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Sydenham’s chorea (SC), a post streptococcal, autoimmune, neuropsychiatric movement disorder, remains the most common cause of chorea worldwide affecting children aged 5–18 years. SC may be the only manifestation of acute rheumatic fever at first presentation, with the implication of potential sequelae, including cardiac complications. SC is rare in UK and a cluster of cases offered an opportunity to examine the course of the disorder. Aims Patients with a neurologist’s diagnosis of SC, referred to Liaison Psychiatry, were interviewed to determine lifetime prevalence of developmental and psychiatric disorders and describe symptoms at onset and relapses of SC and service use. Methods Subjects, age under 18, identified from psychiatric referral records, were invited with their parent(s) to an interview to establish medical and family history, with construction of a detailed time-line of physical and psychiatric symptoms alongside a child/parent semi-structured, validated, psychiatric diagnostic assessment interview, (KSADS- PL) to explore current and most severe past episode of psychopathology and brief examination with a chorea rating scale. Results 12/16 (75%) of referred children, 7 girls, 5 boys, age at interview 10–15 (average 14) attended. Findings highlight pre-existing neuro-developmental vulnerability (6/12), pre-morbid separation difficulties (4/12). Debilitating symptoms at onset included: wheelchair requirements (6/12), speech impairments (6/12), joint pain (6/12), educational problems, school refusal, severe emotional problems and hallucinations. Choreic movements were not specifically recalled by 7/12. Psychopathology was generally most severe during first episode but 6/12 reported relapse of SC, often with recurrent psychopathology. Over time multiple diagnoses were proposed: separation anxiety (8/12), generalised anxiety (6/12), ADHD (7/12), psychosis (2/12). Some psychopathology remitted but 10/12 had psychiatric symptoms consistent with a diagnosis at interview. Service experience varied: 6/12 were not diagnosed on first presentation. After diagnosis, 8/12 had cardiology and 5/12 rheumatology reviews; physiotherapists saw 8/12, occupational therapists 6/12, speech therapists 3/12. 11/12 continued on penicillin, 8/12 had received sodium valproate and range of other psychotropic medicines and therapies were offered. Conclusions SC complicated by psychiatric symptoms may be difficult to manage as both physical and psychiatric symptoms require on-going collaborative assessment and treatment within paediatric services and CAMHS.

Background and Objective The brain is an unusual site for distant metastases of differentiated thyroid carcinoma (DTC). The aim of this study was to document the prevalence of brain metastases from DTC at our institutions and to analyze the current therapies and the outcomes of these patients. Methods We performed a retrospective chart review of patients with DTC and secondary neoplasia of the brain. Results From 2002 to 2016, 9514 cases of thyroid cancer were evaluated across our institutions and 24 patients met our inclusion criteria, corresponding to a prevalence of 0.3% of patients with DTC. Fourteen (58.3%) were female and 10 (41.7%) were male. Fifteen patients had papillary thyroid cancer (PTC) (62.5%). Brain metastases were diagnosed 0 to 37 years (mean ± SD, 10.6 ± 10.4 years) after the initial diagnosis of thyroid cancer. Patients undergoing surgery had a median survival time longer than those that did not undergo surgery (27.3 months vs 6.8 months; P = 0.15). Patients who underwent stereotactic radiosurgery (SRS) had a median survival time longer than those that did not receive SRS (52.5 months vs 6.7 months; P = 0.11). Twelve patients (50%) were treated with tyrosine kinase inhibitors (TKIs), and they had a better survival than those who have not used a TKI (median survival time, 27.2 months vs 4.7 months; P < 0.05). Conclusion The prevalence of brain metastases of DTC in our institutions was 0.3% over 15 years. The median survival time after diagnosis of brain metastases was 19 months. In our study population, the use of TKI improved the survival rates.

In vitro fertilization, popularly referred to as IVF, changed the infertility practice worldwide since its introduction in 1978 and it has continued to evolve. Assisted reproductive technology (ART) refers to all treatments or procedures that include the in vitro handling of both human oocytes and sperm, or embryos, for the purpose of establishing a pregnancy. Today ART is available globally, and the current practice is largely different from that which was used during the early days of its inception. Although advances in laboratory technology and clinical practice have allowed IVF to evolve, it still remains invasive, expensive and is associated with risks. This article reviews the current indications for assisted reproduction and the preparatory steps before starting treatment. It also summarizes the treatment cycle including its main clinical and laboratory aspects, and the complications associated with treatment.

11038 Background: Social media has profoundly impacted our professional lives. Quick access to reliable sources of information and engaging with like-minded experts certainly aids in professional development. The purpose of this study is to assess the perception of oncology experts towards social media based education and to develop a platform based on their feedbacks for constructive engagement of the professionals and to improve educational outcomes. Methods: Based on Kirkpatrick 4 level model, 15 questions were designed for oncology experts. We collected responses through online surveys and by distributing the questionnaires at oncology events. Based on the results obtained, we developed a customised social media application for oncologists in android version. User experience design was done in InVision Studio and Model View Presenter (MVP) design pattern was used in software development. Beta testing of the application was done with 50 experts and questionnaire was given to them at the end of beta testing period to compare the technical advantages of our mobile application with their currently preferred social media platform for oncology based education. Results: Among 311 responders, medical oncologists, radiation oncologists, surgical oncologists, hemato oncologists and oncopathologists constituted 45%, 29%, 16%, 7% and 3% respectively. Only 14% clearly denied that social media has improved educational outcomes. Eighty seven percent felt that they lack adequate knowledge in other areas of expertise and 67% of the oncologists were not well informed about the latest oncology updates. Only 60% could actively engage in interdiscliplinary collaboration due to reasons unspecified. When asked about the best way to learn a topic of interest, majority opined it through peer discussion with experts pertaining to that topic of interest. The two major problems faced by experts while seeking social media based education is academic discussions being unorganised and non-academic discussions unwelcomed. After considering these feedbacks, a mobile application in android version was developed. At the end of beta testing, 96% reported a technical advantage of our customised application over their preferred social media based oncology education. Conclusions: A minimum viable product has been developed after considering the feedbacks received from oncologists of various sub-specialities. Such a customised social media application is more appealing when easily applicable across low and middle income countries and in a manner that allows addition of local language options without changing the application software.

Aim: Sydenham's chorea is a post-streptococcal, autoimmune, neuropsychiatric movement disorder. Sydenham's chorea is a major criterion for diagnosis of acute rheumatic fever with the implication of potential long-term sequelae including cardiac complications. It is well established that there is psychiatric comorbidity in Sydenham's chorea, but there are variations in the literature regarding the nature and prevalence of psychiatric diagnoses associated with Sydenham's chorea. The aim of this review was to systematically evaluate the evidence for psychiatric symptoms presenting with Sydenham's chorea. Knowledge of comorbid psychiatric symptomatology will support early diagnosis and treatment, leading to improved long-term outcomes for children with Sydenham's chorea. Method: The study used a systematic search strategy, using MEDLINE, MEDLINE in Process, EMBASE, and The Cochrane Library. Abstracts were screened to identify relevant papers which were then assessed further. Eligible papers were summarized. Results: A total of 1429 abstracts of relevant studies were found, and 49 papers reporting neuropsychiatric symptoms in Sydenham's chorea were summarized. Obsessive-compulsive disorder was the most commonly studied, and hence reported, neuropsychiatric symptom in children with Sydenham's chorea. The studies analysed used a variety of tools to identify affected children and used different methods for analysing results. Attention-deficit–hyperactivity disorder, affective disorders, tic disorders, executive function disturbances, and psychotic features were also reported as comorbidities. Interpretation: There is good evidence of neuropsychiatric comorbidities in Sydenham's chorea. In countries with a high prevalence of rheumatic fever, the early recognition of salient cognitive and psychiatric symptoms may aid in the management of Sydenham's chorea.

To evaluate the clinical characteristics and outcome of acute pulmonary embolism in elderly in comparison to the younger patients.Study population consisted of 136 patients with a confirmed diagnosis of acute pulmonary embolism. Clinical characteristics and thromboembolic risk factors were analyzed between the elderly (or =65 years of age) and the younger (65 years of age) patients. In-hospital mortality was used as a measure of outcome.Elderly group consisted of 70 patients (age 76.4+/-8.3 years, range 65-96 years; females 58%) and younger group of 66 patients (age 48.5+/-12 years, range 18-64 years, females 59%). Syncope was more frequent in elderly group (19% vs. 6%, P=0.03) but the symptoms of shortness of breath and pleuritic chest pain were not significantly different between groups. Malignancy was the most common risk factor for thrombo-embolism, but immobilization predominated among patients in elderly group (21% vs. 6%, P=0.01). Tachycardia was common in younger patients compared to the elderly. Ventilation-perfusion scan was used more commonly in younger patients (76% vs. 57%, P=0.02), whereas, helical computed-tomography scan was used equally in both groups. Most of the patients had lower extremity duplex study (97% in each group). Inferior vena cava filter placement was common and thrombolytic therapy rare among elderly patients. Patients in elderly group had higher in-hospital mortality (17% vs. 5%, P=0.02).Syncope is a more frequent presenting symptom and immobilization a common risk factor in elderly patients with acute pulmonary embolism. In addition, they have higher in-hospital mortality.

Chagas' heart disease, caused by protozoan Trypanosoma cruzi, is a common cause of cardiomyopathy in the Americas. Transmission of T. cruzi occurs through Reduviids, the kissing bugs. Less common ways of transmission are blood transfusion, congenital transmission, organ transplantation, laboratory accident, breastfeeding, and oral contamination. Infestation results in cardiac dysautonomia, myocardial apoptosis, and myocardial fibrosis. In acute phase, death is mostly caused by myocarditis and in chronic phase, it is mostly by irreversible cardiomyopathy. A majority of the patients with Chagas' disease remain in the latent phase of disease for 10 to 30 years or even for life. Specific anti-Chagas' therapy with trypanocide drugs is useful in acute phase but the management of chronic Chagas' heart disease is mostly empirical. The mortality during the acute phase of cardiac Chagas is around 5%. Five-year mortality of chronic Chagas' disease with cardiac dysfunction is above 50%. The clinical aspects of the Chagas' heart disease are concisely reviewed.

Refractory angina pectoris is defined as Canadian Cardiovascular Society class III or IV angina, where there is marked limitation of ordinary physical activity or inability to perform ordinary physical activity without discomfort, with an objective evidence of myocardial ischemia and persistence of symptoms despite optimal medical therapy, life style modification treatments, and revascularization therapies. The patients with refractory angina pectoris may have diffuse coronary artery disease, multiple distal coronary stenoses, and or small coronary arteries. In addition, a substantial portion of these patients cannot achieve complete revascularization and continue to experience residual anginal symptoms that may impair quality of their life and increase morbidity. This represents an end-stage coronary artery disease characterized by a severe myocardial insufficiency usually with impaired left ventricular function. As the life expectancy is increasing, patients with angina pectoris refractory to conventional antianginal therapeutics are a challenging problem. We review the nonconventional therapies to treat the refractory angina pectoris, including pharmacotherapy, therapeutic angiogenesis, transcutaneus electrical nerve and spinal cord stimulation, enhanced external counterpulsation, surgical transmyocardial laser revascularization, percutaneous transmyocardial laser revascularization, percutaneous in situ coronary venous arterializations, and percutaneous in situ coronary artery bypass. These therapies are not supported by a large body of data and have only a complementary role; therefore, the aggressive traditional and proven treatment of angina pectoris should be continued along with these therapies, used on an individual basis.

Purpose: To evaluate the release of cardiac troponin I in normotensive patients with acute pulmonary embolism in relation to the duration of symptoms. Methods: Fifty-seven normotensive patients with acute pulmonary embolism were included in the study. Patients were divided into two groups based on the duration of symptoms at presentation: symptoms of ≤72 h, group A; symptoms of >72 h, group B. Serum cardiac troponin I levels were measured at presentation. Results: Mean age was 63±18 years and 23 (40%) patients were males. Thirty-three (58%) patients had symptoms of ≤72 h (group A) and 24 (42%) had symptoms of >72 h (group B). Both groups had similar prevalence of right ventricular dysfunction on echocardiography (55% [ n =18] in group A vs. 42% [ n =10] in group B, p =NS). Sixteen patients had elevated serum cardiac troponin I (mean±S.D. 3.3±2.3 ng/ml, range 0.6–8.3 ng/ml). Elevated serum cardiac troponin I was strongly associated with right ventricular dysfunction ( p =0.015). All patients with elevated serum cardiac troponin I ( n =16) were in group A ( p p =0.0005) and 4 of 15 (27%) patients without ( p =NS) right ventricular dysfunction had elevated serum cardiac troponin I. Thirteen of 16 (81%) patients with elevated serum cardiac troponin I had duration of symptoms ≤24 h at presentation. Conclusions: The dynamics of cardiac troponin I release in acute pulmonary embolism in patients who present with symptoms of ≤72 h duration could be different from those who present with longer duration of symptoms. Therefore, the use of cardiac troponin I in risk stratification of acute pulmonary embolism might be limited to the patients presenting within 72 h of the onset of symptoms.

Objective: The purpose of this study was to report a novel electrocardiographic (ECG) phenomenon in acute pulmonary embolism characterized by QT interval prolongation with global T-wave inversion. Methods: Among a total of 140 study patients with a confirmed diagnosis of acute pulmonary embolism, patients who fulfilled the inclusion criteria for QT interval prolongation with global T-wave inversion were examined. Each of these patients had undergone a detailed clinical evaluation including testing for myocardial injury and echocardiography. Results: QT interval prolongation with global T-wave inversion was found in five patients (age 51–68 years) with acute pulmonary embolism. Four were women. Acute pulmonary embolism was diagnosed by ventilation-perfusion scan in three patients and by spiral computed tomography in other two patients. None of the patients had any right or left ventricular regional wall motion abnormalities on echocardiography. All patients had changes characteristic of hemodynamically significant pulmonary embolism, including right ventricular stunning or hypokinesis and dilatation in five patients with paradoxical septal motion in four. Acute coronary syndrome was ruled out in each patient by clinical evaluation, serial ECGs and cardiac markers, and lack of regional wall motion abnormalities on echocardiography. Prolongation of QT intervals (QTc 456–521 ms) with global T-wave inversion was noted on presentation. The ECG changes gradually resolved in 1 week in all patients with appropriate treatment of acute pulmonary embolism. One patient died. None of the patients developed torsade de pointes. Conclusions: Acute pulmonary embolism may occasionally result in reversible QT interval prolongation with deep T-wave inversion, and, thus should be considered among the acquired causes of the long QT syndrome.

Carotid cavernous fistulae are an uncommon disorder, actually consisting of 2 disease processes. One category is a direct internal carotid artery to cavernous sinus fistula. A second category is the indirect or dural type carotid cavernous fistula. It is the purpose of this article to provide an overview of the anatomy of the cavernous sinus and to discuss the classification, clinical findings, diagnostic imaging evaluation, reasons for misdiagnosis, and treatment options.

Chagas heart disease is endemic in 21 countries with approximately 100 million people at risk. It is the most common cause of myocarditis in the Americas and is recognized to have existed for more than 4000 years (isolated from mummies). Chagas disease was discovered during the search to find a cause for the overwhelming deaths occurring in Brazil in the late 18th century. Physician Carlos Chagas discovered Trypanosome minasense in 1908 while researching on malaria. Subsequently, the existence of the barbeiro triatomine (insects bites on the face), the isolation of the Trypanosome cruzi in the triatomine and the first human description of a disease in a 9-month-old child depicted the existence of a new human trypanosomiasis. Chagas named the trypanosome species after his colleague and mentor Oswaldo Cruz. In subsequent papers, Chagas described the morphology and evolutionary cycle of the trypanosome and the clinical features of the disease, including involvement of the heart. Never before or since one physician has fully characterized a disease from its grass roots to the clinical forms more or less all by himself.

Ibutilide is a class III antiarrhythmic drug used for pharmacological cardioversion of recent-onset atrial fibrillation and flutter. The objective of the study was to assess the efficacy of ibutilide in elderly patients (age, >or=65 years). The study population consisted of 32 consecutive elderly patients (17 women, 15 men; mean age, 76 +/- 8 years; age range, 65-94 years) with recent-onset atrial fibrillation (19 patients) or flutter (13 patients). Ibutilide was administered 1-mg intravenously over 10 minutes, and a second 10-minute infusion of 1-mg was given if the arrhythmia did not terminate within 10 minutes after the end of initial infusion. Twenty-six patients received two 1-mg doses of ibutilide. The rate of successful arrhythmia termination was 59% (19 patients): 63% in patients with atrial fibrillation (12 of 19) and 54% in atrial flutter (7 of 12). The mean conversion time was 33 +/- 45 minutes. Three-fourths of the conversions occurred within 45 minutes of treatment. No clinical variables were correlated with success of cardioversion. Patients with a left atrial size of 50 mm or larger had a conversion rate of 50% compared with a conversion rate of 61% in patients with a left atrial size of less than 50 mm (P = NS). Ibutilide-induced lengthening in the QTc interval was of 17 +/- 21 milliseconds. Cardiac complications were torsade de pointes (1 patient), nonsustained ventricular tachycardia (1 patient), and transient bradycardia (1 patient). Torsade de pointes was terminated with direct current cardioversion. Ibutilide appears to be an effective drug for conversion of recent-onset atrial fibrillation and flutter in elderly patients under monitored conditions. Complications are rare and transient.

On 2 May 2008, a 25-year-old male patient on olanzapine 15 mg developed mild central chest pain, and blood tests revealed a high creatine kinase (CK) value at 1016 iu/l. Troponin, CK-MB, CK:MB ratio, full blood count (FBC), urea and electrolytes (UE), C reactive protein (CRP) and glucose were all normal. Liver enzymes were marginally raised: alanine aminotransferase (ALT) 91 iu/l, γ-glutamyl transferase (GGT) 46 iu/l, alkaline phosphatase (ALP) 137 iu/l. The ECG was normal and the chest pain later resolved and was thought likely to be due to costochondritis. A repeat blood test on 7 May revealed further elevation of CK at 1391 iu/l and olanzapine was stopped. CK continued to rise: 19 May 2857 iu/l, 20 May 3285 iu/l, and 22 May 3646 iu/l. On 30 May CK dropped to 708 iu/l, on 20 June it was 593 iu/l, and on 30 June CK was 343 iu/l. The patient was started on amisulpiride on 15 July and CK began to rise again: on 18 July it was 445 iu/l and on 31 July CK was 480 iu/l, at which time the medication was stopped. The patient did not have any signs or symptoms of physical disorder on this occasion.We have never seen a patient develop such high CK values in the absence of any clinical or other significant laboratory abnormalities. We can rule out exercise as the cause as he attends an inpatient unit and we are aware that his exercise has been light to moderate at most; also, he stopped exercising at our request on 7 May 2008, yet CK continued to rise. There is no clinical indication of other causes of elevated CK such as myositis, and CK-MB and CK-MB:CK ratio were normal throughout, so it was not cardiac in origin. We believe olanzapine caused the elevated CK value. When the patient was rechallenged with amisulpiride on 15 May his CK again rose and the medication therefore had to be stopped. There are three similar cases that have been reported in the past when patients on second generation antipsychotics developed CK elevation in the absence of other clinical or laboratory abnormalities. We therefore believe this is an important finding to report.

HRS occurs frequently in patients with advanced cirrhosis of the liver and fulminant hepatitis. The pathogenesis of HRS is not clearly understood; reduced effective plasma volume and intense renal cortical vasoconstriction seem to have important roles. The HRS is a diagnosis by exclusion, and it [table: see text] is often difficult to differentiate this entity from prerenal azotemia and ATN. The HRS is characterized by its relentless progression and usually fatal outcome. The essential steps in the management of HRS are to identify and correct the precipitating factors leading to HRS and avoidance of potential hepatotoxic and nephrotoxic drugs. Patients with potentially reversible liver diseases should be treated aggressively. Volume expansion is important and should be tried first, even though hypovolemia may be not clinically evident. Dialysis may benefit patients with fluid overload and electrolyte imbalance or those awaiting liver transplantation. In selective cases, peritoneovenous shunt may be of value. Liver transplantation is the only curative therapy available at present.

Hoarseness associated with mitral stenosis was initially described by Ortner. Several cardiopulmonary conditions were associated with left recurrent laryngeal nerve palsy over the last 100 years; thus, the syndrome is termed as cardiovocal syndrome or Ortner's syndrome. This study aimed to classify the various predisposing conditions and to explain the pathophysiology and treatment opportunities available for these patients.

The role of electrocardiography in identifying right ventricular (RV) dysfunction in acute pulmonary embolism (APE) was evaluated in 81 patients with APE. The electrocardiographic markers studied were T-wave inversion in leads V1 to V3, the S1Q3T3 pattern, right bundle branch block, and sinus tachycardia. T-wave inversion in leads V1 to V3 had the greatest sensitivity and diagnostic accuracy for identifying RV dysfunction in patients with APE. The S1Q3T3 pattern and right bundle branch block had good specificity but moderate accuracy.

The totally implantable catheter system has gained popularity as venous access when prolonged treatment is needed. Despite its frequent use, intravascular fracture and embolization of catheter fragments from implantable venous port-catheter systems present a rare but potentially life-threatening complication. Any implanted catheters should therefore be removed after completion of the treatment or the system's integrity should be monitored on a regular basis. This report illustrates such a case, which presented with ventricular tachycardia triggered by changes in body position from a fractured Mediport catheter with cardiac migration. A 34-year-old woman had a venous port catheter (Mediport) implanted into the right subclavian vein for neoadjuvant radio-chemotherapy for Hodgkin’s lymphoma. Owing to the patient's difficult venous access the catheter was left in situ after treatment. Three years after insertion of the Mediport she presented with shortness of breath and palpitations when lying in the left lateral position. Physical examination revealed no abnormalities. An electrocardiogram was within normal rhythm. An outpatient Holter monitor revealed multiple episodes of nonsustained and sustained ventricular tachycardia triggered by lying in the left lateral position. A chest radiograph showed a normal location of the port-system, but the distal fragment of the catheter had embolized into the right ventricle. The embolized fragment was extracted with a gooseneck snare technique and the reservoir of the system was removed under local anesthesia without any complications. The patient was free of symptoms at 7 seven months follow-up.

OBJECTIVE To evaluate the racial differences in the efficacy and safety of ibutilide in patients with recent-onset (

The calcium channel antagonists are generally safe in therapeutic dosage, but severe side effects with elevated intake are increasingly described. Typical features include confusion, lethargy, hypotension, sinus node depression, and cardiac conduction defects. Even if patients are stable on presentation, this does not preclude the possible late development of adverse events from the long-acting formulations of calcium channel blockers. A case of toxic overdose with 1440 mg of slow-release diltiazem is presented; this patient was stable on presentation, but rapidly became hemodynamically unstable, requiring treatment with intravenous calcium, temporary pacemaker, inotropic support and mechanical ventilation with a successful outcome. A concise review of the therapeutic considerations is provided.

Objective : Ibutilide, a class III antiarrhythmic agent used for pharmacological cardioversion of atrial arrhythmias, has a potential to cause QT-interval prolongation and torsade de pointes. Purpose of this study was to determine whether women are more prone to develop ibutilide-induced torsade de pointes. Methods : All clinical trials, cases, case series, and related articles in English-language in addition to 51 patients from our institution on the subject were examined. Results : In a database derived from 23 reports in literature and from our institution, 1720 patients received ibutilide for cardioversion of atrial arrhythmias. Only in 87% ( n =1492) patients, data were reported whether or not ibutilide caused torsade de pointes. The overall incidence of torsade de pointes was 3.9% ( n =58) patients. Data on sex distribution of ibutilide-induced torsade de pointes was available in 73% ( n =1096) patients. Torsade de pointes developed in 17 (5.6%) of 304 women and 24 (3%) of 792 men ( P =0.05). It occurred during or within 45 min after completion of the infusion of ibutilide. Treatment instituted was with intravenous magnesium sulfate alone in 14% ( n =8) patients, magnesium sulfate plus lidocaine in 5% ( n =3) patients, magnesium sulfate with electrical cardioversion in 17% ( n =10) patients, electrical cardioversion alone in 19% ( n =11) patients, and precordial thump in 3% ( n =2) patients. In 41% ( n =24) of patients who developed torsade de pointes, it resolved without treatment. There were no reported deaths secondary to torsade de pointes associated with ibutilide infusion. Conclusion : Incidence of ibutilide-induced torsade de pointes is higher in women than in men. Greater caution must be observed while using ibutilide in women.

Ibutilide is a class III antiarrhythmic agent used for the termination of atrial fibrillation and atrial flutter. It mainly affects membrane potassium currents and prolongs the cardiac action potential. This effect is reflected as QT interval prolongation on the surface electrocardiogram. Like other drugs that affect potassium currents, ibutilide is prone to induce a malignant ventricular tachycardia, torsade de pointes. We report four cases of torsade de pointes after administration of ibutilide for pharmacologic cardioversion of atrial fibrillation and atrial flutter; three of these cases required direct current cardioversion for termination of torsade de pointes. All four patients were female. We discuss the risk factors for development of ibutilide-induced torsade de pointes.

A 15 year old girl who had been previously fit and well presented to the child and adolescent mental health services (CAMHS) team with weight loss, irregular menstrual periods, excessive exercise, restriction of energy intake during the day, and binging during the evening, followed by vomiting. Her symptoms had been present for a year, since her father had experienced a myocardial infarction. Clinically her symptoms were in keeping with anorexia nervosa, as shown by her completed eating disorder questionnaire.1 Her body mass index (BMI) was 16 and her weight for height was 85% of the median (50th centile) for age and sex. She had a distorted body image, believing her stomach and ankles were too fat, and she had an extreme fear of gaining weight. She was admitted to an acute medical unit as an emergency after developing severe dehydration with hypotension, tachycardia, dizziness, low energy, and inability to concentrate. She was found to have hypokalaemia, hypophosphataemia, high bicarbonate levels, and a high amylase concentration. She was given fluid replacement and her electrolyte balance was corrected. CAMHS and the specialist eating disorders team followed her up in the community. ### 1 What is the cause of the blood result picture? #### Short answer This picture is caused by excessive vomiting in patients with an eating disorder who are underweight or normal weight. It can also be seen in patients who have been severely restricting their diet or have stopped eating but have had feeding reinstated, putting them at risk of refeeding syndrome. #### Long answer Hypokalaemia is caused by self …