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BackgroundPhase analysis of gated single photon emission computed tomography (SPECT) myocardial perfusion scintigraphy provides a measure of left ventricular dyssynchrony and may have applications for identifying patients suitable for cardiac resynchronisation therapy.Phase analysis is typically described in degrees of cardiac cycle, less intuitive to cardiologists familiar with ECGs. We assessed the relationship between time and degrees, to determine whether they are interchangeable.Methods and results399 patients underwent normal stress-only SPECT myocardial perfusion imaging using Technetium-99m-tetrofosmin. Data analysis used QGS software (Cedars Sinai) calculating bandwidth and standard deviation. Heart rate, age, gender, stress modality, and ejection fraction were analyzed for their relation to phase variables. 13 patients were excluded for conduction abnormalities including right and left bundle branch block and ventricular pacing. Heart rate was strongly correlated to bandwidth and standard deviation measured in time, but unrelated when measured in degrees. Although bandwidth measured by time and degrees were strongly correlated with each other this relationship was not perfect (correlation coefficient 0.87, P < .001). The addition of heart rate to the model explained most of the residual variation between the two. The results for standard deviation were similar.ConclusionIn patients with normal myocardial perfusion and QRS duration bandwidth measured by degrees is not directly interchangeable with time in milliseconds. However most of the variation is explainable by heart rate, which predominantly affects measures of time rather than degrees. We would propose that although the values are less intuitive to cardiologists, normal ranges for phase measured in degrees are potentially more robust.

Objectives Cardiovascular disease accounts for 42% of male and 51% of female mortality within Europe. Kyrgyzstan, population of almost 6 million, has amongst the highest rates within Europe, second only to Uzbekistan for female cardiovascular disease mortality (588 per 100,000). We attempted to identify established cardiovascular disease prevalence within a rural community in Kyrgyzstan using portable echocardiography. Design Free open access echocardiography (VIVID-I, GE, USA) was offered to all adults in Batken district. Routine echocardiographic views were obtained and analysis performed using EchoPac Clinical Workstation (GE, USA). Mild valvular regurgitation, mild LV hypertrophy, patent foramen ovales and mild atrial enlargement were considered mild abnormalities; compensated ischaemic or valvular heart disease – moderate abnormalities, and decompensated congenital, ischaemic or valvular disease – severe abnormalities. Results One hundred and twenty five adults (48 male, 77 female), mean age 53 ± 16 years, underwent echocardiography. Only 16% of participants had no significant abnormality, 46% had mild disease, 25% moderate, compensated disease and 13% had severe disease. Nine percent had congenital heart disease including one tetralogy of Fallot and one Ebstein’s anomaly. Average LV function was normal, however, 19 participants had EF < 50%. Forty percent of participants had a new diagnosis warranting formal follow-up, 12% a new diagnosis of heart failure. Conclusion Using portable echocardiography, we identify a higher than reported prevalence of cardiovascular disease in rural Kyrgyzstan. Absence of portable tools and specialists for early diagnosis might lead to presentation in an advanced stage of disease when little can be done to improve mortality. Embracing remote access diagnostics is essential for disease identification within rural communities.

Anthony Barron explores the relationship between the philosophy of Schopenhauer and the forms and themes of Beckett’s critical and creative writings. He shows that Beckett’s aesthetic preoccupations are consonant with some of Schopenhauer’s seminal arguments regarding the arational basis of artistic composition and appreciation and the impotence of reason in human affairs. While Beckett’s critical writings are, in places, formidably opaque, this work examines the ways in which such texts can be elucidated when their intertextual affinities with Schopenhauer’s arguments are revealed. Using Schopenhauer’s thought as a presiding interpretative framework, Barron demonstrates how the widespread presence of philosophical and theological ideas in Beckett’s creative texts signifies less about his personal convictions than it does about his authorial aims. He thereby highlights the ways in which discursive ideas were appropriated and manipulated by Beckett for purely literary ends. A central contention of this book is that to judge the place of ideas within Beckett’s art, we should ignore questions of their theoretical persuasiveness and consider their role as purely aesthetic devices, the value of which is revealed in terms of the existential impact they have upon his characters. In each of the chapters that deal with Beckett’s fiction, Barron underscores the artistically energizing tensions that exist between the concepts that Beckett’s characters invoke in their attempts to comprehend the import of their experiences and their conative and affective tribulations which invariably prove resistant to such analysis. Here the means by which such conceptual aporias engender semantic potentialities underpin an exploration of Beckett’s creative assimilation of rational discourse. While the focus of this publication is upon Beckett’s early and middle fiction, which was composed at a time when the relationship between the chaos of quotidian ordeals and the value of rational thought became most acutely relevant for him, numerous cross-references to his dramatic and poetical works are provided in order to highlight the overall significance of these issues within his oeuvre.

Although significant progress has been made in the past decade in the treatment of both common and rare cancers, there has been significant concerns about the cost, and especially the value, of certain new oncology drugs. These concerns touch upon a number of issues regarding the price of these medicines, the value they deliver and the ability of healthcare systems to fund them. This paper looks at these perceptions and the extent to which they apply across different oncology products. Whilst it is acknowledged there is evidence that the launch price of pharmaceutical treatments for some forms of cancer has been rising in recent years, this is not uniformly the case; we find evidence to the contrary for some forms of cancer. This is illustrated by the cases of breast and colorectal cancer. We find cancer medicine prices depend on a number of factors, including pre-existing treatment options within a therapeutic class. Indeed, a number of studies have focused on the cost of treatment per month of overall survival gained as a simple (although partial) metric to judge value for money. Given the importance of oncology products being used in combination, developing similar approaches to capturing the overall cost of treatment will be crucial.

Cardiopulmonary exercise testing (CPX) is established for the investigation of cardiac disease. In patients with heart failure multiple variables have shown prognostic benefit, although peak VO2 remains the most widely used. It is accepted that peak VO2 is affected by respiratory disease as well, and may be highly susceptible to influence from respiratory disease coexistent with cardiac disease. I propose an alternative variable will show significantly greater specificity for cardiovascular disease when compared to peak VO2 (and other variables) and aim to identify this 'ideal' variable through the investigation of patients undergoing isolated cardiac interventions. Patients were recruited to the following groups: undergone/going cardiac resynchronisation therapy (CRT); heart failure; mitral valve surgery; COPD or mixed disease. Each patient underwent echocardiography, pulmonary function tests and blood sampling. They then performed (after an initial familiarisation CPX) a baseline CPX. In patients undergoing intervention (CRT and mitral surgery) they underwent another CPX 2-3 months after intervention, and a further CPX at 6 months in the mitral valve group. I assessed the following characteristics to aid in finding an ideal variable: ability to discriminate between heart and lung disease; high reproducibility; relation to exercise capacity and disease severity; and appropriate changes with physiological interventions. ROC curve analysis showed that breathing reserve, OUES and double product had the greatest areas under curve when differentiating COPD from heart failure. OUES also showed excellent test-retest reproducibility and was strongly correlated to disease severity. Following mitral surgery OUES fell less at 2 months than peak VO2; OUES may therefore be influenced to a lesser degree by muscular maladaptation post-surgery. The ideal cardiopulmonary exercise test variable for cardiac patients has yet to be described. OUES appears to show discriminating properties between heart and lung, is reproducible and is less influenced by peripheral changes when compared to peak VO2.

Salmonella septic arthritis is a rare phenomenon. We report on a 3-year-old healthy child who presented with septic arthritis of the hip with a concurrent gastroenteritis but with no pre-existing disease. Salmonella enteritidis was isolated from his blood cultures and from the hip synovial biopsies. Arthrotomy was performed, followed by antibiotics therapy with a favourable response.

Pericyte loss and deficient vascular platelet-derived growth factor receptor-β (PDGFRβ) signaling are prominent features of the blood–brain barrier breakdown described in Alzheimer’s disease (AD) that can predict cognitive decline yet have never been studied in the retina. Recent reports using noninvasive retinal amyloid imaging, optical coherence tomography angiography, and histological examinations support the existence of vascular-structural abnormalities and vascular amyloid β-protein (Aβ) deposits in retinas of AD patients. However, the cellular and molecular mechanisms of such retinal vascular pathology were not previously explored. Here, by modifying a method of enzymatically clearing non-vascular retinal tissue and fluorescent immunolabeling of the isolated blood vessel network, we identified substantial pericyte loss together with significant Aβ deposition in retinal microvasculature and pericytes in AD. Evaluation of postmortem retinas from a cohort of 56 human donors revealed an early and progressive decrease in vascular PDGFRβ in mild cognitive impairment (MCI) and AD compared to cognitively normal controls. Retinal PDGFRβ loss significantly associated with increased retinal vascular Aβ 40 and Aβ 42 burden. Decreased vascular LRP-1 and early apoptosis of pericytes in AD retina were also detected. Mapping of PDGFRβ and Aβ 40 levels in pre-defined retinal subregions indicated that certain geometrical and cellular layers are more susceptible to AD pathology. Further, correlations were identified between retinal vascular abnormalities and cerebral Aβ burden, cerebral amyloid angiopathy (CAA), and clinical status. Overall, the identification of pericyte and PDGFRβ loss accompanying increased vascular amyloidosis in Alzheimer’s retina implies compromised blood–retinal barrier integrity and provides new targets for AD diagnosis and therapy.

BY THE beginning of 1976 Angka Loeu's domination of Cambodia was beyond challenge. The population, socially atomised and physically...

AMPIL Pram Daum, located about 70 kilometres northwest of Battambang, once was a large village in the midst of fertile rice fields. The...