in patients treated with abciximab are described. Infected femoral artery haematoma resulted in the most severe complications.

This short report describes a questionnaire study undertaken in two London teaching hospitals, addressing the true pharmacokinetic implications of aspirin use. It suggests that the real costs of aspirin treatment should include the cost of the therapies used for treatment of associated dyspepsia.

Viral myocarditis is a well-recognised complication of many viruses leading to subsequent cardiomyopathies (dilated type). There are limited data available with respect to dengue virus involvement, an infection which can be asymptomatic and can lead to undifferentiated viral fever syndrome, dengue fever, dengue haemorrhagic syndrome or dengue shock syndrome. Dengue has probably been endemic in Sri Lanka for a long time although no cases of dengue haemorrhagic fever was reported until 1965. Now, several hundred cases a year have been reported annually from 1991.

The only two published articles from Sri Lanka on myocardial involvement described cardiac sequelae, diagnosed quite late, retrospectively, in the non-active phase of the illness. Recent epidemics of the disease in Sri Lanka led us to design a study to look at myocardial involvement in clinically and serologically confirmed cases of dengue infection.

Clinical practice should follow evidence-based medicine, which is derived from clinical trials. The outcomes of clinical practice, however, may not equal that of trials if there are differences in the patients or the quality of treatment they receive. We report the example of cardiac rehabilitation to illustrate this point, comparing the characteristics of patients and treatments offered in randomised controlled trials (RCTs) in this area with those included in two large surveys of cardiac rehabilitation in the UK. We found that cardiac rehabilitation as currently practised in the UK is unlikely to be as effective as clinical trials may suggest.

Peri-operative transoesophageal echocardiography (TOE) has become part of the routine management of patients undergoing cardiac surgery. Its use in guiding not only surgery, but also the haemodynamic management of the patient, has made TOE an indispensable tool in the cardiac operating theatre. Practical aspects of intra-operative TOE are outlined and its application in differing clinical situations is reviewed.

Stress echocardiography has a high diagnostic accuracy for the detection of coronary disease. It is as effective as myocardial perfusion imaging for the stratification of risk in patients with coronary disease and can detect myocardial hibernation after myocardial infarction or in heart failure.

This paper is an executive summary of a recent postal survey carried out by the British Society of Echocardiography to guide future planning.

Individuals with diabetes have an increased risk of developing coronary artery disease and a poorer prognosis once coronary artery disease has developed, compared to patients without diabetes. To avoid confounding, most cardiovascular trials display profiles of traditional risk factors but additional factors are also important in patients with diabetes. We examined the information provided on patients with diabetes included in cardiovascular trials published in general medical journals.

The National Service Framework for Coronary Heart Disease recommends that psychological support should be offered to those patients who require it. A six-month study carried out at Darlington Memorial Hospital looked at psychological support needed by patients following myocardial infarction (MI). The psychological status of MI patients was formally assessed using the Hospital Anxiety and Depression (HAD) scale and appropriate referrals were made to psychological support services to improve patient management. The study also measured the impact that formal assessment of the psychological status of MI patients would have on service providers.

Some 80 MI patients from the Darlington primary care trust (PCT) were eligible for inclusion in the study. Psychological assessment was undertaken at four stages during cardiac rehabilitation and 25 patients were eligible for referral for psychological support as a result of high HAD scores measured during the study period. Ten patients accepted referral, a higher number than during the previous six-month period when HAD scales had not been used. Eight patients were referred to occupational therapy services for help with anxiety issues, one patient was referred to the psychology service and one to liaison psychiatry. Both of these patients required help with depression.

The study also found a high degree of patient satisfaction. The support received may also be required by many other groups of patients.