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Tachyarrhythmias and bradyarrhythmias are often seen in the outpatient setting. Patients can present minimally symptomatic or in extremis. Accurate diagnosis of the rhythm, plus a detailed clinical history, are critical for best management and optimal outcome. A 12-lead electrocardiogram is the cornerstone for diagnosis. Practitioners must identify patients who need immediate transport to an emergency department versus those who can safely wait for an outpatient specialty referral. This article reviews how to accurately diagnose and differentiate the most common tachyarrhythmias and bradyarrhythmias, the associated symptoms, and important concepts for the initial steps in the office management of such arrhythmias., (Copyright © 2017 Elsevier Inc. All rights reserved.)

A series of evidence-based interventions beginning with an intensive care unit diary and a patient/family educational pamphlet were implemented to address the long-term consequences of critical illness after discharge from the intensive care unit, bundled as post-intensive care syndrome and post-intensive care syndrome-family. An extensive literature review and nursing observations of the phenomenon highlighted the potential for this project to have a favorable impact on patients, their families, and the health care team. The goal of this article is to explain the education of all stakeholders; the introduction of the diary, video, and educational pamphlet; and the evaluation of the acceptance of these interventions. This process began with an informal evaluation of the educational products and overall perception of the usefulness of the diary by patients, family members, and staff. The efforts described contribute to the evidence base supporting diaries as an adjunct to intensive care.

Background: There is an increasing demand for noninvasive brain tumor biomarkers to guide surgery and subsequent oncotherapy. We present a novel whole-brain diffusion tensor imaging (DTI) segmentation (D-SEG) to delineate tumor volumes of interest (VOIs) for subsequent classification of tumor type. D-SEG uses isotropic (p) and anisotropic (q) components of the diffusion tensor to segment regions with similar diffusion characteristics., Methods: DTI scans were acquired from 95 patients with low- and high-grade glioma, metastases, and meningioma and from 29 healthy subjects. D-SEG uses k-means clustering of the 2D (p,q) space to generate segments with different isotropic and anisotropic diffusion characteristics., Results: Our results are visualized using a novel RGB color scheme incorporating p, q and T2-weighted information within each segment. The volumetric contribution of each segment to gray matter, white matter, and cerebrospinal fluid spaces was used to generate healthy tissue D-SEG spectra. Tumor VOIs were extracted using a semiautomated flood-filling technique and D-SEG spectra were computed within the VOI. Classification of tumor type using D-SEG spectra was performed using support vector machines. D-SEG was computationally fast and stable and delineated regions of healthy tissue from tumor and edema. D-SEG spectra were consistent for each tumor type, with constituent diffusion characteristics potentially reflecting regional differences in tissue microstructure. Support vector machines classified tumor type with an overall accuracy of 94.7%, providing better classification than previously reported., Conclusions: D-SEG presents a user-friendly, semiautomated biomarker that may provide a valuable adjunct in noninvasive brain tumor diagnosis and treatment planning., (© The Author(s) 2014. Published by Oxford University Press on behalf of the Society for Neuro-Oncology.)

Aim: (18)F-Sodium fluoride ((18)F-NaF) PET/computed tomography (CT) has improved spatial resolution in the cervical spine compared with single photon emission computed tomography/CT techniques using traditional tracers. Limited data are available, however, on its effectiveness in the management of the symptomatic cervical spine, and the aim of this study was therefore to elucidate this issue., Patients and Methods: A retrospective study was carried out between April 2011 and April 2012. Across this period, 66 patients were referred to the department for the assessment of neck pain, of whom 58 were included in the study. (18)F-NaF was used as the tracer and images were acquired on an integrated PET/CT scanner. All studies were evaluated by either consultant nuclear medicine physicians or by a radiologist. Two consultant neurosurgeons correlated the imaging reports with the clinical data from the patient notes to give an overall impression as to how beneficial the test had been with regard to patient management., Results: In 49/58 (84.5%) cases, the (18)F-NaF PET/CT report was thought to have been clinically useful in patient management. In 9/58 (15.5%) cases, the report was thought not to have been clinically beneficial, generally because of high background vertebral uptake of (18)F-fluoride secondary to degenerative disease., Conclusion: As our experience with (18)F-NaF PET/CT broadens, we believe that it will become an increasingly important tool in the evaluation and management of the symptomatic cervical spine.

In a prospective study, patients with a radiologically proven brain tumour underwent diffusion tensor imaging (DTI) prior to definitive diagnosis and treatment. Twenty-eight patients with a histologically proven glioblastoma or metastasis were included in the study. Following the definition of regions of interest, DTI metrics [mean diffusivity (MD) and fractional anisotropy (FA)] were calculated for the tumour volume and the surrounding region of peritumoral oedema. These metrics were then subjected to logistic regression to investigate their ability to discriminate between glioblastomas and cerebral metastases. A cross-validation was performed to investigate the ability of the model to predict tumour. The logistic regression analysis correctly distinguished glioblastoma in 15 of 16 cases (93.8%) and metastasis in 11 of 12 cases (91.7%). Cross-validation resulted in the model correctly predicting 14 of 16 (87.5%) glioblastomas and 10 of 12 (83.3%) metastases studied. MD was significantly higher (p = 0.02) and FA was significantly lower (p = 0.04) within the oedema surrounding metastases than within the oedema around glioblastomas. MD was significantly higher (p = 0.02) within the tumour volume of the glioblastomas. Our results demonstrate that, when DTI metrics from the tumour volume and surrounding peritumoral oedema are studied in combination, glioblastoma can be reliably discriminated from cerebral metastases., (Copyright © 2010 John Wiley & Sons, Ltd.)

Gliomas are the most common primary brain tumors and the majority are highly malignant, with one of the worst prognoses for patients. Gliomas are characterized by invasive growth into normal brain tissue that makes complete surgical resection and accurate radiotherapy planning extremely difficult. We have performed independent component analysis of magnetic resonance spectroscopy imaging data from human gliomas to segment brain tissue into tumor core, tumor infiltration, and normal brain, with confirmation by diffusion tensor imaging analysis. Our data are consistent with previous studies that compared anomalies in isotropic and anisotropic diffusion images to determine regions of potential glioma infiltration. We show that coefficients of independent components can be used to create colored images for easy visual identification of regions of infiltrative tumor growth., ((c) 2009 Wiley-Liss, Inc.)

Object: The visualization of white matter tracts using tractography has previously been achieved by displaying streamlines that pass between regions of interest (ROIs). These techniques require a significant amount of user interaction, and their results are entirely dependent on the positioning of the ROIs. Furthermore, in patients with intracerebral hemorrhage secondary to intracranial vascular malformation, there is often significant cerebral edema and susceptibility artifact from the hematoma, which degrade the reliability of tractography. In this paper, the authors' objectives were to visualize the motor pathways of patients with hemorrhagic and nonhemorrhagic vascular malformations by using a novel semiautomated technique that functions without the need for multiple ROIs., Methods: The authors investigated the tractography appearance of the descending motor pathways in 6 patients with intracranial vascular malformations. Of these patients 4 presented with a spontaneous intracranial hemorrhage, 2 of whom were clinically hemiparetic. Diffusion tensor imaging was performed using a 1.5-T clinical MR imaging system, and whole-brain tractography was performed after reconstruction of the data. A fractional anisotropy threshold of 0.05 was used to terminate the tractography. The semiautomatic motor pathway segmentation technique required definition of a single voxel within the corticospinal tract of the medulla from which the descending motor pathways were automatically defined by grouping together all streamlines within the entire image with a geometry similar to that of the single streamline generated from this initial voxel. The results of this segmentation were then visually assessed and compared with the patient's motor function., Results: The authors' semiautomatic algorithm consistently visualized the location of the descending motor pathways in patients with nonhemorrhagic and hemorrhagic vascular malformations. In 1 patient whose complete right hemiplegia (complete paralysis) was caused by a large left frontal hematoma that bisected the descending motor pathways, the authors were unable to reconstruct the motor pathways due to severe tract degeneration. However, in all cases in which motor function was intact or only mildly impaired, the technique clearly delineated the motor pathways, even in the presence of large anatomical displacement by the vascular abnormality or associated hemorrhage., Conclusions: Semiautomatic tractography allows consistent and rapid demonstration of the descending motor pathways in patients with hemorrhagic and nonhemorrhagic intracranial vascular malformations. The technique allows the use of a comparatively low fractional anisotropy threshold and does not require the definition of multiple ROIs. These techniques may help to improve the clinical feasibility and potentially the reliability of tractography for the evaluation of patients with intracranial vascular malformations as well as other space-occupying lesions of the brain.

The authors prospectively performed echocardiographic and Doppler studies on 13 patients with inflammatory myopathy to evaluate ventricular function, to assess valve morphology and function, and to obtain hemodynamic data. No patient had a reduction in left ventricular function or evidence of significant valvular disease. Hemodynamic assessment suggested evidence of pulmonary hypertension in 9 patients. They conclude that cardiomyopathy in association with inflammatory myopathy is unusual and that the suggestion of pulmonary hypertension is unexplained and merits further evaluation.

To examine the hypothesis that patients with inflammatory muscle disease have impairments in cardiac and/or pulmonary function that are masked by peripheral muscle weakness, complete PFTs, echo/Doppler studies and exercise testing were performed in 11 patients with polymyositis. Maximal inspiratory and expiratory pressures and expiratory flow rates were normal. One patient had evidence of restrictive lung disease; two had a reduced Dsb. Seven patients had evidence of pulmonary hypertension. Only three patients had normal aerobic capacity; VO2 max in the other 8 patients was 46 +/- 8 percent of predicted when they stopped exercising. Four patients had a normal O2 pulse; seven patients had a reduced O2 pulse while five of seven patients exceeded 85 percent of their target heart rate. We conclude that while asymptomatic impairments in pulmonary function are uncommon in polymyositis, the incidence of pulmonary hypertension is high, but symptoms may be masked by the peripheral muscle weakness.

With the advancement of surgical techniques and myocardial protection we can expect that patients previously felt to be inoperable because of poor ventricular function will be surgical candidates. This group of patients will on occasion develop severe left ventricular dysfunction in the peri-operative period. Optimum management in this setting will require acquisition of haemodynamic data, assessment of ventricular loading conditions and inotropic state and the selection of appropriate drug therapy. Drugs are available with specific haemodynamic profiles and therapy is enhanced by matching the abnormal haemodynamics of patients with an appropriate therapeutic agent. If the patient fails to respond quickly to pharmacotherapy, consideration should be directed toward use of an intra-aortic balloon pump.

Left ventricular outflow tract obstruction by a mitral valve prosthesis was noted several years following surgery when symptoms of congestive heart failure occurred. The diagnosis was made using two-dimensional echocardiography and Doppler techniques and confirmed at heart catheterization, using micromanometer tipped catheters.