Search

Differential diagnosis of wide QRS tachycardia (WQRST) on the electrocardiogram remains a challenging exercise. Correct diagnosis is important for prescribing appropriate therapy and determining prognosis. Differential diagnosis of wide QRS tachycardia revolves around differentiation between supraventricular tachycardia with aberrant conduction and ventricular tachycardia. Observations such as clinical history, findings of physical examination during tachycardia, AV dissociation, QRS morphology in lead V1 and lead V6, precordial concordance, RS complexes in precordial leads, contralateral bundle branch block during wide QRS tachycardia, R wave morphologies in lead aVR, and ventricular initial/terminal velocity of conduction ratio can help arrive at the correct diagnosis with reasonable accuracy. The observations described here can help arrive at the correct diagnosis of WQRST with both reasonable accuracy and confidence., The diagnosis of wide QRS tachycardia can be challenging, but is essential for appropriate therapy. The differentiation is often between supraventricular tachycardia with aberrant conduction and ventricular tachycardia. A review of historical, clinical, electrocardiographic information during wide QRS tachycardia while keeping in mind the pitfalls and exceptions, may help arrive at the correct diagnosis with reasonable accuracy and confidence

The majority of patients diagnosed with cancer are ≥65 years. However, inclusion of older patients with cancer in clinical trials is limited, and so there is less evidence to guide systemic therapeutic decisions in these patients. There is also debate surrounding the definition of “older patients”. Additionally, comorbidities, as well as life expectancy will influence compliance to any treatment, and physicians may favour less intense regimens for these patients or best supportive care alone. In patients with biliary tract cancer (BTC), surgery followed by adjuvant capecitabine (BILCAP phase 3 trial) is the only potentially curative option, but patients often present with advanced disease, and palliative systemic treatment is given. The availability of novel targeted therapies (oral and monotherapy) in selected populations of patients with BTC may increase the therapeutic artillery for these older patients. Trials to date in patients with BTC have not been age-specific and have not always included age subgroup analysis, and so the evidence to support treatment of older patients is derived via extrapolation, primarily, with only 35% being >60 years in the adjuvant BILCAP study, for example. When this evidence is provided, treated patients tend to gain equivalent survival benefit, irrespective of age. A comprehensive clinical geriatric assessment is recommended. Revision of existing BTC treatment guidelines should incorporate some reference to best practice in older patients with BTC. Observational data may also provide valuable insights in this population. Age sub-group analysis should be encouraged in prospective clinical trials including patients with BTC, with age-specific trials favoured.

IntroductionPancreatic exocrine insufficiency (PEI) in patients with pancreatic malignancy is well documented in the literature and is known to negatively impact on overall survival and quality of life. A lack of consensus opinion remains on the optimal diagnostic test that can be adapted for use in a clinical setting for this cohort of patients. This study aims to better understand the prevalence of PEI and the most suitable diagnostic techniques in patients with advanced pancreatic malignancy.Methods and analysisThis prospective observational study will be carried out in patients with pancreatic malignancy (including adenocarcinoma and neuroendocrine neoplasms). Consecutive patients with inoperable pancreatic malignancy referred for consideration of first-line chemotherapy will be considered for eligibility. The study comprises three cohorts: demographic cohort (primary objective to prospectively investigate the prevalence of PEI in patients with inoperable pancreatic malignancy); sample size 50, diagnostic cohort (primary objective to design and evaluate an optimal diagnostic panel to detect PEI in patients with inoperable pancreatic malignancy); sample size 25 and follow-up cohort (primary objective to prospectively evaluate the proposed PEI diagnostic panel in a cohort of patients with inoperable pancreatic malignancy); sample size 50. The following is a summary of the protocol and methodology.Ethics and disseminationFull ethical approval has been granted by the North West Greater Manchester East Research and Ethics Committee, reference: 17/NW/0597. This manuscript reflects the latest protocol V.8 approved 21 April 2020. Findings will be disseminated by presentation at national/international conferences, publication in peer-review journals and distribution via patient advocate groups.Trial registration number194255, NCT0361643.

The use of container-oriented orchestration platforms such as Kubernetes, is becoming more popular due to their ability to hide from developers the deployment details of the application and the capability of these platforms to support autoscaling and failure recovery. Most container orchestration environments have focused on supporting the HTTP protocol and are challenging to use in protocols such as SIP and RTP. When SIP/RTP services are deployed in the Kubernetes environment, failures related to port mapping and affinity occur. These failures are reflected as packets sent to the non-existent ports in either the overlay or underlay network in Kubernetes. This paper details these failures and presents solutions for resolving the SIP/RTP port mapping and the RTP affinity constraint failures. The SIP/RTP port mapping failure is solved by correctly mapping the internal SIP/RTP ports to those exposed externally by Kubernetes while the RTP affinity constraint solution leverages the concept of the creation of unique endpoints and labels for each RTP service port opened for a SIP call. The paper also offers some insight into the challenges faced in replicating the SIP constraint affinity failure. These solutions have been implemented in a Kubernetes aware SIP Proxy (SIP-K8S-Proxy) that supports port mapping and managing of the RTP affinity as well. The overhead associated with implementing this solution has been computed to be about 2 seconds in the establishment of a SIP call.

BACKGROUND Brain metastases (BMs) incidence in patients with extra-pulmonary neuroendocrine neoplasms (EP-NENs) is unclear, with no available management recommendations. This study aimed to review the clinical presentation, management and survival outcomes of patients with EP-NENs and BMs at a European Centre of Excellence. METHODS A retrospective single-centre analysis of consecutive patients with EP-NENs (Aug 2004-Feb 2020) was conducted. Median overall survival (OS)/survival from BMs diagnosis were estimated (Kaplan Meier). RESULTS Of 786 patients, 15 (1.9%) had BMs, median age 61y (range 15–77); 8 (53%) male, primary NEN site: unknown 40%; oesophageal 13%; small bowel 13%; pancreas 13%; gastric 7%; cervix 7% and bladder 7%. Most patients with BMs had grade 3 (G3) NENs (11, 73%), 3 (20%) were G2 and 1 (7%)G1. Eight (53%) had poorly-differentiated NENs, 6 well-differentiated and 1 not recorded. Two (13%) patients had synchronous BMs at diagnosis, whilst 13 (87%) developed BMs metachronously. Median time to development of BMs after initial NEN diagnosis: 15.9 months (range 2.5–139.5). Five patients had a solitary BM, 4 had 2–9 lesions and 6 had >10 BMs. The most commonly affected sites were the cerebrum (13, 87%), cerebellum (6, 40%), leptomeninges (2, 13%) and orbit (1, 7%). The most common presenting symptoms were limb weakness, headache, confusion, visual disturbance (each n=3, 20%), seizures (2, 13%), word-finding difficulty (2, 13%) and facial weakness/ptosis (1, 7%). Median OS from initial NEN diagnosis was 23.6-months [95%-CI 15.2–31.3]; median time to death from BMs diagnosis was 3.0-months [95%-CI 0.0–8.3]. Treatment of BMs was surgery (n=3); radiotherapy (n=6); 5 had WBRT, one localised radiotherapy (orbit). Six (40%) had best supportive care. CONCLUSION BMs in patients with EP-NENs are rare and predominantly in G3 NENs, with diverse intracranial distribution. Although uncommon, BMs from NENs behave aggressively and greater understanding is needed to improve therapeutic outcomes.

This paper discusses the issue with scaling SIP/RTP services in a container orchestration cluster such as Kubernetes. In order to run SIP/RTP services in the Kubernetes platform, we require that state and affinity between the two ends, be maintained by the container orchestration cluster. Currently Kubernetes primarily supports stateless services like HTTP. The paper explains the challenge of the Kubernetes overlay network for SIP/RTP services by presenting four failure scenarios with the objective to validate the failure scenarios and present viable solutions. Two of the four failure scenarios have been validated and our approach to counter these failures are presented. One proposed solution is based on a SIP back-to-back user agent or proxy integrated with the Kubernetes environment and a second that leverages the Kubernetes Ingress architecture and services. A third probable solution discussed are the service meshes.

Background: Molecular profiling is becoming increasingly relevant in the management of patients with advanced cancer, to identify targetable aberrations and prognostic markers to enable a precision medicine strategy. Methods: Eligible patients were those diagnosed with advanced biliary tract cancer (BTC) including intrahepatic (iCCA) and extrahepatic cholangiocarcinoma (eCCA), gallbladder cancer (GBC), and ampullary carcinoma (Amp) who underwent molecular profiling between April 2017 and June 2020 based on analysis of either tumour samples (FoundationOne CDx&reg, /Oncomine&reg, platforms) or ctDNA (FoundationOne Liquid&reg, platform (Foundation Medicine, Cambridge, MA, USA)). Baseline patient characteristics and molecular profiling outcomes were extracted. The primary aim was to describe sample failure rate. Secondary aims included description of reason for sample failure, summary of findings derived from molecular profiling, and assessment of concordance between paired tissue and ctDNA samples. Results: A total of 149 samples from 104 individual patients diagnosed with advanced BTC were identified and eligible for this analysis: 68.2% iCCA, 100% advanced stage, 94.2% received palliative therapy. The rate of sample failure was 26.8% for tissue and 15.4% for ctDNA, p-value 0.220, predominantly due to insufficient (defined as &lt, 20%) tumour content in the sample (the reason for 91.2% of tissue sample failure). Of the 112 samples successfully analysed, pathological molecular findings were identified in the majority of samples (88.4%) and identification of pathological findings using ctDNA, was possible regardless of whether the patient was on active treatment at time of blood acquisition or not (p-value 1.0). The rate of targetable alterations identified was 40.2% across all successfully-analysed samples (39 iCCA, 6 non-iCCA): IDH1 mutations (19.1% of individual patients), FGFR2 alterations (10.1% and 5.6% of individual patients had FGFR2 fusions and mutations, respectively), 10.6% of all patients (12.4% of patients with successfully analysed samples) entered trials with matched targeted therapies as a consequence. Concordance of findings for paired tissue and paired tissue-ctDNA was high (3/3, 100% and 6/6, 100%, respectively). Twelve ctDNA samples were taken prior to palliative treatment initiation, median maximum mutant allele frequency (MAF) was 0.47 (range 0.21&ndash, 19.8), no significant association between reported maximum MAF and progression-free survival (PFS) or overall survival (OS) (all Cox regression p-values &gt, 0.273). A total of 15 patients (16.6%) harboured alterations in DNA damage repair (DDR) genes, when treated with platinum-based chemotherapy, there was a trend towards increased partial response rate (21.4% vs. 15.9%, p-value 0.653), radiological benefit rate (64.3% vs. 36.2%, p-value 0.071), and longer OS (median OS 20.4 months (95% CI 7.9&ndash, 26.7) vs. 13.3 (95 CI 11.0&ndash, 16.4), Cox Regression HR 0.79 (95% CI 0.39&ndash, 1.61), p-value 0.527). Conclusions: Molecular profiling is of use for identification of novel therapeutic strategies for patients with advanced BTC (mainly iCCA). One in four archived tissue samples may have insufficient tumour content for molecular profiling, ctDNA-based approaches may overcome these obstacles.

Resistance to gemcitabine chemotherapy is common in patients with pancreatic ductal adenocarcinoma (PDAC), biliary tract cancer (BTC) and ovarian cancers (OC), conferring poor survival. Use of ProTide technology led to the development of a ‘partially-activated’ monophosphorylated gemcitabine compound, termed NUC-1031. NUC-1031 enters cancer cells independent of the human equilibrative nucleoside transporter, does not require deoxycytidine kinase-mediated activation and resists cytidine deaminase-mediated breakdown into toxic by-products. The phase I PRO-001 trial recruited 68 patients with advanced solid tumours; of the 49 patients that had response-evaluable disease, 5 (10%) had a partial response (PR) and 33 (67%) had stable disease (SD). Subsequently, the PRO-002 study assessed the safety and efficacy of NUC-1031 combined with carboplatin for patients with OC (n = 25); preliminary data from this study reported one (4%) unconfirmed complete response (CR), 8 (35%) PRs and 13 (57%) patients with SD, the final outcome data are awaited. The ABC-08 trial for advanced BTC assessed safety and efficacy of NUC-1031 combined with cisplatin; 14 patients were recruited with a 50% objective response rate in the intention to treat population at interim analysis. ACELARATE, the phase III trial in first-line advanced PDAC comparing NUC-1031 to gemcitabine monotherapy, recruited 200 patients but has been paused for futility analysis. Early studies demonstrate NUC-1031 is well tolerated with favourable pharmacokinetic profiles. NUC-1031 use in PDAC remains unclear, but encouraging results of disease control in BTC and OC has prompted phase II and III trial development. NuTide 121, is a phase III trial comparing cisplatin-NUC 1031 combination to the standard of care cisplatin-gemcitabine and recruitment is ongoing. Recruiting trials and mature data from existing studies will help inform on the impact of NUC-1031 on patient survival over standard gemcitabine.

Advanced hepatocellular cancer (HCC) is the fourth leading cause of cancer-related death globally and is most common in elderly patients with a peak incidence in the UK at ages 85-89 years. In addition to the well-established risk factors of alcohol and viral hepatitis B and C, rising obesity and associated non-alcoholic fatty liver disease is projected to contribute to increased incidence of advanced HCC in elderly patients. The management of advanced HCC is changing rapidly; for over a decade the multi-kinase inhibitor sorafenib has been the only treatment option that offered a proven survival advantage, but in the last 4 years other treatment options have emerged including other kinase inhibitors, and monoclonal antibodies targeting angiogenesis and immune checkpoint inhibitors. Recent clinical trials have recruited older patients with no maximum age exclusion criteria, and age has not been found to be predictive for treatment effect in subgroup analyses. Chronological age is an unreliable measure of fitness for treatment and frailty may be a more apt descriptor, but the lack of a unified assessment tool has limited its use in current practice. Development of unified frailty assessments and prospective large-scale studies of novel systemic therapies where age and frailty are evaluated would be informative.

The Fixed Node Assisted Collection Tree Protocol (FNA-CTP) is a Collection Tree Protocol (CTP) for sensor network that has been augmented with special fixed nodes in order to support mobility. The algorithm functions like the conventional CTP algorithm taking advantage of the fixed nodes only when it loses a parent. Prior simulation analysis of CTP in mobile environments demonstrated that conventional CTP has significant overhead when the sensor nodes are mobile even if some nodes are fixed. On the other hand, FNA-CTP reduces the overhead due to fixed nodes and alterations to the trickle algorithm. This chapter presents experimental analysis of the FNA-CTP algorithm implemented on a set of sensor nodes that support tinyOS in an indoor sports field. Unlike the simulation results, the experimental results show that CTP outperforms the FNA-CTP algorithm though this primarily because it was not possible to recreate an experiment where the sink node was out of range of the mobile nodes resulting in less parent changes in CTP than FNA-CTP. In this chapter we present details and challenges of these experiments such as capturing and pre-processing of the packets captured by a sniffer in the field as well as at the sink.

Exposure to low-quality news videos on a newspaper website led a younger audience to see the news organization as less credible and lacking in value. Findings offer a cautionary tale for news organizations because even a few low-quality news videos on a newspaper website might damage newspapers’ fervent effort to attract a younger audience.

Repeated implantation failure (RIF) implies at least 3 consecutive treatment cycles of failed in vitro fertilization-embryo transfer (IVF-ET), in which 1 or 2 quality embryos...

Paracetamol (PCT) is a mostly used analgesic and antipyretic drug [1]. Overdoses can cause of liver and kidney damage [2]. The primary metabolism of PCT occurred in the liver...

Background: Occupational exposure is a significant factor for having respiratory symptoms and impairment of lung function in the working population. Construction workers impose a great risk of respiratory diseases since they continuously expose to construction hazards at their working place. The objective of this study was to explore the status of respiratory health of construction workers as well as correlation of blood parameters with it.Methods: This cross-sectional study was conducted among construction workers along with the control group (university staffs) by randomly selecting 50 individuals in each group from September 2019 to February 2020 in Tangail, Bangladesh. Questionaries’ survey was executed followed by spirometry and oximetry. After confirming abnormalities of lung function, blood was drawn for further IgE, ESR, and CRP analysis.Results: Significantly (p

Previous literature has sought prognostic factors for the survival of anal cancer patients. The present study aimed to determine prognostic factors for local disease recurrence, distant metastasis and survival for patients treated with radical chemoradiotherapy (CRT) at the Rosemere Cancer Centre, Preston, UK.Patients treated with CRT for nonmetastatic squamous cell anal cancer between September 2000 and January 2013 were studied. Kaplan-Meier and Cox regression analysis assessed the prognostic value of age, sex, tumour size, the proportion of the anal canal circumference involved (ACCI), nodal disease, tumour location and pretreatment haemoglobin.One hundred and 48 patients with a mean age of 63 years were studied, of whom 15% suffered local disease recurrence and 10% developed distant metastasis. The 5-year overall and cancer-specific survival rates were 84% and 86%, respectively. Predictors of local recurrence were tumour size5 cm and over two-thirds ACCI (P 0.01). Predictors of distant metastasis and poor survival were tumour size5 cm (P 0.01), node positive disease on imaging (P 0.05), over two-thirds ACCI (P 0.01) and a pretreatment haemoglobin level below 130 g/l (P 0.05). Multivariate analysis found large tumour size to be the most significant factor for local recurrence (P = 0.002) and survival (P = 0.02) whilst over two-thirds ACCI was most predictive of distant metastasis (P 0.001). Age, gender, palpable lymph nodes and tumour location were not of prognostic value for local disease recurrence, distant metastasis or survival.Tumour size, nodal disease, over two-thirds ACCI and low pretreatment haemoglobin confer poorer prognostic and survival outcomes. Use of intensity-modulated radiation therapy may allow greater radiation doses to be given for locally advanced tumours, thus improving local control and survival and reducing morbidity.

Background: A diagnosis of an old Inferior Wall Myocardial Infarction (IMI), on a routinely performed Electrocardiogram (ECG) often leads to further consultations and imaging studies. The aim of this study was to assess the predictive value of Q waves in inferior leads, alone or in combination with repolarization abnormalities, for the diagnosis of inferior wall myocardial infarction confirmed by imaging studies. Methods: Fifty-six patients, in whom computerized interpretation of the electrocardiogram resulted in the diagnosis of inferior wall myocardial infarction, and in whom imaging studies were also available, were included in this study. Electrocardiograms were performed using the GE MACHD 5500. Electrocardiograms were interpreted using the MUSE GE system. Echocardiograms and nuclear medicine cardiac imaging were performed and interpreted using standard equipment and techniques. S AS 9.3 software (SAS Institute, Inc., Cary, North Carolina) was used to calculate 95% exact binomial confidence intervals (CI) for the population PPVs. Results: Computerized interpretation of the ECGs leading to the diagnosis of old inferior wall myocardial infarction when compared with inferior wall myocardial infarction confirmed by imaging studies, had a positive predictive value of 52.78%. Adding the criteria of Q waves wider than 0.04 ms, using manual interpretation of ECG, increased the positive predictive value of the test to 80%. However, the presence of ST changes and/or negative or isoelectric T waves, in the presence of diagnostic Q waves in the inferior leads, increased the positive predictive value to 92%. Conclusion: These results suggest that the computerized interpretation of ECG results in a high rate of false positive readings of old inferior myocardial infarction. This may result in overutilization of imaging modalities. Presence of diagnostic Q waves in inferior leads, if accompanied by repolarization abnormalities, improves the accuracy of the electrocardiogram for the diagnosis of inferior wall myocardial infarction..

BACKGROUND Atrial fibrillation is a relatively common arrhythmia often seen in patients with permanent pacemakers. In this study we aimed to assess the incidence of atrial fibrillation in patients whose pacemakers were programmed to pace in the right ventricle (VVI) and compared it with patients whose pacemakers were programmed in non-VVI mode(i.e. AAI or DDD). MATERIAL AND METHODS Records of the patients with permanent pacemaker or implantable-cardioverter-defibrillator were evaluated and analyzed. These patients had regular periodic follow-up evaluation over the last 10 years. (January 1, 2002 to December 31, 2012). Patient demographic, pacemaker data, pacing mode, review and analysis of arrhythmia log for occurrence of new atrial fibrillation and echocardiographic findings for left atrial size, mitral regurgitation, were analyzed and recorded. Left atrial size was classified as mild, moderate or severe enlargement, depending on the left atrial dimension. RESULTS Average age was 68 years. There was no gender predominance (51% male). Mean follow-up duration was 6 years and 3 months. Hispanic population represented the majority of the patients (65.4%). Majority of the devices (80.0%) were programmed as DDD pacing mode. Fifty-five patients (52.8%) did not develop atrial fibrillation. 85.7% of the patients paced in VVI-mode had atrial fibrillation while atrial fibrillation occurred in 37.4% among patients paced in non-VVI-mode. This difference was statistically significant (P

The Metropolitan Water Reclamation District of Greater Chicago (District) initiated a research study to determine the total numbers and percentages of antibiotic resistant fecal coliform (FC) bacteria in raw sewage (RS) entering and final effluents (FE) discharged from its seven Water Reclamation Plants (WRPs). The density of FC was determined on m-FC agar containing ampicillin (ampR-16 μg/ml), gentamycin (genR-8 μg/ml), tetracycline (tetR-8 μg/ml), or all three antibiotics. The study was primarily undertaken to determine whether secondary sewage treatment at the District WRPs adequately reduces the numbers and percentages of FCampR, FCtetR, FCgenR, FCamp/tet/genR in the FE. The numbers of ampR, tetR, genR, and amp/tet/genR FC observed in RS ranged from 2.0 × 105 to 1.1 × 107, 9.5 × 104 to 2.2 × 106, 95 to 1.5 × 104 and 90 to 9.5 × 103 per 100 mL, respectively. Secondary sewage treatment without disinfection was shown to reduce the number of antibiotic resistant FC by two-three orders of magnitude. The numbers of FCampR, FCtetR, FCgenR, and FCamp/tet/genR observed in non-disinfected FE ranged from 2.0 × 102 to 6.4 × 103, 2.2 × 102 to 4.1 × 103, 9 to FCtetR > FCgenR > FCamp/tet/genR. Only one FCamp/tet/genR bacteria was found in this study indicating that multiple-antibiotic resistant FC was virtually eliminated by secondary sewage treatment. The results of multivariate regression analysis showed that the percentages of antibiotic resistant FC in the FE from all seven District WRPs were lower than the percentages of these organisms in RS (p

Detectable levels of dioxins have been reported in biosolids, but very little information is available on the effect of long-term application of biosolids on dioxins accumulation in soil and uptake by plants. We analyzed dioxins in soil and corn tissue samples from field plots after 30 continuous applications of biosolids at 0 (Control), 16.8, and 67.2 Mg biosolids ha(-1) yr(-1) resulting in 0, 504, and 2016 Mg ha(-1) cumulative loadings of biosolids, respectively. The levels of dioxins in soil were only 79.9, 115.5, and 247.5 ng toxic equivalents (TEQs) kg(-1) in the 0, 504, and 2016 Mg biosolids ha(-1) plots, respectively. Dioxins were not detected in the corn grain, and only trace levels (6.8-7.5 ng TEQs kg(-1)) were found in the corn stover; however, these values were not statistically different between control and biosolids-amended soils. These observations suggest that although long-term application of biosolids may increase the levels of dioxins in soil, it does not affect dioxins uptake by corn.

Patient: Female, 70 Final Diagnosis: SA block induced by pyridostigmine Symptoms: Asymptomatic Medication: Pyridostigmine Clinical Procedure: Pacemaker insertion Specialty: Electrophysiology Objective: Unusual clinical course Background: Myasthenia gravis requires a long-term treatment with a parasympathomimetic agent, which may result in bradycardia and asystole. Pharmacologic treatment with a reversible inhibitor of inosine monophosphate dehydrogenase (IMPDH) and Methylprednisolone is seen to improve the muscular symptoms but may reinforce potential bradyarrhythmias. This potential side effect can be treated with the levo isomer of atropine, Hyoscyamine, or Glycopyrollate in an intact conduction system. Case Report: A 70-year old Caucasian female patient with a family history of myasthenia gravis presented with mild weakness of the bilateral facial muscles, moderate dysarthria, dysphagia, diplopia predominantly on the right side and difficulty tracking ocular movements bilaterally. The treatment with pharmacological agents was initiated. Subsequently she developed asymptomatic bradycardia and SA-block. An improvement on Hyoscyamine failed to appear. A dual chamber pacemaker was placed. Conclusions: In symptomatic or asymptomatic bradycardia with significant high grade SA-block in patients with myasthenia gravis the insertion of a permanent pacemaker can be the definitive solution.

Myasthenia gravis requires a long-term treatment with a parasympathomimetic agent, which may result in bradycardia and asystole. Pharmacologic treatment with a reversible inhibitor of Inosine Monophosphate Dehydrogenase (IMPDH) and Methylprednisolone are seen to improve the muscular symptoms but may reinforce potential bradyarrhythmias. This potential side effect can be treated with the levo isomer of atropine, Hyoscyamine, or Glycopyrollate in an intact conduction system. Case presentation:A 70-year old Caucasian female patient with a family history of myasthenia gravis presented with mild weakness of the bilateral facial muscles, moderate dysarthria, dysphagia, diplopia predominantly on the right side and difficulty tracking ocular movements bilaterally. The treatment with pharmacological agents was initiated. Subsequently she developed asymptomatic bradycardia and SA-block. An improvement on Hyoscyamine failed to appear. A dual chamber pacemaker was placed. Conclusion: In symptomatic bradycardia or asymptomatic, however, significant high grade SA-block in patients with myasthenia gravis the insertion of a permanent pacemaker can be the definitive solution.

Essential cardiac electrophysiology : , Essential cardiac electrophysiology : , کتابخانه دیجیتال جندی شاپور اهواز

Aim: Recent literature has sought prognostic factors for survival outcomes in anal cancer patients. Similarly, our study aims to determine prognostic factors for local disease recurrence, distant metastases and survival from patients treated with standardized radical chemo-radiotherapy at the Rosemere Cancer Centre, Lancashire, UK. Methods: Patients treated with radical concurrent chemoradiation for non-metastatic squamous cell anal cancer from September 2000 to January 2013 were retrospectively studied. Kaplan-Meier and Cox Regression proportional hazards methods were used to assess prognostic value of age, sex, tumour size, anal canal circumference involved (ACCI), nodal disease, tumour location and pre-treatment haemoglobin. Results: A total of 148 patients (95 females, 53 males) with a mean age of 63 were studied. From the sample population 15% of patients suffered local disease recurrence and 10% developed distant metastases. The estimated five-year overall survival and cancer specific survival was 84% and 86% respectively. Predictors of local recurrence were tumour size greater than 5cm and over two-thirds ACCI (p Conclusions: Tumour size, nodal disease, over two thirds ACCI and low pre-treatment haemoglobin confer poorer prognostic and survival outcomes. Future use of intensity modulated radiation therapy (IMRT) can decrease patient morbidity, which may allow increase of radiation doses for locally advanced anal cancers and thus improve local control and survival outcomes. Disclosure: All authors have declared no conflicts of interest.

e15000 Background: Tumour size, nodal involvement and sex are recognized prognostic factors in squamous cell anal cancer. Our study aims to evaluate survival and potential prognostic factors amongs...

In early fetal life, the atrial and ventricular myocardia are continuous. After approximately the first month of gestation, the formation of the annulus fibrosus begins the anatomical and electrical separation of the atria and ventricles, leaving the atrioventricular node and bundle of His as the only electrical connection between the upper and lower chambers. In approximately 0.3% of the population (3 of every 1000 individuals), however, this process of electrical isolation is incomplete. In these subjects, unobliterated myocardial strands persist, making one, or at times more, direct electrical connections between the atrial and ventricular myocardium. These congenitally anomalous fibers are known as accessory pathways or bypass tracts.

The commonly used term sick sinus syndrome refers to a constellation of disorders of sinus rhythm that includes (1) inappropriate sinus bradycardia, (2) barious forms of sinoatrial block, (3) sinus arrest, (4) tachycardia-bradycardia syndrome, (5) sinoatrial nodal suppression by ectopic beats, and (6) sinoatrial reentry. This group of arrhythmias is very often associated with other manifestations of conduction system disease, such as aytrioventricular, fascicular, and bundle branch block, and suppression of escape rhythms from subsidiary pacemakers.

The supraventricular tachycardias can be divided into those arrhythmias originating within the atria per se and those in which the atrioventricular node or accessory atrioventricular connections play a role. The latter arrhythmias are discussed in Chapter 13. Four important tachyarrhythmias, namely, atrial fibrillation, atrial flutter, atrial tachycardia, and multifocal atrial tachycardia, are considered in this chapter, as are premature atrial complexes and ectopic atrial rhythm.

The driving impulse of the heart ordinarily arises in the P cells of the sinoatrial node. Pace-making foci are not, however, limited to the sinus node; others exist outside of it in the atrial myocardium. This observation has lead some electrocardiographers to speak of the atrial pace-making complex, a term that includes foci both within and outside of the sinus node.

In most cases of atrioventricular block, a single level of conduction delay is sufficient to explain the electrocardiographic findings. Consequently, the AV node and distal conduction structures are represented in laddergrams as a one-tiered structure. However, in the case of rapid atrial arrhythmias, as many as three consecutive levels of conduction delay, each with its own conduction characteristics, may be postulated to explain the observed atrioventricular conduction ratios.

Spontaneous changes of P-wave polarity without change in heart rate were noted on the resting electrocardiogram of a patient admitted because of chest pain. Intracardiac and His bundle electrograms were compatible with a sequence of activation from high to low right atrium with both positive and negative P waves in lead aVR. The decrease in the P-His interval with positive P waves in lead aVR is consistent with selective conduction via the posterior internodal pathway.

Of 1,599 patients who underwent surgery for direct myocardial revascularization In 1973 at Cleveland Clinic Hospital, 19 patients (1.2 percent) developed primary ventricular fibrillation or ventricular tachycardia during the immediate postoperative period. Occurrence of postoperative ventricular tachyarrhythmias could not be predicted by assessment of preoperative symptoms or by evaluation of the extent of coronary artery disease and left ventricular function. There was no increase in early or late mortality or morbidity (including postoperative myocardial infarction) among patients who developed postoperative primary ventricular tachyarrhythmias.