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Embolic stroke following cardioversion of atrial fibrillation to sinus rhythm with oral amiodarone therapy Sir, Risk of stroke associated with atrial fibrillation is well recognized.'-3 Patients not anticoagulated who undergo elective cardioversion are at risk of developing embolic complications.4 Amiodarone is frequently used for treatment of atrial fibrillation and it is known to cause chemical cardioversion. We report a case of disabling stroke after amiodarone-induced cardioversion of atrial fibrillation.A 66 year old woman with a history of paroxysmal atrial fibrillation was treated with amiodarone as she had symptomatic atrial fibrillation of 5 weeks duration. She was not on prophylactic antiarrhythmic drugs and her previous attacks were infrequent and short lasting. Although she was hypertensive she had not suffered from ischaemic heart disease or transient ischaemic attacks. She was on propranolol 160 mg daily for hypertension.Clinical examination revealed atrial fibrillation at 120/min and her blood pressure was 120/80 mmHg. There was no evidence of cardiomegaly, valvular heart disease or carotid bruits. Her chest X-ray was normal and the electrocardiogram confirmed atrial fibrillation. Eleven days after commencing amiodarone the patient felt her heart rhythm change as she no longer experienced palpitations or difficulty in breathing. Approximately 4 hours later she developed sudden onset numbness and weakness of the right arm and leg. She had evidence of hemiparesis and extensor plantar response on the right side and her pulse was regular at a rate of 66 per min. The electrocardiogram confirmed sinus rhythm. Routine blood tests including thyroid function tests were normal. M-mode echocardiography revealed normal sized left atrium, left ventricle and a normal ejection fraction. Computed tomographic brain scan showed evidence of an area of cerebral infarction in the left parietal lobe. Anticoagulation was commenced 3 weeks later and amiodarone therapy was continued. With intensive rehabilitation she made a gradual but satisfactory recovery.It is likely that this patient suffered from a thromboembolic stroke following chemical cardioversion due to amiodarone. Although she received treatment for hypertension the sudden onset neurological deficit with no progression coincided well with the change in her heart rhythm. As she had suffered from atrial fibrillation in the past she was well aware of the physical symptoms relating to changes in her heart rhythm. This episode of atrial fibrillation had lasted longer than usual and the reversion to sinus rhythm was influenced by the recent addition of amiodarone.

A case of post-gastrectomy malnutrition with hypoproteinaemia and multiple deficiencies is reported. The initial cachectic state was associated with low secretion of proteases. The authors have observed a rapid improvement of clinical and laboratory findings and an increase of pancreatic enzyme secretion after administration of a high protein diet and pancreatic extracts. Interruption of the treatment and return to alcoholic habits resulted in a relapse to malnutrition and, finally, a fatal issue.

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