Cardiovascular Magnetic Resonance is increasingly used to differentiate the aetiology of cardiomyopathies. Late Gadolinium Enhancement (LGE) is the reference standard for non-invasive imaging of ...myocardial scar and focal fibrosis and is valuable in the differential diagnosis of ischaemic versus non-ischaemic cardiomyopathy. Diffuse fibrosis may go undetected on LGE imaging. Tissue characterisation with parametric mapping methods has the potential to detect and quantify both focal and diffuse alterations in myocardial structure not assessable by LGE. Native and post-contrast T1 mapping in particular has shown promise as a novel biomarker to support diagnostic, therapeutic and prognostic decision making in ischaemic and non-ischaemic cardiomyopathies as well as in patients with acute chest pain syndromes. Furthermore, changes in the myocardium over time may be assessed longitudinally with this non-invasive tissue characterisation method.
Summary Background In patients with suspected coronary heart disease, single-photon emission computed tomography (SPECT) is the most widely used test for the assessment of myocardial ischaemia, but ...its diagnostic accuracy is reported to be variable and it exposes patients to ionising radiation. The aim of this study was to establish the diagnostic accuracy of a multiparametric cardiovascular magnetic resonance (CMR) protocol with x-ray coronary angiography as the reference standard, and to compare CMR with SPECT, in patients with suspected coronary heart disease. Methods In this prospective trial patients with suspected angina pectoris and at least one cardiovascular risk factor were scheduled for CMR, SPECT, and invasive x-ray coronary angiography. CMR consisted of rest and adenosine stress perfusion, cine imaging, late gadolinium enhancement, and MR coronary angiography. Gated adenosine stress and rest SPECT used99m Tc tetrofosmin. The primary outcome was diagnostic accuracy of CMR. This trial is registered at controlled-trials.com , number ISRCTN77246133. Findings In the 752 recruited patients, 39% had significant CHD as identified by x-ray angiography. For multiparametric CMR the sensitivity was 86·5% (95% CI 81·8–90·1), specificity 83·4% (79·5–86·7), positive predictive value 77·2%, (72·1–81·6) and negative predictive value 90·5% (87·1–93·0). The sensitivity of SPECT was 66·5% (95% CI 60·4–72·1), specificity 82·6% (78·5–86·1), positive predictive value 71·4% (65·3–76·9), and negative predictive value 79·1% (74·8–82·8). The sensitivity and negative predictive value of CMR and SPECT differed significantly (p<0·0001 for both) but specificity and positive predictive value did not (p=0·916 and p=0·061, respectively). Interpretation CE-MARC is the largest, prospective, real world evaluation of CMR and has established CMR's high diagnostic accuracy in coronary heart disease and CMR's superiority over SPECT. It should be adopted more widely than at present for the investigation of coronary heart disease. Funding British Heart Foundation.
This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.
A ...comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
Visual sensitivity varies across the visual field in several characteristic ways. For example, sensitivity declines sharply in peripheral (vs. foveal) vision and is typically worse in the upper (vs. ...lower) visual field. These variations can affect processes ranging from acuity and crowding (the deleterious effect of clutter on object recognition) to the precision of saccadic eye movements. Here we examine whether these variations can be attributed to a common source within the visual system. We first compared the size of crowding zones with the precision of saccades using an oriented clock target and two adjacent flanker elements. We report that both saccade precision and crowded-target reports vary idiosyncratically across the visual field with a strong correlation across tasks for all participants. Nevertheless, both group-level and trial-by-trial analyses reveal dissociations that exclude a common representation for the two processes. We therefore compared crowding with two measures of spatial localization: Landolt-C gap resolution and three-dot bisection. Here we observe similar idiosyncratic variations with strong interparticipant correlations across tasks despite considerably finer precision. Hierarchical regression analyses further show that variations in spatial precision account for much of the variation in crowding, including the correlation between crowding and saccades. Altogether, we demonstrate that crowding, spatial localization, and saccadic precision show clear dissociations, indicative of independent spatial representations, whilst nonetheless sharing idiosyncratic variations in spatial topology. We propose that these topological idiosyncrasies are established early in the visual system and inherited throughout later stages to affect a range of higher-level representations.
General of the Armies John J. Pershing (1860–1948) had a long and distinguished military career, but he is most famous for leading the American Expeditionary Forces in World War I. He published a ...memoir, My Experiences in the World War , and has been the subject of numerous biographies, but the literature regarding this towering figure and his enormous role in the First World War deserves to be expanded to include a collection of his wartime correspondence. Meticulously edited by John T. Greenwood, volume 2 of John J. Pershing and the American Expeditionary Forces in World War I, 1917–1919 covers the period of October 1 through December 31, 1917. During this time, Pershing focused his efforts on working with the French Ministry of War, the General Staff, and the field Army on training and equipping the AEF's few available combat divisions for frontline service. Russia's defection from the coalition and the surprising Italian defeat at Caporetto in October rocked the Allied ranks, and this volume addresses the creation of the Supreme War Council and the House's American War Mission—bodies that reexamined the Entente's military and diplomatic strategy and ultimately cemented the alliance. The correspondence also reveals how the House Mission revived the divisive issue of amalgamating arriving American troops into existing British and French combat divisions—something that Pershing utterly opposed and saw as a threat to the AEF. The dispute never resolved and irritated British prime minister Lloyd George and French premier Georges Clemenceau so much that both would try to engineer Pershing's removal in the following year. Extracts from the large volume of rarely referenced cablegrams represent an important contribution to Pershing's wartime story.
Cardiac masses are usually first detected at echocardiography. In their further evaluation, cardiac magnetic resonance (MR) imaging has become a highly valuable technique. MR imaging offers ...incremental value owing to its larger field of view, superior tissue contrast, versatility in image planes, and unique ability to enable discrimination of different tissue characteristics, such as water and fat content, which give rise to particular signal patterns with T1- and T2-weighted techniques. With contrast material-enhanced MR imaging, additional tissue properties such as vascularity and fibrosis can be demonstrated. MR imaging can therefore contribute to the diagnosis of a cardiac mass as well as be used to detail its relationship to other cardiac and extracardiac structures. These assessments are important to plan therapy, such as surgical intervention. In addition, serial MR studies can be used to monitor tumor regression after surgery or chemotherapy. Primary cardiac tumors are very rare; metastases and pseudotumors (eg, thrombus) are much more common. This article provides an overview of cardiac masses and reviews the optimal MR imaging techniques for their assessment.
Disclaimer: The use of venovenous extracorporeal membrane oxygenation (VV ECMO) in adults has rapidly increased worldwide. This ELSO guideline is intended to be a practical guide to patient ...selection, initiation, cannulation, management, and weaning of VV ECMO for adult respiratory failure. This is a consensus document which has been updated from the previous version to provide guidance to the clinician.
In this article, I consider what I have long taken to be the two foundational principles of the Berlin School of Gestalt psychology, namely, that perceptual configurations are “distinguishable from” ...or “other than” the elements from which they are configured and that the identity of such “elements” is determined by their relation to other elements within perceptual configurations. Yet, while it seems clear that Max Wertheimer (1880–1943), Kurt Koffka (1886–1941), and Wolfgang Köhler (1887–1967) were all committed to the first principle, it is less clear that they were committed (or were all committed) to the second principle. This is perhaps not surprising because commitment to the second principle would seem to undermine the first principle. I note that Wilhelm Wundt (1832–1920) appears to have been one of few psychologists clearly committed to the second principle, which is perhaps why, despite appearances to the contrary, he does not seem to have been committed to the first principle. Finally, I discuss some questions raised by this analysis and relate it to recent developments in theoretical psychology and a perennial question in social psychology.
General of the Armies John J. Pershing (1860–1948) had a long and distinguished military career, but he is most famous for leading the American Expeditionary Forces in World War I. He published a ...memoir, My Experiences in the World War, and has been the subject of numerous biographies, but the literature regarding this towering figure and his enormous role in the First World War deserves to be expanded to include a collection of his wartime correspondence. Meticulously edited by John T. Greenwood, volume 1 of John J. Pershing and the American Expeditionary Forces in World War I, 1917–1919 covers the period of April 7 through September 30, 1917. The letters speak to such topics as Pershing's appointment to command the US expeditionary force, his initial preparations, and early meetings with Allied civilian and military leaders, including Field Marshal Sir Douglas Haig and General Henri Philippe Pétain. Drawing heavily on Pershing's extensive personal papers, this collection includes his letters and cablegrams exchanged with Secretary of War Newton D. Baker and Chiefs of Staff Hugh L. Scott and Tasker H. Bliss. Extracts from the large volume of rarely referenced cablegrams represent an important contribution to Pershing's wartime story. Two appendices provide the reader with details of Pershing's relations with the Allied governments and armies (as he reported them in an unpublished part of his Final Report of Gen. John J. Pershing in 1920) and his personal appraisal of Marshal Ferdinand Foch as he knew him during the war. These volumes of wartime correspondence provide new insight into the work of a legendary soldier and the historic events in which he participated, and offer a valuable resource for any serious Pershing or World War I scholar.
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