Background-Pacemaker pocket infection is a potentially serious problem after permanent pacemaker implantation. Antibiotic prophylaxis is commonly prescribed to reduce the incidence of this complication, but current trial evidence of its efficacy is conflicting. A large prospective randomised trial was therefore performed of antibiotic prophylaxis in permanent pacemaker implantation. The intention was firstly to determine whether antibiotic prophylaxis is efficacious in these patients and secondly to identify which patients are at the highest risk of infection. Methods-A prospective randomised open trial of flucloxacillin (clindamycin if the patient was allergic to penicillin) v no antibiotic was performed in a cohort of patients undergoing first implantation of a permanent pacing system over a 17 month period. Intravenous antibiotics were started at the time of implantation and continued for 48 hours. The trial endpoint was a repeat operation for an infective complication. Results-473 patients were entered into a randomised trial. 224 received antibiotic prophylaxis and 249 received no antibiotics. A further 183 patients were not randomised but were treated according to the operator's preference (64 antibiotics, 119 no antibiotics); these patients are included only in the analysis of predictors ofinfection. Patients were followed up for a mean (SD) of 19(5) months. Among the patients in the randomised group there were nine infections requiring a repeat operation, all in the group not receiving antibiotic (P = 0.003). In the total patient cohort there were 13 infections, all but one in the non-antibiotic group (P = 0.006).

Background-In acute myocardial infarction patients who do not reperfuse their infarct arteries shortly after thrombolytic treatment have a high morbidity and mortality. Management of this high risk group remains problematic, especially in centres without access to interventional cardiology. Additional thrombolytic treatment may result in reperfusion and improved left ventricular function. Methods-Failure of reperfusion was assessed non-invasively as less than 25% reduction of ST elevation in the electrocardiographic lead with maximum ST shift on a pretreatment electrocardiogram. 37 patients with acute myocardial infarction who showed electrocardiographic evidence of failed reperfusion 30 minutes after 1.5 MU streptokinase over 60 minutes were randomly allocated to receive either alteplase (tissue type plasminogen activator (rt-PA) 100 mg over three hours) (19 patients) or placebo (18 patients). 43 patients with electrocardiographic evidence of reperfusion after streptokinase acted as controls. Outcome was assessed from the Selvester Q wave score of a predischarge electrocardiogram and a nuclear gated scan for left ventricular ejection fraction 4-6 weeks after discharge. Results-Among patients in whom ST segment elevation was not reduced after streptokinase, alteplase treatment resulted in a significantly smaller electrocardiographic infarct size (14% (8%) v 20% (90%), P = 0.03) and improved left ventricular ejection fraction (44 (10%) v 34% (16%), P = 0-04) compared with placebo. This benefit was confined to patients who failed fibrinogenolysis after streptokinase (fibrinogen > 1 gIl). In patients in whom ST segment elevation was reduced after streptokinase, infarct size and left ventricular ejection fraction were not significantly different from those in patients treated with additional alteplase. Conclusion-Patients without electrocardiographic evidence of reperfusion after streptokinase may benefit from further thrombolysis with alteplase. (Br Heart 7 1995;74:348-353)

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Angina pectoris is a common medical condition with a high mortality and morbidity rate and normally requires medical therapy to control symptoms. The impact of angina and treatment strategies are gauged almost solely on clinical measurements. This approach does not provide insight into the effects of the disease from the patients' perspectives. Understanding these effects enables a patient centred approach to care, which may facilitate adherence to treatment strategies. Previous studies examining heart disease from the patients' perspective have tended to focus on myocardial infarction or coronary surgery and not, as this study does, on angina per se. Unstructured interviews of seven patients with clinically stable angina pectoris were carried out and analysed using a phenomenological approach. Seven themes were identified: limitation and adjustment; resignation; indignation; caution; reluctant compliance; surprise; and the unknown. Patients made adjustments to their lifestyles because of the limitations imposed on them by angina. These changes were accepted reluctantly, initially with annoyance, but ultimately with resignation. They were cautious in everyday activities to avoid something ‘worse’ happening. On the whole, they were surprised that they had developed the disease despite little understanding of risk factors. They had not considered the long-term effects of the disease. Angina patients need to have access to information sources to understand the disease and to make adjustments to their lives. An opportunity to discuss the disease with a specialist health care professional is essential. The study showed that phenomenology has a contribution to make in areas such as cardiology where the research agenda is predominantly positivistic.