A man in his seventies has a regular tachycardia of 150 beats per minute (bpm). His ECG shows atrial flutter.
He has no symptoms, is taking no medication and bloods are normal. While I await the result of open-access echocardiography what is the favoured option?
Having a ventricular rate of 150bpm is not good for the long-term function of the myocardium. Atrial flutter is very stable, and pharmacological cardioversion rarely works. But flutter is sensitive to electricity, therefore I would anticoagulate him, anticipating that DC cardioversion would be a likely option.
What to do next depends on how long he will have to wait for his echocardiogram.
Ventricular rate control would be a good idea, but you need to accomplish this safely.
Flutter is likely to be associated with organic heart disease. If the QRS complexes on the ECG are normal, then significant left ventricular dysfunction is unlikely, and a beta-blocker or verapamil might be appropriate.
But if the QRS complexes are abnormal, you should expedite the echocardiogram.
Dr Andrew Clark, consultant cardiologist at Castle Hill Hospital, Hull
One of my patients is a 12-year-old who is normally well, and apparently has good family support. She has no known problems at school or with school work, but her parents are now having battles to get her to go.
One parent has been away recently and the other is a teacher in the school.
What is the best way to deal with cases like this?
The first question to consider is, why this has happened now. At 12 years of age, the girl might have recently started secondary school, which is a huge change from the protective primary school environment.
Parents might be unaware of problems that do not cause disruption in class. She might be being bullied, or having difficulties with developing new friendships or managing the workload. Or perhaps something has happened on the journey to school.
The fact that one parent is a teacher at the school complicates this case. Teasing by peers might be making it harder for her to confide in her parents.
If there is no problem at school, the underlying issue is usually separation anxiety. Parents often respond to this either by becoming anxious themselves or by rejecting the child, both of which cause further distress and clinging behaviour. Allowing the child to stay off school only maintains the problem.
Anxiety lessens if it is confronted. The best approach is making it clear that the girl must go to school, while acknowledging that she is worried and physically helping her to get there. It might help to arrange for a supportive teacher to greet her and to build in a reward system.
If she has been off school for a while, it might be best to start with her going in for part of the day and gradually building up. Co-operation from the school is crucial.
Sometimes separation anxiety is precipitated by problems such as domestic violence, conflict or parental illness. The child is scared to leave them in case something happens.
Issues involving other siblings could be contributing. If one sibling is receiving extra attention, for example because they are unwell, other children might find they receive more attention from their parents by being difficult. Refusing to go to school is an excellent way to get your parents to spend time with you. If this is the problem, the parents need to give this girl positive attention while being firm about school.
School refusal can easily become chronic and parents need to be feeling strong and supported themselves. Sources of help include educational welfare officers, school nurses, local child and adolescent mental health services (CAMHS) or educational psychologists.
The girl herself might benefit from cognitive behavioural therapy and relaxation training through the local CAMHS.
The Royal College of Psychiatrists' leaflet Children who do not go to school can be downloaded free from www.rcpsych.ac.uk.
Dr Ann York, consultant child and adolescent psychiatrist and senior lecturer at St George's Hospital Medical School, London.