A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study

Background: Patients with chest pain contribute substantially to emergency department attendances, lengthy hospital stay, and inpatient admissions. A reliable, reproducible, and fast process to identify patients presenting with chest pain who have a low short-term risk of a major adverse cardiac event is needed to facilitate early discharge. We aimed to prospectively validate the safety of a predefined 2-h accelerated diagnostic protocol (ADP) to assess patients presenting to the emergency department with chest pain symptoms suggestive of acute coronary syndrome. Methods: This observational study was undertaken in 14 emergency departments in nine countries in the Asia-Pacific region, in patients aged 18 years and older with at least 5 min of chest pain. The ADP included use of a structured pre-test probability scoring method (Thrombolysis in Myocardial Infarction [TIMI] score), electrocardiograph, and point-of-care biomarker panel of troponin, creatine kinase MB, and myoglobin. The primary endpoint was major adverse cardiac events within 30 days after initial presentation (including initial hospital attendance). This trial is registered with the Australia-New Zealand Clinical Trials Registry, number ACTRN12609000283279. Findings: 3582 consecutive patients were recruited and completed 30-day follow-up. 421 (11•8%) patients had a major adverse cardiac event. The ADP classified 352 (9•8%) patients as low risk and potentially suitable for early discharge. A major adverse cardiac event occurred in three (0•9%) of these patients, giving the ADP a sensitivity of 99•3% (95% CI 97•9–99•8), a negative predictive value of 99•1% (97•3–99•8), and a specificity of 11•0% (10•0–12•2). Interpretation: This novel ADP identifies patients at very low risk of a short-term major adverse cardiac event who might be suitable for early discharge. Such an approach could be used to decrease the overall observation periods and admissions for chest pain. The components needed for the implementation of this strategy are widely available. The ADP has the potential to affect health-service delivery worldwide.

Environmental degradation of lignin/poly(hydroxybutyrate) blends

Blends of lignin and poly(hydroxybutyrate) (PHB) were obtained by melt extrusion. They were buried in a garden soil for up to 12 months, and the extent and mechanism of degradation were investigated by gravimetric analysis, thermogravimetric analysis (TGA), differential scanning calorimetry (DSC), X-ray photoelectron spectroscopy (XPS), scanning electron microscopy (SEM) and Fourier transform infra-red spectroscopy (FTIR) over the entire range of compositions. The PHB films were disintegrated and lost 45 wt% of mass within 12 months. This value dropped to 12 wt% of mass when only 10 wt% of lignin was present, suggesting that lignin both inhibited and slowed down the rate of PHB degradation. TGA and DSC indicated structural changes, within the lignin/PHB matrix, with burial time, while FTIR results confirmed the fragmentation of the PHB polymer. XPS revealed an accumulation of biofilms on the surface of buried samples, providing evidence of a biodegradation mechanism. Significant surface roughness was observed with PHB films due to microbial attack caused by both loosely and strongly associated micro-organisms. The presence of lignin in the blends may have inhibited the colonisation of the micro-organisms and caused the blends to be more resistant to microbial attack. Analysis suggested that lignin formed strong hydrogen bonds with PHB in the buried samples and it is likely that the rate of breakdown of PHB is reduced, preventing rapid degradation of the blends.

Detecting anomalous user activity

Systems, methods and articles for determining anomalous user activity are disclosed. Data representing a transaction activity corresponding to a plurality of user transactions can be received and user transactions can be grouped according to types of user transactions. The transaction activity can be determined to be anomalous in relation to the grouped user transactions based on a predetermined parameter.

Et tu, George? Campaign journalism and the politics of compromise

There is a category of film about journalism in which journalism is not the star, but the supporting player, and journalists not the protagonists but the Greek chorus, commenting on and also changing the realities they report. In such films the news media are a structuring presence driving the plot, shaping the narrative, constructing what we might think of as a pseudo-reality. Like Daniel Boorstin’s notion of the pseudo-event (introduced in his still-relevant book The Image, 1962), this pseudo-reality is so-named because it would not exist were it not for the demands of the news media’s hunger for stories, and knowledge of the damage they can do with those stories, on the calculations and actions of the key actors. Pseudo-realities form as responses to what political actors think journalists and their organisations need and want, or as efforts to shape journalistic accounts in ways favourable to themselves. Films about politics often feature pseudorealities of this kind, in which the events and actions driving the plot have only a tenuous relationship with important things going on in the everyday world beyond the political arena. Everything we see is about image, perception, appearance.

Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010 : a systematic analysis for the Global Burden of Disease Study 2010

Background Non-fatal health outcomes from diseases and injuries are a crucial consideration in the promotion and monitoring of individual and population health. The Global Burden of Disease (GBD) studies done in 1990 and 2000 have been the only studies to quantify non-fatal health outcomes across an exhaustive set of disorders at the global and regional level. Neither effort quantified uncertainty in prevalence or years lived with disability (YLDs). Methods Of the 291 diseases and injuries in the GBD cause list, 289 cause disability. For 1160 sequelae of the 289 diseases and injuries, we undertook a systematic analysis of prevalence, incidence, remission, duration, and excess mortality. Sources included published studies, case notification, population-based cancer registries, other disease registries, antenatal clinic serosurveillance, hospital discharge data, ambulatory care data, household surveys, other surveys, and cohort studies. For most sequelae, we used a Bayesian meta-regression method, DisMod-MR, designed to address key limitations in descriptive epidemiological data, including missing data, inconsistency, and large methodological variation between data sources. For some disorders, we used natural history models, geospatial models, back-calculation models (models calculating incidence from population mortality rates and case fatality), or registration completeness models (models adjusting for incomplete registration with health-system access and other covariates). Disability weights for 220 unique health states were used to capture the severity of health loss. YLDs by cause at age, sex, country, and year levels were adjusted for comorbidity with simulation methods. We included uncertainty estimates at all stages of the analysis. Findings Global prevalence for all ages combined in 2010 across the 1160 sequelae ranged from fewer than one case per 1 million people to 350 000 cases per 1 million people. Prevalence and severity of health loss were weakly correlated (correlation coefficient −0·37). In 2010, there were 777 million YLDs from all causes, up from 583 million in 1990. The main contributors to global YLDs were mental and behavioural disorders, musculoskeletal disorders, and diabetes or endocrine diseases. The leading specific causes of YLDs were much the same in 2010 as they were in 1990: low back pain, major depressive disorder, iron-deficiency anaemia, neck pain, chronic obstructive pulmonary disease, anxiety disorders, migraine, diabetes, and falls. Age-specific prevalence of YLDs increased with age in all regions and has decreased slightly from 1990 to 2010. Regional patterns of the leading causes of YLDs were more similar compared with years of life lost due to premature mortality. Neglected tropical diseases, HIV/AIDS, tuberculosis, malaria, and anaemia were important causes of YLDs in sub-Saharan Africa. Interpretation Rates of YLDs per 100 000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Prevalences of the most common causes of YLDs, such as mental and behavioural disorders and musculoskeletal disorders, have not decreased. Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges. Effective and affordable strategies to deal with this rising burden are an urgent priority for health systems in most parts of the world. Funding Bill & Melinda Gates Foundation.

Reply to William B. Grant

THE UVI working group acknowledges the contribution of Vitamin D to bone health as stated in our paper. However, we concluded that an optimal level of Vitamin D for humans has not yet been established with any certainty...

An afternoon with Chopin and George Sand

An original edutainment piece written by Caroline Heim and Christian Heim. Frederic Chopin and George Sands' turbulent and fraught relationship is dramatised through Chopin's music and Sand's writings.

The economics of awards, status and performance: the John Bates Clark Medal and the Fellowship of the Econometric Society

This thesis investigates whether receiving an important award in academia raises recipients’ subsequent research productivity and status compared to a synthetic control group of non-recipient scholars with similar previous research performance. It examines the case of being awarded the John Bates Clark Medal and becoming a Fellow of the Econometric Society finding evidence of positive incentive and status effects that raise both productivity and citation levels.

A systematic review of mathematical models of mosquito-borne pathogen transmission: 1970-2010

Mathematical models of mosquito-borne pathogen transmission originated in the early twentieth century to provide insights into how to most effectively combat malaria. The foundations of the Ross–Macdonald theory were established by 1970. Since then, there has been a growing interest in reducing the public health burden of mosquito-borne pathogens and an expanding use of models to guide their control. To assess how theory has changed to confront evolving public health challenges, we compiled a bibliography of 325 publications from 1970 through 2010 that included at least one mathematical model of mosquito-borne pathogen transmission and then used a 79-part questionnaire to classify each of 388 associated models according to its biological assumptions. As a composite measure to interpret the multidimensional results of our survey, we assigned a numerical value to each model that measured its similarity to 15 core assumptions of the Ross–Macdonald model. Although the analysis illustrated a growing acknowledgement of geographical, ecological and epidemiological complexities in modelling transmission, most models during the past 40 years closely resemble the Ross–Macdonald model. Modern theory would benefit from an expansion around the concepts of heterogeneous mosquito biting, poorly mixed mosquito-host encounters, spatial heterogeneity and temporal variation in the transmission process.

Feeling it out : Clark Beaumont

This catalogue essay was written to accompany Clark Beaumont's 2014 exhibition at Kings Artist Run in Melbourne, 'Feeling It Out'. It contextualises Clark Beaumont's work within a history of women's participation and achievement in modern and contemporary art, and suggests that this body of work may work through issues of anxiety, ambivalence and doubt about the art world.

Recasting the theory of mosquito-borne pathogen transmission dynamics and control

Mosquito-borne diseases pose some of the greatest challenges in public health, especially in tropical and sub-tropical regions of theworld. Efforts to control these diseases have been underpinned by a theoretical framework developed for malaria by Ross and Macdonald, including models, metrics for measuring transmission, and theory of control that identifies key vulnerabilities in the transmission cycle. That framework, especially Macdonald’s formula for R0 and its entomological derivative, vectorial capacity, are nowused to study dynamics and design interventions for many mosquito-borne diseases. A systematic review of 388 models published between 1970 and 2010 found that the vast majority adopted the Ross–Macdonald assumption of homogeneous transmission in a well-mixed population. Studies comparing models and data question these assumptions and point to the capacity to model heterogeneous, focal transmission as the most important but relatively unexplored component in current theory. Fine-scale heterogeneity causes transmission dynamics to be nonlinear, and poses problems for modeling, epidemiology and measurement. Novel mathematical approaches show how heterogeneity arises from the biology and the landscape on which the processes of mosquito biting and pathogen transmission unfold. Emerging theory focuses attention on the ecological and social context formosquito blood feeding, themovement of both hosts and mosquitoes, and the relevant spatial scales for measuring transmission and for modeling dynamics and control.

Cungellela by William ‘Dura Danje’ Leisha and Shem ‘Curan Danje’ Leisha

Research background: Cungelela is an intercultural music project undertaken in collaboration with William ‘Dura Danje’ Leisha and Shem ‘Curan Danje’ Leisha. The project contributes to cultural maintenance for Australian First Nations peoples, and is informed by prior work in this area by scholars including Peter Dunbar-Hall, Chris Gibson and Karl Neuenfeldt. These existing studies have discussed the complexities of intercultural collaboration, and the types of cultural politics that are involved when Indigenous and non-Indigenous musicians and scholars work together on projects of cultural significance. Critical race theory has also informed the creative work, as a means of interpreting the implicit and explicit discourses of race that arise through intercultural creative practice. The project asked the research question, in what ways can collaborative music making contribute to intercultural understanding and support cultural maintenance for Australian First Nations people affected by the Stolen Generations? Research contribution: This project has identified that collaborative production of recorded popular music can produce shared affective, embodied and transformative forms of knowledge about the impact of the Stolen Generations on Australian First Nations peoples. Research significance: The compact disc was presented by Aunty Anne Leisha as part of an invited presentation at the World Indigenous Nations Higher Education Consortium in New Mexico, 2013. The work also formed part of a refereed conference presentation at the 2013 conference of the International Association for the Study of Popular Music held at the University of Oviedo, Gijon, Spain.

Comparison of high sensitivity troponin T and I assays in the diagnosis of non-ST elevation acute myocardial infarction in emergency patients with chest pain

Objectives: Concentrations of troponin measured with high sensitivity troponin assays are raised in a number of emergency department (ED) patients; however many are not diagnosed with acute myocardial infarction (AMI). Clinical comparisons between the early use (2 h after presentation) of high sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI) assays for the diagnosis of AMI have not been reported. Design and methods: Early (0 h and 2 h) hs-cTnT and hs-cTnI assay results in 1571 ED patients with potential acute coronary syndrome (ACS) without ST elevation on electrocardiograph (ECG) were evaluated. The primary outcome was diagnosis of index MI adjudicated by cardiologists using the local cTnI assay results taken ≥6 h after presentation, ECGs and clinical information. Stored samples were later analysed with hs-cTnT and hs-cTnI assays. Results: The ROC analysis for AMI (204 patients; 13.0%) for hs-cTnT and hs-cTnI after 2 h was 0.95 (95% CI: 0.94–0.97) and 0.98 (95% CI: 0.97–0.99) respectively. The sensitivity, specificity, PLR, and NLR of hs-cTnT and hs-cTnI for AMI after 2 h were 94.1% (95% CI: 90.0–96.6) and 95.6% (95% CI: 91.8–97.7), 79.0% (95% CI: 76.8–81.1) and 92.5% (95% CI: 90.9–93.7), 4.48 (95% CI: 4.02–5.00) and 12.86 (95% CI: 10.51–15.31), and 0.07 (95% CI: 0.04–0.13) and 0.05 (95% CI:0.03–0.09) respectively. Conclusions: Exclusion of AMI 2 h after presentation in emergency patients with possible ACS can be achieved using hs-cTnT or hs-cTnI assays. Significant differences in specificity of these assays are relevant and if using the hs-cTnT assay, further clinical assessment in a larger proportion of patients would be required.