Tutorial : 1
باطنيةد. مزاحم الجيتجي
عدد الاوراق (13)
ELECTROCARDIOGRAPHY(ECG)A 55 year old man with 4 hours of "crushing" chest pain.
Acute inferior myocardial infarctionST elevation in the inferior leads II, III and aVF
reciprocal ST depression in the anterior leads See also HYPERLINK "http://www.ecglibrary.com/ami.html" \t "_parent" acute anterior HYPERLINK "http://www.ecglibrary.com/ami.html" \t "_parent" MI. HYPERLINK "http://www.ecglibrary.com/rbbb.html" \t "_parent"
HYPERLINK "http://www.ecglibrary.com/rbbb.html" \t "_parent" Right Bundle Branch Block and HYPERLINK "http://www.ecglibrary.com/sbrady.html" \t "_parent" sinus bradycardia are also present.
normal QT interval
Calculate the corrected QT interval (QTc) by dividing the QT interval by the square root of the preceeding R - R interval. Normal = 0.42 s. Causes of HYPERLINK "http://www.ecglibrary.com/l_qt.html"long QT intervalmyocardial infarction, myocarditis, diffuse myocardial disease hypocalcaemia, hypothyrodism subarachnoid haemorrhage, intracerebral haemorrhage drugs (e.g. sotalol, amiodarone)
hereditary HYPERLINK "http://www.ecglibrary.com/l_qt.html"Romano Ward syndrome (autosomal dominant) Jervill + Lange Nielson syndrome (autosomal recessive) associated with sensorineural deafness normal ST segment no elevation or depression causes of elevation include acute MI (e.g. HYPERLINK "http://www.ecglibrary.com/ami.html"anterior, HYPERLINK "http://www.ecglibrary.com/infmi.html"inferior), HYPERLINK "http://www.ecglibrary.com/lbbbimi.html"left bundle branch block, normal variants (e.g. athletic heart, Edeiken pattern, high-take off), acute pericarditis causes of depression include myocardial ischaemia, HYPERLINK "http://www.ecglibrary.com/dig.html"digoxin effect, HYPERLINK "http://www.ecglibrary.com/lvhlah.html"ventricular hypertrophy, HYPERLINK "http://www.ecglibrary.com/postlat.html"acute posterior MI, HYPERLINK "http://www.ecglibrary.com/pe.html"pulmonary embolus, HYPERLINK "http://www.ecglibrary.com/lbbbimi.html"left bundle branch block normal T wave causes of tall T waves include HYPERLINK "http://www.ecglibrary.com/highk.html"hyperkalaemia, HYPERLINK "http://www.ecglibrary.com/infmi.html"hyperacute myocardial infarction and HYPERLINK "http://www.ecglibrary.com/lbbbimi.html"left bundle branch block causes of small, flattened or inverted T waves are numerous and include ischaemia, age, race, hyperventilation, anxiety, drinking iced water, HYPERLINK "http://www.ecglibrary.com/lvhlah.html"LVH, drugs (e.g. HYPERLINK "http://www.ecglibrary.com/dig.html"digoxin), pericarditis, HYPERLINK "http://www.ecglibrary.com/pe.html"PE, intraventricular conduction delay (e.g. HYPERLINK "http://www.ecglibrary.com/rbbb.html"RBBB)and electrolyte disturbance. normal U wave
A 63 year old woman with 10 hours of chest pain and sweating.
SHAPE \* MERGEFORMAT
Acute anterior myocardial infarction
ST elevation in the anterior leads V1 - 6, I and aVLreciprocal ST depression in the inferior leads
A 60 year old woman with 3 hours of chest pain.
Acute posterior myocardial infarction
(hyperacute) the mirror image of acute injury in leads V1 - 3(fully evolved) tall R wave, tall upright T wave in leads V1 -3
usually associated with inferior and/or lateral wall MI
A 53 year old man with Ischaemic Heart Disease.
SHAPE \* MERGEFORMATOld inferior myocardial infarction
a Q wave in lead III wider than 1 mm (1 small square) and
a Q wave in lead aVF wider than 0.5 mm and
a Q wave of any size in lead II
A 79 year old man with 5 hours of chest pain.
Acute myocardial infarction in the presence of left bundle branch block
Features suggesting acute MI
ST changes in the same direction as the QRS (as shown here)
ST elevation more than you'd expect from LBBB alone (e.g. > 5 mm in leads V1 - 3)
Q waves in two consecutive lateral leads (indicating anteroseptal MI) (ref. Sgarbossa EB et al, N Engl J Med 1996;334:481-7)
An 83 year old man with aortic stenosis.
Left ventricular hypertrophy (LVH) There are many different criteria for LVH. Sokolow + Lyon (Am Heart J, 1949;37:161) S V1+ R V5 or V6 > 35 mm Cornell criteria (Circulation, 1987;3: 565-72) SV3 + R avl > 28 mm in men SV3 + R avl > 20 mm in women Framingham criteria (Circulation,1990; 81:815-820) R avl > 11mm, R V4-6 > 25mm S V1-3 > 25 mm, S V1 or V2 + R V5 or V6 > 35 mm, R I + S III > 25 mm Romhilt + Estes (Am Heart J, 1986:75:752-58) Point score system Left atrial abnormality (dilatation or hypertrophy) M shaped P wave in lead II prominent terminal negative component to P wave in lead V1 (shown here) See also - HYPERLINK "http://www.ecglibrary.com/m_sten.html" \t "_parent" mitral stenosis.
A 75 year old lady with loud first heart sound and mid-diastolic murmur.
Mitral StenosisThere is HYPERLINK "http://www.ecglibrary.com/af_fast.html" \t "_parent" atrial fibrillation. No P waves are visible. The rhythm is irregularly irregular (random).
There is the suggestion of right ventricular hypertrophy. Right axis deviation and deep S waves in the lateral leads. Another important feature of right ventricular hypertrophy not shown here is a dominant R wave in lead V1.
The combination of Atrial Fibrillation and Right Axis Deviation on the ECG suggests the possibility of mitral stenosis.
See also - HYPERLINK "http://www.ecglibrary.com/lvhlah.html" \t "_parent" aortic stenosis.
A 59 year old lady with chronic bronchitis.
Right atrial hypertrophy
A P wave in lead II taller then 2.5 mm (2.5 small squares).The P wave is usually pointed.
An 84 year old lady with hypertension
There are a number of abnormalities here.
left anterior hemiblock
HYPERLINK "http://www.ecglibrary.com/axis.html" \t "_parent" QRS axis more left than -30 degrees
initial R wave in the inferior leads (II, III and aVF)
absence of any other cause of HYPERLINK "http://www.ecglibrary.com/axis.html" \l "l" \t "_parent" left axis deviation
left ventricular hypertrophy
In the presence of left anterior hemiblock the HYPERLINK "http://www.ecglibrary.com/lvhlah.html" \t "_parent" diagnostic criteria of LVH are changed. Rosenbaum suggested that an S wave in lead III deeper than 15 mm as predictive of LVH.
long PR interval (also called first degree heart block)
PR interval longer than 0.2 seconds
left atrial hypertrophy
M shaped P wave in lead II
P wave duration > 0.11 seconds
terminal negative component to the P wave in lead V1
A 73 year old woman with dizziness.
SHAPE \* MERGEFORMAT
2 to 1 AV block
every other P wave is conducted to the ventricles
2 to 1 AV block starts after the 5th QRS in this 3 channel recording. The first non-conducted P wave is indicated with an arrow.
the PR interval of conducted P waves is constant
in this lady there is a HYPERLINK "http://www.ecglibrary.com/lll.html" \t "_parent" long PR interval (and HYPERLINK "http://www.ecglibrary.com/lbbbimi.html" \t "_parent" left bundle branch block)
2 to 1 AV block cannot be classified into Mobitz type I or II as we do not know if the 2nd P wave would be conducted with the same or longer PR interval.
A 70 year old man with exercise intolerance
Complete Heart BlockP waves are not conducted to the ventricles because of block at the AV node. The P waves are indicated below and show no relation to the QRS complexes. They 'probe' every part of the ventricular cycle but are never conducted.
The ventricles are depolarised by a ventricular escape rhythm
An 82 year old lady with dizzy spells.
Atrial fibrillation and complete heart block
Fibrillary waves of atrial fibrillation and no P waves.Regular ventricular rhythm
The wider the QRS of the ventricular escape rhythm the less reliable the escape mechanism.
AF with complete heart block can be easily missed and is an indication for a permanent pacemaker.
A 55 year old man with 4 hours of "crushing" chest pain.
Right Bundle Branch Block
wide QRS, more than 120 ms (3 small squares)secondary R wave in lead V1
other features include slurred S wave in lateral leads and T wave changes in the septal leads
See also HYPERLINK "http://www.ecglibrary.com/lll.html" \t "_parent" Left Bundle Branch Block. HYPERLINK "http://www.ecglibrary.com/infmi.html" \t "_parent"
HYPERLINK "http://www.ecglibrary.com/infmi.html" \t "_parent" Acute inferior MI and HYPERLINK "http://www.ecglibrary.com/sbrady.html" \t "_parent" sinus bradycardia are also present.
A 34 year old lady with asthma.
Sinus tachycardia
P wave rate greater than 100 bpmSee also HYPERLINK "http://www.ecglibrary.com/sbrady.html" \t "_parent" sinus bradycardia.
A 60 year old man with hypertension.
trial Bigeminyeach beat is followed by an HYPERLINK "http://www.ecglibrary.com/apb.html" \t "_parent" atrial premature beat
A 48 year old man with thumping sensations in his chest. SHAPE \* MERGEFORMAT
Atrial Premature Beat (APB)
an abnormal P wave (arrowed in figure below)
As P waves are small and rather shapeless the difference in an APB is usually subtle. The one shown here is a clear example.
occurs earlier than expected
followed by a compensatory pause - but not a full compensatory pause (see HYPERLINK "http://www.ecglibrary.com/l_qt.html" \t "_parent" ventricular HYPERLINK "http://www.ecglibrary.com/l_qt.html" \t "_parent" premature beat
A 76 year old man with breathlessness.
Atrial fibrillation with rapid ventricular response
Irregularly irregular ventricular rhythm.Sometimes on first look the rhythm may appear regular but on closer inspection it is clearly irregular.
A 60 year old woman with hypertension.
SHAPE \* MERGEFORMATAtrial fibrillation with pre-existing left bundle branch block
Sometimes this can be confused with HYPERLINK "http://www.ecglibrary.com/vtavd1.html" \t "_parent" ventricular tachycardia but closer inspection can identify the irregularity.Irregularly irregular rhythm - suggesting AF.
Features of typical HYPERLINK "http://www.ecglibrary.com/lbbbimi.html" \t "_parent" left bundle branch block
wide QRS >120 ms (3 small squares)
no secondary R wave in lead V1
no lateral Q waves
A 68 year old lady on digoxin complaining of lethargy.
SHAPE \* MERGEFORMATAtrial flutter
A characteristic 'sawtooth' or 'picket-fence' waveform of an intra-atrial re-entry circuit usually at about 300 bpm.
This lady was taking rather too much digoxin and has a very slow ventricular response.
An 57 year old lady with palpitations.
Atrial flutter with 2:1 AV conduction The sawtooth waveform of atrial flutter can usually be seen in the inferior leads II, III and aVF if one looks closely. Sometimes the rapid atrial rate can be seen in V1. Suspect atrial flutter with 2:1 block when you see a rate of about 150 bpm. The atrial rate is shown to be twice the ventricular rate in the figure below. See also HYPERLINK "http://www.ecglibrary.com/aflut.html" \t "_parent" atrial flutter with slow ventricular response.
A 47 year old man with a long history of palpitations and, lately, blackouts.
Wolf-Parkinson-White syndrome with atrial fibrillation irregularly irregular, wide complex tachycardia impulses from the atria are conducted to the ventricles via either both the AV node and accessory pathway producing a broad fusion complex or just the AV node producing a narrow complex (without a delta wave) or just the accessory pathway producing a very broad 'pure' delta wave people who develop this rhythm and have very short R - R intervals are at higher risk of VFA lady with Romano-Ward syndrome.
Long QT interval The QT interval normally varies with heart rate - becoming shorter at faster rates. It is usually corrected using the cycle length (R-R interval) as shown opposite. normal QTc = 0.42 seconds Romano-Ward syndrome is an autosomal dominantly inherited form of long QT interval and there is a risk of recurrent ventricular tachycardia, particularly HYPERLINK "http://www.ecglibrary.com/tdp.html" \t "_parent" Torsade de Pointes. Ventricular premature beats (VPBs) 2 ventricular premature beats are also shown in this ECG They are: broad occur earlier than normal and are followed by a full compensatory pause (the distance between the normal beats before and after the VPB is equal to twice the normal cycle length).A 50 year old man with chest pain for 24 hours
entricular bigeminya HYPERLINK "http://www.ecglibrary.com/l_qt.html" \t "_parent" ventricular premature beat follows each normal beat
There are also features of an HYPERLINK "http://www.ecglibrary.com/infmi.html" \t "_parent" acute inferior myocardial infarction.
A 70 year old man with exercise intolerance.
Complete Heart Block
P waves are not conducted to the ventricles because of block at the AV node. The P waves are indicated below and show no relation to the QRS complexes. They 'probe' every part of the ventricular cycle but are never conducted.
The ventricles are depolarised by a ventricular escape rhythm.
A 45 year old lady with palpitations and history of chronic renal failure
Ventricular tachycardia A wide QRS tachycardia is VT until proven otherwise (1). Features suggesting VT include:- evidence of AV dissociation independent P waves (shown by arrows here) capture or fusion beats beat to beat variability of the QRS morphology very wide complexes (> 140 ms) the same morphology in tachycardia as in ventricular ectopics history of ischaemic heart disease absence of any rS, RS or Rs complexes in the chest leads (2) concordance (chest leads all positive or negative) 1) Griffith MJ, Garrat CJ, Mounsey P, Camm AJ. Ventricular tachycardia as the default diagnosis in broad complex tachycardia. Lancet. 1994;343:386- 2) Brugada P, Brugada J, Mont L, et al. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991;83:1649-1659A 69 year old man 2 weeks after an inferior myocardial infarction
Ventricular tachycardia A wide QRS tachycardia is VT until proven otherwise (1). Features suggesting VT include:- evidence of AV dissociation independent P waves capture or fusion beats beat to beat variability of the QRS morphology (shown here) very wide complexes (> 140 ms) the same morphology in tachycardia as in ventricular ectopics history of ischaemic heart disease absence of any rS, RS or Rs complexes in the chest leads (2) concordance (chest leads all positive or negative) 1) Griffith MJ, Garrat CJ, Mounsey P, Camm AJ. Ventricular tachycardia as the default diagnosis in broad complex tachycardia. Lancet. 1994;343:386- 2) Brugada P, Brugada J, Mont L, et al. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991;83:1649-1659 N.B. The computer-aided diagnosis can often be misleading.A 60 year old man with Ischaemic Heart Disease.
Polymorphous ventricular tachycardia (Torsade de pointes).
This is a form of VT where there is usually no difficulty in recognising its ventricular origin.wide QRS complexes with multiple morphologies
changing R - R intervals
the axis seems to twist about the isoelectric line
it is important to recognise this pattern as there are a number of reversible causes
heart block
hypokalaemia or hypomagnesaemia
drugs (e.g. tricyclic antidepressant overdose)
HYPERLINK "http://www.ecglibrary.com/l_qt.html" \t "_parent" congenital long QT syndromes
other causes of long QT (e.g. IHD)
This recording has been kindly donated by Dr G. Butrous of St George's Medical School London who is a cardiologist involved in HYPERLINK "http://www.sghms.ac.uk/cardiology/eurtop/" \t "_parent" EUROTOP.
A 36 year old lady with recurrent blackouts.
implantable cardioverter defibrillator Most of this 12-lead recording is polymorphic ventricular tachycardia but, in the rhythm strip, the large deflection (arrowed) is the defibrillator discharging. Following the defibrillation a dual chamber pacemaker can be seen. OK so I cheated a little with this one as the odds of catching this on a 12-lead ECG recording are very slim indeed. This is a reconstructed 12-lead recording from an electrophysiology study testing the device after placement.
A 60 year old man with 2 hours of "crushing" chest pain suddenly collapses.
Ventricular fibrillation
bizarre, irregular, random waveformno clearly identifiable QRS complexes or P waves
wandering baseline
A 12 lead of Ventricular fibrillation should not usually be taken ... for obvious reasons. Instead of continuing to record the ECG you should check the patient's pulse and reach for the defibrillator!
A 72 year old man with a permanent pacemaker.
SHAPE \* MERGEFORMATVentricular pacemaker pacing spikes (best seen here in V4 - V6) will be seen - they may be subtle the paced QRS complexes are abnormally wide In this example the pacemaker starts when there is a long R - R interval following a blocked atrial premature beat (arrowed in figure below). Sinus rhythm takes over again later in the rhythm strip.
A 36 year old lady with recurrent blackouts.
Implantable cardioverter defibrillator Most of this 12-lead recording is polymorphic ventricular tachycardia but, in the rhythm strip, the large deflection (arrowed) is the defibrillator discharging. Following the defibrillation a dual chamber pacemaker can be seen. OK so I cheated a little with this one as the odds of catching this on a 12-lead ECG recording are very slim indeed. This is a reconstructed 12-lead recording from an electrophysiology study testing the device after placement.A 25 year old man with bouts of tachycardia.
Wolf-Parkinson-White syndrome short PR interval, less than 3 small squares (120 ms) slurred upstroke to the QRS indicating pre-excitation (delta wave) broad QRS secondary ST and T wave changes Localising the accessory pathway An accessory pathway, bundle of Kent, exists between atria and ventricles and causes early depolarisation of the ventricle. The location of the pathway may be deduced as follows:-
A 23 year old man with epsiodes of tachycardia.
Wolf-Parkinson-White syndrome short PR interval, less than 3 small squares (120 ms) slurred upstroke to the QRS indicating pre-excitation (delta wave) broad QRS secondary ST and T wave changes Localising the accessory pathway An accessory pathway, bundle of Kent, exists between atria and ventricles and causes early depolarisation of the ventricle. The location of the pathway may be deduced as follows:-
hank you to Soren Strange MD, Department of Cardiology, Frederiksberg Hospital, Denmark for providing this recording.
A 23 year old man with episodes of palpitations.
Wolf-Parkinson-White syndrome with atrial fibrillationirregularly irregular, wide complex tachycardia
impulses from the atria are conducted to the ventricles via either
both the AV node and accessory pathway producing a broad fusion complex
or just the AV node producing a narrow complex (without a delta wave)
or just the accessory pathway producing a very broad 'pure' delta wave
people who develop this rhythm and have very short R - R intervals are at higher risk of VF
A 56 year old man with breathlessness and raised JVP.
Pericardial effusion with electrical alternans
The QRS axis alternates between beats. In this example it is best seen in the chest leads where the QRS points in different directions!This is rarely seen and is due to the heart moving in the effusion.
A lady with Romano-Ward syndrome.
Long QT interval
The QT interval normally varies with heart rate - becoming shorter at faster rates. It is usually corrected using the cycle length (R-R interval) as shown opposite.normal QTc = 0.42 seconds
Romano-Ward syndrome is an autosomal dominantly inherited form of long QT interval and there is a risk of recurrent ventricular tachycardia, particularly HYPERLINK "http://www.ecglibrary.com/tdp.html" \t "_parent" Torsade de Pointes.
Ventricular premature beats (VPBs)
2 ventricular premature beats are also shown in this ECG
They are: broad , occur earlier than normal , and are followed by a full compensatory pause (the distance between the normal beats before and after the VPB is equal to twice the normal cycle length).
A 50 year old man with bouts of tachycardia.
Lown Ganong Levine Syndrome
short PR interval, less than 3 small squares (120 ms)no HYPERLINK "http://www.ecglibrary.com/wpw.html" \t "_parent" delta wave
In this ECG there is also non-specific inferolateral ST-T changes and HYPERLINK "http://www.ecglibrary.com/lvhlah.html" \t "_parent" voltage criteria for left ventricular HYPERLINK "http://www.ecglibrary.com/lvhlah.html" \t "_parent" hypertrophy.
A 40 year old woman with pleuritic chest pain and breathlessness.
Acute pulmonary embolus
The following, often transient, changes may be seen in a large pulmonary embolus.
an S1Q3T3 pattern
a prominent S wave in lead I
a Q wave and inverted T wave in lead III
sinus tachycardia
T wave inversion in leads V1 - V3
Right Bundle Branch Block
low amplitude deflections
A 58 year old man on haemodialysis presents with profound weakness after a weekend fishing trip.
This man's serum potassium was 9.6 mmol/L.
Hyperkalaemia
The following changes may be seen in hyperkalaemia
small or absent P waves
atrial fibrillation
wide QRS
shortened or absent ST segment
wide, tall and tented T waves
ventricular fibrillation
A 22 year old lady with prolonged vomiting.
This lady's serum potassium was 1.8 mmol/L.
HypokalaemiaThe following changes may be seen in hypokalaemia.
small or absent T waves
prominent U waves (see diagram)
first or second degree AV block
slight depression of the ST segment
A 55 year old man with a history of a piggy-back heart transplant for ischaemic cardiomyopathy.
Piggy-back heart transplant. 2 hearts in one chest.
two distinct QRS morphologies
two distinct rates
A 64 year old lady on digoxin
igitalis effect
shortened QT intervalcharacteristic down-sloping ST depression, reverse tick appearence, (shown here in leads V5 and V6)
dysrhythmias
ventricular / atrial premature beats
paroxysmal atrial tachycardia with variable AV block
ventricular tachycardia and fibrillation
many others
The electrical axis at a glance ... 2 glances actually.
Using leads I and aVF the axis can be calculated to within one of the four quadrants at a glance.
If the axis is in the "left" quadrant take your second glance at lead II.
SHAPE \* MERGEFORMAT
both I and aVF +ve = normal axis
both I and aVF -ve = axis in the HYPERLINK "http://www.ecglibrary.com/axis.html" \l "nw" \t "_parent" Northwest Territorylead I -ve and aVF +ve = HYPERLINK "http://www.ecglibrary.com/axis.html" \l "r" \t "_parent" right axis deviation
lead I +ve and aVF -ve
lead II +ve = normal axis
lead II -ve = HYPERLINK "http://www.ecglibrary.com/axis.html" \l "l" \t "_parent" left axis deviation
causes of a Northwest axis (no man's land)
emphysema
hyperkalaemia
lead transposition
artificial cardiac pacing
ventricular tachycardia
causes of right axis deviation
normal finding in children and tall thin adults
right ventricular hypertrophy
chronic lung disease even without pulmonary hypertension
anterolateral myocardial infarction
left posterior hemiblock
pulmonary embolus
Wolff-Parkinson-White syndrome - left sided accessory pathway
atrial septal defect
ventricular septal defect
causes of left axis deviation
left anterior hemiblock
Q waves of inferior myocardial infarction
artificial cardiac pacing
emphysema
hyperkalaemia
Wolff-Parkinson-White syndrome - right sided accessory pathway
tricuspid atresia
ostium primum ASD
injection of contrast into left coronary artery
note: left ventricular hypertrophy is not a cause left axis deviation
'ECGs by Example' notes on the book This is the official webpage for comments, corrections and superfluous trivia associated with our ECG book. ECGs by Example. Jenkins + Gerred Published 1997, HYPERLINK "http://www.churchillmed.com/"Churchill Livingstone (ISBN 0 443 056978). Authors: HYPERLINK "http://www.ecglibrary.com/molly/runners.html"Dean Jenkins and Stephen Gerred Reviewers: Hamish Charleson and Hugh McAllister Publishing team: Laurence Hunter and Barbara Simmons Stocked in the following online bookstores HYPERLINK "http://www.acses.com/acsesbin/nph-cat.cgi?position=0&type=ISBN&input=0443056978"Acses.com HYPERLINK "http://www.amazon.com/exec/obidos/ASIN/0443056978/002-5510199-4691428"Amazon.com HYPERLINK "http://www.blackwell.co.uk/cgi-bin/bb_item2?0443056978"Blackwell's Online Bookshop HYPERLINK "http://www.bookpages.co.uk/twist/twist.plx?form=\\inetpub\\web\\bookpages\\scripts\\BookDetails.htx&UID=559767!PPP=20!CID=1!SID=108!CSL=P!CXR=1!CS=&ISBN=0443056978"bookpages.co.uk - worldwide delivery HYPERLINK "http://www.books.com/scripts/view.exe?isbn~0443056978"Books.com HYPERLINK "http://www.donfer.demon.co.uk/card.htm"Donald Ferrier Ltd. HYPERLINK "http://www.hbuk.co.uk/cgi-bin/catsearch?form_type=search&keyword=ecgs+by+example&s_field=all&maxhits=50"Harcourt Brace HYPERLINK "http://www.waterstones.co.uk//bin/bookinfo/0443056978"Waterstone's UK
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