A review of hand-held Electrocardiogram (ECG) recording devices

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): St Barts NHS Trust

Introduction

The advent of portable hand-held devices to record an electrocardiogram (ECG) in-clinic, has the potential to streamline patient assessment in many clinical environments. These ECG technologies are able to record one to six lead ECGs and enable rapid responses to clinical situations. These devices may also have a role in reducing interdepartmental movement of patients during the COVID-19 pandemic, by facilitating a one-stop shop for clinical evaluation.  However despite their benefit, they can be more prone to artefact than a 12-lead ECG.

Purpose

To describe the currently available hand-held ECG technologies, their ease of use and diagnostic accuracy for rhythm assessment.

Method

An online review was conducted to identify new ECG technologies. Clinical colleagues were also surveyed for recommendations with respect to specifications, availability of alternative products, and informed of the inclusion /exclusion criteria. The review included devices which had built-in abnormal rhythm notification or display, were cost-effective and easy to use. Devices were automatically excluded if cutaneous skin electrodes were required, no in-built ECG display or notification, additional data transfer required to access ECG data or a high unit cost.

Results

An initial search uncovered nine devices, with five meeting inclusion /exclusion criteria. These devices were tabulated and compared predefined criteria (See table 1: ECG Technology comparisons). The analysis revealed that all devices utilised two finger placement on their recording electrodes to produce immediate ECG results – no cutaneous ECG application required. The KardiaMobile 6L™ had the largest number of beneficial features, namely multi-channel device, QTc interpretation, rapid diagnosis time and low cost. The intended use of hand-held devices is to detect AF. Four of five devices produced a snapshot ECG for rhythm identification on their display. However, AfibAlert™ devices provided an instant light alert if atrial fibrillation (AF) was detected. Instant check™, Dimitek™ and AfibAlert™ benefit from being complete stand-alone devices. In contrast, KardioMobile devices have a built-in ECG display for instant review however, they require a smart phone or tablet to store and transfer the data. These devices support a reliable internal AF algorithm to obtain a high negative predicted value to safely rule out AF. Frequent premature atrial contractions (PACs) are often difficult to distinguish from AF and can lead to high false-positive rate. Hand-held devices are prone to artefact, however accurate visual assessment able to significantly reduce the amount of ECGs deemed uninterpretable.

Conclusions

Hand-held ECG technology has potential to become a useful, cost-effective tool during patient consultations, with rapid identification of clinically important arrhythmias. However, limitations exist across providers. A pilot trial of these devices is planned to assess further.

Herniography: a prospective, randomized study between midline and left iliac fossa puncture techniques

AIM

To determine whether an optimal site of injection exists for herniography.

MATERIALS AND METHODS

This was a prospective, randomized study of 93 consecutive patients who were referred for herniography over a period of 9 months. Patients underwent either a left iliac fossa (LIF) or midline puncture. Parameters assessed included initial adequate needle placement, complications, pain scores and body mass index (BMI). The groups were compared using Chi-squared test for categorical data, Student's t-test for continuous data and the Mann-WhitneyU-test for skewed data, withP < 0.05 considered statistically significant

RESULTS

Four complications were encountered (4%), and these were equally distributed between the two groups. Adequate initial positioning of the needle was similar in both groups. The volume of local anaesthetic used was correlated with discomfort using a pain scale: a volume of >6 ml resulted in significantly more pain. More frequent initial adequate needle placement was observed in thin patients (BMI < 45 kg/m(2)) with experienced operators. Conversely, increased body mass index resulted in more difficult needle placement.

CONCLUSION

Herniography is a safe procedure with few complications. There was no significant difference comparing the midline and LIF approaches.Nadkarni, S.et al. (2001). Clinical Radiology56, 389-392.

The role of the radiologist in surgical management: an audit of clinico-radiological conferences

A prospective analysis of the radiological findings and final diagnoses of 342 patients discussed at joint surgical/radiological conferences over a seven-month period was undertaken in an attempt to define the role of the radiologist in the clinical management of surgical patients. Although the diagnosis had already been correctly made on clinical or radiological grounds in 38% (130/342) of patients presented at the X-ray conferences, careful review of the films resulted in an immediate firm diagnosis in a further 9% (31/342), or promoted further radiological investigations which were responsible for an eventual definitive diagnosis in 20% of the remainder (32/169). The input of the radiologist in selecting the most appropriate additional investigation was particularly valuable in the management of more complex clinical problems.

A blinded prospective trial of low-residue versus normal diet in preparation for barium enema

This study was undertaken to determine whether the omission of a low-residue diet in the days leading up to barium enema resulted in poorer bowel preparation. 300 patients were randomized prospectively into one of two groups. One group followed a low-residue diet for the 3 days leading up to the study, the other continued their usual diet. Both groups had two doses of "Picolax" the day before the study. 17 patients did not attend, and a further two patients were excluded, leaving 281 patients for prospective study. The subsequent investigation was assessed blind by a consultant radiologist and graded for faecal residue, mucosal coating and diagnostic quality. No statistically significant difference was found between the two groups for amount of faecal residue (p < 0.25), mucosal coating (p < 0.25) or diagnostic quality (p < 0.5). We conclude, therefore, that a preliminary low-residue diet is unnecessary in the preparation of patients for barium enema. Patients should continue with their usual diet up to the day prior to the test and then have standard purgative preparation.

Intestinal endometriosis: presentation, investigation, and surgical management

The study was undertaken to identify the presenting features of intestinal endometriosis and to evaluate its investigation and surgical management. Twenty-six cases of intestinal endometriosis were identified during a fourteen year period. The commonest site of occurrence was the rectosigmoid region (11 cases) followed by the appendix (9 cases), and ileocaecal region (6 cases). Abdominal pain was the main presenting feature in 20 cases, with associated nausea and vomiting in 12 cases and altered bowel habit in ten. Other presenting features included rectal bleeding, abdominal bloating and tenesmus. Endometriosis was not suspected preoperatively in any of the patients without a past history of this condition. Accurate preoperative diagnosis proved very difficult, with only laparoscopy providing definite evidence of intestinal endometriosis prior to formal surgery. Colonic resections were performed in 12 cases, small bowel resection in six cases and appendicectomy in nine cases, together with resection of adjacent adherent structures. This series illustrates the difficulty of establishing an accurate preoperative diagnosis, and the propensity of intestinal endometriosis to mimic other gastrointestinal diseases, particularly carcinoma and inflammatory bowel disease.

Xanthogranulomatous cholecystitis

Clinical, radiological and pathological findings in 31 patients with xanthogranulomatous cholecystitis have been reviewed. The spectrum of presentation was similar to that of cholelithiasis but fewer patients had biliary colic (17 per cent) and there were more complications (32 per cent). Four patients had a biliary fistula and four a perforated gallbladder with abscess formation. Patients characteristically had gallstones. Appearances often mimicked carcinoma of the gallbladder at ultrasonography and/or laparotomy, with xanthogranulomatous tissue extending to adjacent structures. Xanthogranulomatous cholecystitis and carcinoma of the gallbladder coexisted in three patients. The possibility should be considered that an 'inoperable tumour' of the gallbladder may in fact be xanthogranulomatous cholecystitis, a benign condition that frozen-section biopsy may confirm.

A comparative trial of magnesium citrate (Citramag) and Picolax for barium enema bowel preparation

It has previously been suggested that a single dose of magnesium citrate produces adequate cleansing of the bowel for barium enema examination. To determine whether such a regimen has any advantage over the widely used two doses of Picolax, a prospective randomized blinded trial was performed with over 100 patients allocated to each of the bowel preparation regimens. Radiographs were assessed for quality of mucosal coating, faecal residue and overall quality of bowel preparation. Patient compliance was good with both regimens. Normal daily activities were inconvenienced significantly more by the Picolax (P < 0.001), whereas the magnesium citrate (Citramag) caused more interruption of sleep (P < 0.01). Mucosal coating was similar with both regimens. There was more faecal residue and poorer overall bowel preparation with Citramag (P < 0.001), although diagnostic accuracy was only infrequently felt to be compromised as a result. Citramag may offer an alternative to Picolax in patients where minimal disruption to daily activities is desirable and where the detection of polyps is not critical.

Anterior abdominal wall hernias: diagnosis by ultrasound and tangential radiographs

Spigelian and epigastric hernias can cause diagnostic problems as they often present in elderly, obese patients with few specific symptoms or signs. Early diagnosis is important as both groups of hernia have a high rate of bowel strangulation. The combined value of ultrasound and tangential radiographs in the diagnosis of these hernias is presented along with a review of the literature.

Upper tract tumours following cystectomy for bladder cancer. Is routine intravenous urography worthwhile?

The incidence and presentation of upper tract tumours were studied in 180 patients who had previously undergone cystectomy for transitional cell carcinoma of the bladder. Intravenous urography was performed routinely 3 months after cystectomy, 1 year later and at 3-yearly intervals thereafter. Ten patients developed upper tract tumours; 1 presented with loin pain and the remainder with haematuria. Six patients underwent nephroureterectomy and 5 of them lived for at least 4 years; 4 were inoperable and only 1 survived longer than 6 months. In this series, all patients with upper tract tumours presented with symptoms and routine intravenous urography failed to detect any asymptomatic lesions. Routine radiological assessment of the upper tracts to detect tumours is not justified following cystectomy.

Ultrasound in the investigation of the right iliac fossa mass

Patients presenting with a right iliac fossa (RIF) mass are a diagnostic problem. The objective of this study was to assess the role of ultrasound (US) in their investigation. A prospective series of 50 patients presenting with a clinically suspected RIF mass was examined by US and the finding correlated with the final diagnosis. There was a positive finding in 34 patients (68%). Ultrasound correctly identified the organ of origin in 33 (97%) and was able to guide the patients' further management. In 12 cases no abnormality was found in the RIF, of which 11 had no positive findings at follow-up and one was shown to have an unrelated abnormality at laparotomy. In four cases the findings were due to normal variants. Ultrasound is the imaging modality of first choice in patients presenting with a RIF mass.

Case report: recurrent liposarcoma of the oesophagus

A case of recurrent liposarcoma of the oesophagus is presented. The clinical and radiological findings are discussed. Our case displays the characteristic features and behaviour of a common sarcoma arising in a rare site.

Pleural effusions and pancreatico-pleural fistulae associated with asymptomatic pancreatic disease

Four patients are described in whom recurrent large pleural effusions developed secondary to asymptomatic pancreatic disease. The diagnosis was made by measuring the amylase content of the pleural fluid. Endoscopic retrograde cholangiopancreatography (ERCP) and computed tomography (CT) were useful in demonstrating pancreatico-pleural fistulae. Two patients underwent laparotomy and distal pancreatectomy. One recovered spontaneously after ERCP appeared to relieve an obstruction of the pancreatic duct and the other recovered after a period of parenteral nutrition. We suggest that pleural fluid amylase content should be measured in any case of exudative pleural effusion of unknown aetiology.

The dexamethasone suppression test and depressive symptoms in early and late withdrawal from alcohol

Results of the dexamethasone suppression test (DST) in 30 alcoholic patients tested on day 5 and again on day 25 after their last drink are presented. Nineteen patients (63%) failed to suppress cortisol on day 5; three (11%) failed to suppress cortisol on day 25. Depressive symptoms, measured by the Beck Depression Inventory, were significantly correlated with DST results; the lifetime diagnosis of depressive illness was not. The authors conclude that the DST is not useful in detecting primary affective disorders during the early phase of withdrawal from alcohol.

Complete External Dislocation of the Astragalus Bone

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