A comparative analysis of risk stratification tools for emergency department patients with chest pain

Background: Appropriate disposition of emergency department (ED) patients with chest pain is dependent on clinical evaluation of risk. A number of chest pain risk stratification tools have been proposed. The aim of this study was to compare the predictive performance for major adverse cardiac events (MACE) using risk assessment tools from the National Heart Foundation of Australia (HFA), the Goldman risk score and the Thrombolysis in Myocardial Infarction risk score (TIMI RS). Methods: This prospective observational study evaluated ED patients aged ≥30 years with non-traumatic chest pain for which no definitive non-ischemic cause was found. Data collected included demographic and clinical information, investigation findings and occurrence of MACE by 30 days. The outcome of interest was the comparative predictive performance of the risk tools for MACE at 30 days, as analyzed by receiver operator curves (ROC). Results: Two hundred eighty-one patients were studied; the rate of MACE was 14.1%. Area under the curve (AUC) of the HFA, TIMI RS and Goldman tools for the endpoint of MACE was 0.54, 0.71 and 0.67, respectively, with the difference between the tools in predictive ability for MACE being highly significant [chi2 (3) = 67.21, N = 276, p < 0.0001]. Conclusion: The TIMI RS and Goldman tools performed better than the HFA in this undifferentiated ED chest pain population, but selection of cutoffs balancing sensitivity and specificity was problematic. There is an urgent need for validated risk stratification tools specific for the ED chest pain population.

Narratives of possession : reading for saga authorship

The aim of this thesis is to show how character analysis can be used to approach conceptions of saga authorship in medieval Iceland. The idea of possession is a metaphor that is adopted early in the thesis, and is used to describe Icelandic sagas as works in which traditional material is subtly interpreted by medieval authors. For example, we can say that if authors claim greater possession of the sagas, they interpret, and not merely record, the sagas' historical information. On the other hand, tradition holds onto its possession of the narrative whenever it is not possible for an author to develop his own creative and historical interests. The metaphor of possession also underpins the character analysis in the thesis, which is based on the idea that saga authors used characters as a vehicle by which to possess saga narratives and so develop their own historical interests. The idea of possession signals the kinds of problems of authorship study which are addressed here, in particular, the question of the authors' sense of saga writing as an act either of preservation or of creation. While, in that sense, the thesis represents an additional voice in a long-standing debate about the saga writers' relation to their source materials, I argue against a clear-cut distinction between creative and non-creative authors, and focus instead on the wide variation in authorial control over saga materials. This variation suggests that saga authorship is a multi-functional activity, or one which co-exists with tradition. Further, by emphasising characterisation as a method, I am adding to the weight of scholarship that seeks to understand the sagas in terms of their literary effects. The Introduction and chapter one lay out the theoretical scope of this thesis. My aim in these first two sections is to inform the reader of the type of critical questions that arise when authorship is approached in relation to characterisation, and to suggest an interpretive framework with which to approach these questions. In the Introduction this aim manifests as a brief discussion of the application of the term "authorship" to the medieval Icelandic corpus, a definition of the scope of this study, and an introduction to the connections, made throughout this thesis, between saga authors, the sagas' narrative style, and the style of characterisation in the sagas. Chapter one is a far more detailed discussion of our ability to make these connections. In particular, the chapter develops the definition of the analytical term "secondary authorship" that I introduce in order to delineate the type of characterisation that is of most interest in this thesis. "Secondary authorship" is a literary term that aims to sharpen our approach to saga authors' relationship to their characters by focusing on characters who make representations about the events of the saga. The term refers to any instance in which characters behave in a manner that resembles the creativity, interpretation, and understanding associated with authorship more generally. Character analysis cannot, however, be divorced from socio-historical approaches to the saga corpus. Most importantly, the sagas themselves are socio-historical representations that claim some degree of truth value. This claim that the sagas make by implication about their historicity is the starting point of a discussion of authorship in medieval Iceland. Therefore, at the beginning of chapter one I discuss some of the approaches to the social context of saga writing. This discussion serves as an introduction to both the culture of saga writing in medieval Iceland and to the nature of the sagas' historical perspective, and reflects my sense that literary interpretations of the sagas cannot be isolated from the historical discourses that frame them. The chapter also discusses possession, which, as I note above, is used alongside the concept of secondary authorship to describe the saga authors' relationship with the stories and characters of the past. At the close of chapter one, I offer a preliminary list the various functions of saga authorship, and give some examples of secondary authorship. From this point I am able to tie my argument about secondary authorship to specific examples from the sagas. Chapter two examines the effect of family obligations and domestic points of view in the depiction of characters' choices and conception of themselves. The examples that are given in that chapter - from Gisla saga Súrssonar and Íslendinga saga - are the first of a number of textual analyses that demonstrate the application of the concepts of secondary authorship and possession of saga narratives. The relationship between narratives about national and domestic matters shows how authorial creativity in the area of kinship obligation provides the basis for the saga's development of historical themes. Thus, the two major case studies given in chapter two tie authorial engagement with characters to the most influential social institution in early and medieval Iceland, the family. The remaining chapters represent similar attempts to relate authorial possession of saga characters to central socio-historical themes in the sagas, such as the settlement process in early Iceland and its influence on the development of regional political life (chapter three). Likewise, the strong authorial interest in an Icelander's journey to Norway in Heimskringla is presented as evidence of the author's use of a saga character to express an Icelandic interpretation of Norwegian history and to promote a sense that Iceland shared the ownership of regal history with Norway (chapter four). In that authorial engagement with the Icelander abroad, we witness saga characterisation being used as a basis for historical interpretation and the means by which foreign traditions and influence, not least the narratives of royal lives and of the Christianisation, are claimed as part of medieval Icelanders' self-conception. While saga authors observe the conventions of saga narration, characters are often subtly positioned as the authors' interpretive mirrors, especially clear than when they act as secondary authors. Nowhere is this more apparent than in Brennu- Njáls saga, which contains many characters who voice the author's claim to interpret the past. Even Hrútr Herjólfsson, through his remarkable perception of events and his conspicuous comments about them, acts as a secondary author by enabling the author to emphasise the importance of the disposition of characters. In Laxdœla saga and Þorgils saga ok Hafliða, authorial interest in characters' perception is matched by the thematising of learning, from the inception of knowledge as prophecy or advice to complete understanding by saga characters (chapter six). In Þorgils saga skarða, a character's inner development from an excessively ambitious and politically ruthless youth to a Christian leader killed by his kinsman allows the author to shape a political life into a lesson about leadership and the community's ability to moderate and contain the behaviour of extraordinary individuals. The portrayal draws on methods of characterisation that we can identify in Grettis saga Ásmundarson, Fóstbrœðra saga, and Orkneyinga saga. A comparison of the characterisation of figures with intense political or military ambitions suggests that saga authors were interested in the community's ability to balance their strength and ability with a degree of social moderation. The discussion of these sagas shows that character study can be used to analyse how the saga authors added their own voice to the voices passed down to medieval Icelanders in traditional narratives. Authorial engagement with characters allowed inherited traditions about early Norway and Iceland and records of thirteenth century events to be transformed into sophisticated historical works with highly creative elements. Through secondary authorship, saga authors took joint-possession of narratives and contested the power of tradition in setting the interpretive framework of a saga.

Topological design and modulation strategy for buck-boost three-level inverters

To date, designed topologies for DC-AC inversion with both voltage-buck and boost capabilities are mainly focused on two-level circuitries with extensions to three-level possibilities left nearly unexplored. Contributing to this area of research, this paper presents the design of a number of viable buck-boost three-level inverters that can also support bidirectional power conversion. The proposed front-end circuitry is developed from the Cuk-derived buck-boost two-level inverter, and by using the "alternative phase opposition disposition" (APOD) modulation scheme, the buck-boost three-level inverters can perform distinct five-level line voltage and three-level phase voltage switching by simply controlling the active switches located in the designed voltage boost section of the circuits. As a cost saving option, one active switch can further be removed from the voltage-boost section of the circuits by simply re-routing the gating commands of the remaining switches without influencing the ac output voltage amplitude. To verify the validity of the proposed inverters, Matlab/PLECS simulations were performed before a laboratory prototype was implemented for experimental testing.

In search of the missing link in CSR : an analysis of the government influence

Research on corporate social responsibility (CSR) has not differentiated the varying degree of government influence in its multiple roles on different types of CSR. However, different il1fluences resulting from the different roles he govemment plays in the CSR arena an shape different CSR behavior. This paper examines the efficacy of the govemment influence on four types of corporate social responsibilities: legal, economic, philanthropic and ethical. We argue that the govemment influence on firms' CSR disposition varies in intensizv and salience depending on the level of interdependency between the government and the firm and the deployable strategies available to the govemment. We have identified the strongest link between the government as mandator and legal CSR and weakest link between the govemment as endorser and ethical CSR. We provide implications for government policy makers and future studies in this area.

Retrospective observational study of patients who present to Australian rural emergency departments with undifferentiated chest pain

Aim To identify the demographic and clinical characteristics of patients who present to Australian rural emergency departments with chest pain. Design Retrospective, observational study Setting Rural emergency departments (ED) in Queensland, Australia Participants 337 consecutive adult patients with undifferentiated chest pain that presented between 1st September 2013 and 30th November 2013. Main outcome measures Service indicators, discharge diagnoses and disposition Results Presentations for undifferentiated chest pain represented 3.5% of all patient presentations during the sampling period. The mean age of patients was 48 years and 54% were male. Overall, 92% of patients left the ED within the 4-hour NEAT target. The majority of presentations were related to cardiac concerns (39%), followed by non-cardiac chest pain (17%), musculoskeletal (15%) and respiratory (10%) conditions. More than half of these patients were discharged at the completion of the ED service (52.8%), 40.6% were admitted, 3.3% left at own risk, 2.4% did not wait and less than 1% of patients required transfer to another hospital directly from the ED. Conclusions This study has provided information on the characteristics and processes of care for patients presenting to Australian rural EDs with undifferentiated chest pain that will inform service planning and further research to evaluate the effectiveness of care for these patients.

Individual differences in the processing of punishment and reward cues : an application to road safety messages

This thesis examined the extent to which individual differences, as conceptualised by the revised Reinforcement Sensitivity Theory, influenced young drivers' information processing and subsequent acceptance of anti-speeding messages. Using a multi-method approach, the findings highlighted the utility of combining objective measures (a cognitive response time task and electroencephalography) with self-report measures to assess message processing and message acceptance, respectively. This body of research indicated that responses to anti-speeding messages may differ depending on an individual's personality disposition. Overall, the research provided further insight into the development of message strategies to target high risk drivers.

Personally significant learning: The challenge

The article explores the importance for young individuals to have a powerful disposition to be self-managing learners after completing their schooling. It presents several propositions which aim to unlearn the best educational experience a school principal can give for young people and their teachers. The use of digital technologies is mentioned.

Trends in hospital admission for stroke in Calgary

Background Stroke incidence has fallen since 1950. Recent trends suggest that stroke incidence may be stabilizing or increasing. We investigated time trends in stroke occurrence and in-hospital morbidity and mortality in the Calgary Health Region. Methods All patients admitted to hospitals in the Calgary Health Region between 1994 and 2002 with a primary discharge diagnosis code (ICD-9 or ICD-10) of stroke were included. In-hospital strokes were also included. Stroke type, date of admission, age, gender,discharge disposition (died, discharged) and in-hospital complications (pneumonia, pulmonary embolism, deep venous thrombosis) were recorded. Poisson and simple linear regression was used to model time trends of occurrence by stroke type and age-group and to extrapolate future time trends. Results From 1994 to 2002, 11642 stroke events were observed. Of these, 9879 patients (84.8%) were discharged from hospital, 1763 (15.1%) died in hospital, and 591 (5.1%) developed in-hospital complications from pneumonia, pulmonary embolism or deep venous thrombosis. Both in-hospital mortality and complication rates were highest for hemorrhages. Over the period of study, the rate of stroke admission has remained stable. However, total numbers of stroke admission to hospital have faced a significant increase (p=0.012) due to the combination of increases in intracerebral hemorrhage (p=0.021) and ischemic stroke admissions (p=0.011). Sub-arachnoid hemorrhage rates have declined. In-hospital stroke mortality has experienced an overall decline due to a decrease in deaths from ischemic stroke, intracerebral hemorrhage and sub-arachnoid hemorrhage. Conclusions Although age-adjusted stroke occurrence rates were stable from 1994 to 2002, this is associated with both a sharp increase in the absolute number of stroke admissions and decline in proportional in-hospital mortality. Further research is needed into changes in stroke severity over time to understand the causes of declining in-hospital stroke mortality rates.

Metal-Ion-Dependent Oxidative DNA Cleavage by Transition Metal Complexes of a New Water-Soluble Salen Derivative

A new water-soluble, salen [salen = bis(salicylidene) ethylenediamine]-based ligand, 3 was developed. Two of the metal complexes of this ligand, i.e., 3a, [Mn(III)] and 3b, [Ni(II)], in the presence of cooxidant magnesium monoperoxyphthalate (MMPP) cleaved plasmid DNA pTZ19R efficiently and rapidly at a concentration similar to 1 mu M. In contrast, under comparable conditions, other metal complexes 3c, [Cu(II)] or 3d, [Cr(III)] could not induce any significant DNA nicking. The findings with Ni(II) complex suggest that the DNA cleavage processes can be modulated by the disposition of charges around the ligand.

Use of α- and β-subunit specific antibodies in studying interaction of hCG with Leydig cell receptors

Antisera (a/s) raised to individual α- and β-subunits of human chorionic gonadotropin (hCG) have been characterized for specificity using immunoaffinity procedures and used to study the disposition of the two subunits when intact hCG is complexed with luteinizing hormone (LH) receptor of the Leydig cells. Three kinds of experiments were done. (a) The ability of the preformed hormone-antibody (H-Ab) complex to bind to receptor and stimulate a response; (b) the ability of the a/s to dissociate hCG from its complex with the receptor and thereby terminate response; and (c) the ability of the premixed antibody and receptor to compete for binding of labeled hCG. Although the subunit specific a/s used here were equipotent in binding hCG (capacity to bind and Ka being very similar), their behavior once the receptor preparation or Leydig cell is introduced into the system was drastically different. The β-subunit antibody relative to the α-subunit antibody, appeared to be poorly effective in preventing hCG from either binding to the receptor or inhibiting the continuation of response. The results suggest that hCG upon interaction with the receptor loses the determinants specific to the β-region more rapidly compared to those specific to the α-region suggesting thereby that the initial interaction of hCG with the receptor should be occurring through sites in the β-subunit. Although the α-subunit portion of the hCG molecule is available for binding to the antibody for a relatively longer time, the biological response of the cell seems very sensitive to such binding with the antibody as it invariably results in loss of response. In the Leydig cell system, the ability of the a/s to bind hCG that is already complexed to the receptor appears to be dependent upon the time of addition of the antibody to the incubation medium. The antisera were totally ineffective in inhibiting steroidogenic response to hCG if added 60 min after addition of hCG. This would suggest that the hormone-receptor complex once formed perhaps continues to change its orientation with the result that with time relatively less and less of antigenic determinants become available for antibody binding.

Interaction Between Two Residues in the Inter-Domain Interface of Escherichia coli Peptidase N Modulates Catalytic Activity

The role of interaction between Asn259 (catalytic domain) with Gln821 (C-terminal domain) in PeptidaseN was investigated. The k(cat) of PeptidaseN containing Asn259Asp or Gln821Glu is enhanced whereas it is suppressed in Asn259AspGln821Glu. Structural analysis shows this interaction to change the relative disposition of active site residues, which modulates catalytic activity.

Isotonic designs for phase I trials

The purpose of a phase I trial in cancer is to determine the level (dose) of the treatment under study that has an acceptable level of adverse effects. Although substantial progress has recently been made in this area using parametric approaches, the method that is widely used is based on treating small cohorts of patients at escalating doses until the frequency of toxicities seen at a dose exceeds a predefined tolerable toxicity rate. This method is popular because of its simplicity and freedom from parametric assumptions. In this payer, we consider cases in which it is undesirable to assume a parametric dose-toxicity relationship. We propose a simple model-free approach by modifying the method that is in common use. The approach assumes toxicity is nondecreasing with dose and fits an isotonic regression to accumulated data. At any point in a trial, the dose given is that with estimated toxicity deemed closest to the maximum tolerable toxicity. Simulations indicate that this approach performs substantially better than the commonly used method and it compares favorably with other phase I designs.

Civil Procedure — Commentary and Materials, 6th Edition

This book provides a comprehensive analysis of the practical and theoretical issues encountered in Australian civil procedure, including alternative dispute resolution. Each chapter features in-depth questions and notes together with lists of further reading to aid understanding of the issue. It also examines and discusses each substantive and procedural step in the trial process. Topics include jurisdiction of a court to consider a matter, alternative dispute resolution, limitations of actions, commencing proceedings, group proceedings, pleading, summary disposition, gathering evidence, affidavits, interlocutory procedures, settlement, trial and appeal, costs Each of the state, territory and federal procedures is covered.

Isänmaa ja Ranska : Suomalainen frankofilia 1880-1914

In Finland the period 1880 -1914 constituted an essential phase in the creation of the great national project as well as it was a golden time of Francophilia. With Francophilia, i.e. French-mindedness, is here understood a collectively upheld strong sympathy towards France and French culture. However, the Francophilia of late nineteenth century Finland was free from apparent political intentions and remained a chosen disposition. The strength of its drive was not only based on the older European admiration of everything French, but also on the growing fascination for a novelty emerging besides the traditional influences of the Germanic culture. In Finnish society Francophilia mostly worked as an opposite force to the most confined conceptions of what was considered national ; as a consequence France came to denote more than a country and Francophilia contained an important symbolical meaning in the construction of the Finnish nation. The main tasks of the study are to introduce as the first large historical presentation of the subject a covering examination of the many descriptions of Paris-phases of assorted artists, authors, and intellectuals, to clarify the mental relationship of the Finnish intelligentsia to France prior to national independence, and finally to provide these developments with case studies of certain life paths. However, the examination is not biographical, because the starting point remains within the rhetoric arguments of Francophilia and patriotism as these appeared within the public sphere. Historical persons have thus been dealt with primarily as reflectors of the then-current French-minded mentality. Such Francophiles in Finland were first and foremost Werner Söderhjelm, Juhani Aho, L. Onerva and V. A. Koskenniemi. The networks of the Finnish cultural field are mostly displayed through these examples. In previous research the intensive relationship of Finnish artists and authors with France has not been connected with actual concepts of nationalism. The respective periods of the intellectuals in Paris have simply been viewed as devoid of ideological links with the contemporary advancement of the fatherland, or even as opposites to the patriotic pursuits in Finland. From the viewpoint of this study these now canonized creators of a Finnish culture are primarily seen as patriots and fellow countrymen, and only secondly as artists and artist s colleagues. The dissertation is constructed as both a regional survey of the idealization of France and a study of Finnish history through the mirror of Francophilia. As such France only held an instrumental role for the receiving culture, i.e. for the construction of Finland, as no "objective truths" were sought for in France. Keywords: France, francophilia, Finnishness, national project, Paris

Synthetic studies towards the phloroglucin natural product hyperforin: construction of the fully prenylated bicyclic core

An approach towards the highly functionalized bicyclo[3.3.1]nonan-9-one core of the complex PPAP-based natural product hyperforin, with the full complement of prenyl substituents in required stereo-disposition, is delineated.