Prospective external validation of an accelerated (2-h) acute coronary syndrome rule-out process using a contemporary troponin assay

Background: Recently there have been efforts to derive safe, efficient processes to rule out acute coronary syndrome (ACS) in emergency department (ED) chest pain patients. We aimed to prospectively validate an ACS assessment pathway (the 2-Hour Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker (ADAPT) pathway) under pragmatic ED working conditions. Methods: This prospective cohort study included patients with atraumatic chest pain in whom ACS was suspected but who did not have clear evidence of ischaemia on ECG. Thrombolysis in myocardial infarction (TIMI) score and troponin (TnI Ultra) were measured at ED presentation, 2 h later and according to current national recommendations. The primary outcome of interest was the occurrence of major adverse cardiac events (MACE) including prevalent myocardial infarction (MI) at 30 days in the group who had a TIMI score of 0 and had presentation and 2-h TnI assays <99th percentile. Results: Eight hundred and forty patients were studied of whom 177 (21%) had a TIMI score of 0. There were no MI, MACE or revascularization in the per protocol and intention-to-treat 2-h troponin groups (0%, 95% confidence interval (CI) 0% to 4.5% and 0%, 95% CI 0% to 3.8%, respectively). The negative predictive value (NPV) was 100% (95% CI 95.5% to 100%) and 100% (95% CI 96.2% to 100%), respectively. Conclusions: A 2-h accelerated rule-out process for ED chest pain patients using electrocardiography, a TIMI score of 0 and a contemporary sensitive troponin assay accurately identifies a group at very low risk of 30-day MI or MACE.

Living well with diabetes: 24-month outcomes from a randomized trial of telephone-delivered weight loss and physical activity intervention to improve glycemic control

OBJECTIVE: To evaluate the effectiveness of a telephone-delivered behavioral weight loss and physical activity intervention targeting Australian primary care patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: Pragmatic randomized controlled trial of telephone counseling (n = 151) versus usual care (n = 151). Reported here are 18-month (end-of-intervention) and 24-month (maintenance) primary outcomes of weight, moderate-to-vigorous-intensity physical activity (MVPA; via accelerometer), and HbA1c level. Secondary outcomes include dietary energy intake and diet quality, waist circumference, lipid levels, and blood pressure. Data were analyzed via adjusted linear mixed models with multiple imputation of missing data. RESULTS: Relative to usual-care participants, telephone counseling participants achieved modest, but significant, improvements in weight loss (relative rate [RR] -1.42% of baseline body weight [95% CI -2.54 to -0.30% of baseline body weight]), MVPA (RR 1.42 [95% CI 1.06-1.90]), diet quality (2.72 [95% CI 0.55-4.89]), and waist circumference (-1.84 cm [95% CI -3.16 to -0.51 cm]), but not in HbA1c level (RR 0.99 [95% CI 0.96-1.02]), or other cardio-metabolic markers. None of the outcomes showed a significant change/deterioration over the maintenance period. However, only the intervention effect for MVPA remained statistically significant at 24 months. CONCLUSIONS: The modest improvements in weight loss and behavior change, but the lack of changes in cardio-metabolic markers, may limit the utility, scalability, and sustainability of such an approach.

Diabetes in South Asians

Economic, dietary and other lifestyle transitions have been occurring rapidly in most South Asian countries, making their populations more vulnerable to developing Type 2 diabetes and cardiovascular diseases. Recent data show an increasing prevalence of Type 2 diabetes in urban areas as well as in semi-urban and rural areas, inclusive of people belonging to middle and low socio-economic strata. Prime determinants for Type 2 diabetes in South Asians include physical inactivity, imbalanced diets, abdominal obesity, excess hepatic fat and, possibly, adverse perinatal and early life nutrition and intra-country migration. It is reported that Type 2 diabetes affects South Asians a decade earlier and some complications, for example nephropathy, are more prevalent and progressive than in other races. Further, prevalence of pre-diabetes is high, and so is conversion to diabetes, while more than 50% of those who are affected remain undiagnosed. Attitudes, cultural differences and religious and social beliefs pose barriers in effective prevention and management of Type 2 diabetes in South Asians. Inadequate resources, insufficient healthcare budgets, lack of medical reimbursement and socio-economic factors contribute to the cost of diabetes management. The challenge is to develop new translational strategies, which are pragmatic, cost-effective and scalable and can be adopted by the South Asian countries with limited resources. The key areas that need focus are: generation of awareness, prioritizing health care for vulnerable subgroups (children, women, pregnant women and the underprivileged), screening of high-risk groups, maximum coverage of the population with essential medicines, and strengthening primary care. An effective national diabetes control programme in each South Asian country should be formulated, with these issues in mind.

An Integrated Assessment Of The Suitability Of Domestic Solar Still As A Viable Safe Water Technology For India

Improving access to safe drinking water can result in multi-dimensional impacts on people's livelihood. This has been aptly reflected in the Millennium Development Goals (MDG) as one of the major objectives. Despite the availability of diverse and complex set of technologies for water purification, pragmatic and cost-effective use of the same is impeding the use of available sources of water. Hence, in country like India simple low-energy technologies such as solar still are likely to succeed. Solar stills would suffice the basic minimum drinking water requirements of man. Solar stills use sunlight, to kill or inactivate many, if not all, of the pathogens found in water. This paper provides an integrated assessment of the suitability of domestic solar still as a viable safe water technology for India. Also an attempt has been made to critically assess the operational feasibility and costs incurred for using this technology in rural India.

Socio-environmental impact of idol immersion: dimensions and directions

India possesses a diverse and rich cultural heritage and is renowned as a 'land of festivals'. These festivals attract massive community involvement paving way to new materials such as 'Plaster of Paris' being used for 'modernizing' the representation of idols with very little thought given to the issues of toxicity and environmental impacts. Another dimension to the whole issue is the plight of the artisans and the workers involved in the trade. Owing to the unorganized nature of the industry there is minimal or no guidelines pertaining-to the worker safety and health risks of the people involved. This paper attempts to address the complexities of the inherent hazards as a consequence of these socio-environmental issues and trace the scientific rationale in addressing them in a practical and pragmatic way.

The non-literary Latin letters. A study of their syntax and pragmatics

This dissertation studies the language of Latin letters that were written in Egypt and Vindolanda (in northern Britain) during the period 1st century BC 3rd century AD on papyri, ostraca, and wooden tablets. The majority of the texts is, in one way or another, connected with the Roman army. The focus of the study is on syntax and pragmatics. Besides traditional philological methods, modern syntactic theory is used as well, especially in the pragmatic analysis. The study begins with a critical survey of certain concepts that are current in the research on the Latin language, most importantly the concept of vulgar Latin , which, it is argued, seems to be used as an abstract noun for variation and change in Latin . Further, it is necessary to treat even the non-literary material primarily as written texts and not as straightforward reflections of spoken language. An examination of letter phraseology shows that there is considerable variation between the two major geographical areas of provenance. Latin letter writing in Egypt was influenced by Greek. The study highlights the importance of seeing the letters as a text type, with recurring phraseological elements appearing in the body text as well. It is argued that recognising these elements is essential for the correct analysis of the syntax. Three areas of syntax are discussed in detail: sentence connection (mainly parataxis), syntactically incoherent structures and word order (the order of the object and the verb). For certain types of sentence connection we may plausibly posit an origin in spoken Latin, but for many other linguistic phenomena attested in this material the issue of spoken Latin is anything but simple. Concerning the study of historical syntax, the letters offer information about the changing status of the accusative case. Incoherent structures may reflect contaminations in spoken language but usually the reason for them is the inability of the writer to put his thoughts into writing, especially when there is something more complicated to be expressed. Many incoherent expressions reflect the need to start the predication with a thematic constituent. Latin word order is seen as resulting from an interaction of syntactic and pragmatic factors. The preference for an order where the topic is placed sentence-initially can be seen in word order more generally as well. Furthermore, there appears a difference between Egypt and Vindolanda. The letters from Vindolanda show the order O(bject) V(erb) clearly more often than the letters from Egypt. Interestingly, this difference correlates with another, namely the use of the anaphoric pronoun is. This is an interesting observation in view of the fact that both of these are traditional Latin features, as opposed to those that foreshadow the Romance development (VO order and use of the anaphoric ille). However, it is difficult to say whether this is an indication of social or regional variation.

Les formes d’adresse dans un corpus de films français et leur traduction en finnois

The use of forms of address in French films and their Finnish translations The use of forms of address constitutes an integral part of speakers’ communicative competence. In fact, they are not only used to assign to whom the speech is addressed, but also to construct the relationship between speakers. However, the choice of a suitable form is not necessarily evident in modern, pluralistic society. By the notion form of address, I refer to pronouns of address (tu vs. vous) and different nouns of address like names, titles (Monsieur, Madame, Mademoiselle), kinship terms, occupational terms, terms of endearment and insults. The purpose of the present thesis is, first, to study the semantic and pragmatic values of forms of address in dialogues of modern French films, and, second, their translation in Finnish subtitles. It is evident that film language is not spontaneous, but only a representation of authentic speech, and that subtitles are a written version of the original spoken language. Consequently, this thesis studies spoken fictive dialogues and their written translations. The methods applied in the study are the Interactional and Pragmatic Approach as well as Translatology. The role of forms of address in an interpersonal relationship is studied with dimensions of distance and power (Brown and Gilman 1960, Kerbrat-Orecchioni 1992), whereas the pragmatic dimension permits studying in particular the use of forms of address in speech acts (Kerbrat-Orecchioni 2001). The translation strategies are studied with the help of Venuti’s (1995) notions of foreignizing and domesticating strategies. The results of the thesis suggest that the pronoun use in the studied films is usually reciprocal. However, the relations of power have not disappeared, but are expressed in a more discrete manner with nouns of address (for instance vous + Docteur vs. vous + Anita). The use of the pronoun of address vous seems still to be common, but increased intimacy is expressed by accompanying familiar nouns of address like first names. The nominal forms of address accompany different speech acts, but not in a systematic manner. In a dialogue they appear usually in the first speech act, and more rarely in the response, but not in both. In addition, they have an important role in the mechanics of conversation. The translators here face multiple demands, and their translations seem mostly to be a compromise between foreignizing and domesticating strategies.

Zur Sättigung der Valenz in den Kleinen Meldungen des Typus Notiz : Eine pragmatisch fundierte Analyse

Valency Realization in Short Excerpts of News Text. A Pragmatics-funded analysis This dissertation is a study of the so-called pragmatic valency. The aim of the study is to examine the phenomenon both theoretically by discussing the research literature and empirically based on evidence from a text corpus consisting of 218 short excerpts of news text from the German newspaper Frankfurter Allgemeine Zeitung. In the theoretical part of the study, the central concepts of the valency and the pragmatic valency are discussed. In the research literature, the valency denotes the relation among the verb and its obligatory and optional complements. The pragmatic valency can be defined as modification of the so-called system valency in the parole, including non-realization of an obligatory complement, non- realization of an optional complement and realization of an optional complement. Furthermore, the investigation of the pragmatic valency includes the role of the adjuncts, elements that are not defined by the valency, in the concrete valency realization. The corpus study investigates the valency behaviour of German verbs in a corpus of about 1500 sentences combining the methodology and concepts of valency theory, semantics and text linguistics. The analysis is focused on the about 600 sentences which show deviations from the system valency, providing over 800 examples for the modification of the system valency as codified in the (valency) dictionaries. The study attempts to answer the following primary question: Why is the system valency modified in the parole? To answer the question, the concept of modification types is entered. The modification types are recognized using distinctive feature bundles in which each feature with a negative or a positive value refers to one reason for the modification treated in the research literature. For example, the features of irrelevance and relevance, focus, world and text type knowledge, text theme, theme-rheme structure and cohesive chains are applied. The valency approach appears in a new light when explored through corpus-based investigation; both the optionality of complements and the distinction between complements and adjuncts as defined in the present valency approach seem in some respects defective. Furthermore, the analysis indicates that the adjuncts outside the valency domain play a central role in the concrete realization of the valency. Finally, the study suggests a definition of pragmatic valency, based on the modification types introduced in the study and tested in the corpus analysis.

La coordination et les phrases juxtaposées en français

Coordination and juxtaposed sentences The object of this study is the examination of the relations between juxtaposed clauses in contemporary French. The matter in question is sentences which are composed of several clauses adjoined without a conjunction or other connector, as in: Je détournai les yeux, mon c ur se mit à battre. The aim of the study is to determine, which quality is the relation in these sentences and, on the other hand, what is the part of the coordination there. Furthermore, what is this relation of coordination, which, according to some grammars, manifests through a conjunction of coordination, but which, according to some others is marked in juxtaposed sentences through different features. The study is based on a corpus of written French from literary and journalistic text sources. Syntactic, semantic and textual properties in the clauses are discussed. The analysis points to differences so, it has been noted, in each case, if one of the clauses is affirmative and the other negative and if in the second clause, the subject has not been repeated. Also, an analysis has been made on the ground of the tense, mode, phrase structure type, and thematic structure, taking into account, in each case, if the clauses are identical or different. Punctuation has been one of the properties considered. The final aim has been to eliminate gradually, based on the partition of properties, subordinate sentences, so that only the hard core of coordinate sentences remains. In this way, the coordination could be defined similarly as the phoneme is defined as a group of distinctive features. The quantitative analyses have led to the conclusion that the sentences which, from a semantic point of view, are interpreted as coordinating, contain the least of these differences, while the sentences which can be considered as subordinating present the most of these differences. The conditions of coordination are, in that sense, hierarchical, so that the syntactic constraints have to make room for semantic, textual and cognitive factors. It is interesting to notice that everyone has the ability to produce correct coordinating structures and recognize incorrect coordinating structures. This can be explained by the human ability to categorize which has been widely researched in the semantic of prototype. The study suggests that coordination and subordination could be considered as prototypical cognitive categories based on different linguistic and pragmatic features.

Coordinated Verb Pairs in Texts

This dissertation discusses the relation between lexis, grammar and textual organisation. The major premise adopted here is that grammatical structures are motivated both by semantic potential of words and by text-pragmatic demands. In other words, it is argued that grammatical structures form the interface between lexis and textual organisation, and that linguistic analysis should not concentrate on analysing grammatical structures in isolation, independent of context. From this point of view, grammatical structures are said to be 'well-formed' only in relation to the context they occur in. This study is based on a corpus of three million words of recent Finnish fiction from which all the occurrences of the coordinated verb pairs ([V ja V] -pairs]) containing one of the intransitive motion verbs 'lähteä' (to go), 'mennä' (to go), 'päästä' (to get into), 'nousta' (to get up), and 'laskea' (to go down), were extracted. This set of verbs was established using methods described in earlier work by Lagus & Airola (2001, and 2005). The quantitative analysis of the [V ja V] -pairs was used to carry out a qualitative analysis of individual texts. In analysing the texts, an analogy was made between musical and textual structure. The results show among others that individual verbs specialise in different functions when occurring in coordinated verb pairs. One aspect was that those verb pairs including the verb 'nousta' tend to function as markers of textual boundaries and thus reflect the organisation of narrative substance. The verb 'mennä' has weakened literal meanings, but strengthened modal meanings when occurring in [V ja V] -pairs, and, in many cases, the verb 'lähteä' in [V ja V] -pairs function as an aspectual marker rather than a pure verb of motion. That there is a gradient from the concrete sense of motion into more differentiated senses of a verb in [V ja V] -pairs alongside the structure-creating potential of the [V ja V] -pairs themselves suggest an ongoing grammaticalisation process of the patterns discussed.

A Sketch of the Phonology and Grammar of Rajbanshi

This dissertation is a synchronic description of the phonology and grammar of two dialects of the Rajbanshi language (Eastern Indo-Aryan) as spoken in Jhapa, Nepal. I have primarily confined the analysis to the oral expression, since the emerging literary form is still in its infancy. The grammatical analysis is therefore based, for the most part, on a corpus of oral narrative text which was recorded and transcribed from three informants from north-east Jhapa. An informant, speaking a dialect from south-west Jhapa cross checked this text corpus and provided additional elicited material. I have described the phonology, morphology and syntax of the language, and also one aspect of its discourse structure. For the most part the phonology follows the basic Indo-Aryan pattern. Derivational morphology, compounding, reduplication, echo formation and onomatopoeic constructions are considered, as well as number, noun classes (their assignment and grammatical function), pronouns, and case and postpositions. In verbal morphology I cover causative stems, the copula, primary and secondary agreement, tense, aspect, mood, auxiliary constructions and non-finite forms. The term secondary agreement here refers to genitive agreement, dative-subject agreement and patient (and sometimes patient-agent) agreement. The breaking of default agreement rules has a range of pragmatic inferences. I argue that a distinction, based on formal, semantic and statistical grounds, should be made between conjunct verbs, derivational compound verbs and quasi-aspectual compound verbs. Rajbanshi has an open set of adjectives, and it additionally makes use of a restricted set of nouns which can function as adjectives. Various particles, and the emphatic and conjunctive clitics are also considered. The syntactic structures studied include: non-declarative speech acts, phrase-internal and clause-internal constituent order, negation, subordination, coordination and valence adjustment. I explain how the future, present and past tenses in Rajbanshi oral narratives do not seem to maintain a time reference, but rather to indicate a distinction between background and foreground information. I call this tense neutralisation .

Teatterinjohtamisen dramaturgiaa : Keskeiset tehtävät, arjen ongelmat ja rakenteelliset muutostarpeet

DRAMATURGY OF THEATRE MANAGEMENT Essential tasks, everyday problems and the need for structural changes Theatre justifies its existence only through high quality performances. Maintaining the artistic level and organizing performances are the primary tasks of a manager, even though in everyday life this often seems to be overshadowed by all the other tasks of a manager s work. How does a theatre manager design strategies and make everyday decisions if aims are to have artistically meaningful performances, financial success and a socially healthy ensemble, when not only artistic work or leadership of an organization are to be taken into consideration, but also a manpower-based art institution with long traditions? What does theatre management consist of and what kind of dramaturgical movement happens in it? Based on interviews carried out in five different city theatres in Finland in the years 2004-2008, incident stories were written within a continuous comparison theory frame. Social constructionism within a dramaturgic framework enabled versatile dialog on a manager s work and problem areas. The result is an interpretative study, where instead of common regularities, many details are collected that can be taken into consideration when similar situations occur. Based on the interviews and historical data, four factors that influence a manager s work were chosen: ownership, media, work community and programme. Within theatre management, the central problems were 1) the inconsistent use of theatre resources and problems in corporate governance caused by the administrative models; 2) the theatre s image, based on the image of its manager, as presented by the media and its influence on the wellbeing of the staff; 3) unsolved problems between the staff left behind by the previous managers and problems related to casting; 4) knowledge of the audience. These points influence how the manager plans the artistic programme and divides the resources. The theatre manager s job description has remained quite the same since the early days of Kaarlo Bergbom. In the future, special attention should be placed on why managers face fairly similar problems decade after decade. Reducing these problems partly depends on whether structural improvements are made to a theatre s close network of owners, financers and labour unions. During this study clear evidence was seen that structural changes are necessary in the production of performances and in the creation of a more versatile programme. In this process, different kinds of co-operation, experiments, development projects, continuing education and international relations have special importance, especially if the aim is to make it possible for all citizens of Finland to enjoy a vibrant and revitalized theatre.

Internationalizing school curriculum in Australasia: As niche, by test, or at heart?

Global citizenship has emerged as a pressing curricular priority which all educational systems are currently grappling with. The challenge is to negotiate how this orientation might sit alongside the more traditional mission of mass school curriculum in building collective ballast for a national identity through a common morality and shared narratives, or may conflict with efforts to protect and promote indigenous and minority identities. As a case study of how these agendas interact, this chapter will consider curricular responses to global imperatives in the variegated conditions across the Australasian region (defined as Australia, New Zealand and Papua New Guinea). The chapter will outline recent developments in the social, economic and political contexts surrounding curricular reforms in these settings, and demonstrate how these developments have changed the conditions of possibility and strength of purpose behind efforts to internationalise school curricula. Three types of systemic responses are then described: firstly, an appetite for globally branded curricula such as the International Baccalaureate, Montessori, and Cambridge University Certificates to distinguish some in a stratified market; secondly, convergence in curriculum to improve national performance on international standardised tests; and thirdly, the infusion of cosmopolitan sensibilities, regional identities and intercultural competencies as a core curricular goal for all. The chapter considers the various pragmatic interpretations of ‘internationalisation’ in these responses, and argues that the third response seems both the most difficult to enact, and the most vulnerable to political interference.

Patient decision aids in routine maternity care: Benefits, barriers, and new opportunities

Background and aim Participation in decision-making, supported by comprehensive and quality information provision, is increasingly emphasised as a priority for women in maternity care. Patient decision aids are tools that can offer women greater access to information and guidance to participate in maternity care decision-making. Relative to their evaluation in controlled settings, the implementation of patient decision aids in routine maternity care has received little attention and our understanding of which approaches may be effective is limited. This paper critically discusses the application of patient decision aids in routine maternity care and explores viable solutions for promoting their successful uptake. Discussion A range of patient decision aids have been developed for use within maternity care, and controlled trials have highlighted their positive impact on the decision-making process for women. Nevertheless, evidence of successful patient decision aid implementation in real world health care settings is lacking due to practical and ideological barriers that exist. Patient-directed social marketing campaigns are a relatively novel approach to patient decision aid delivery that may facilitate their adoption in maternity care, at least in the short-term, by overcoming common implementation barriers. Social marketing may also be particularly well suited to maternity care, given the unique characteristics of this health context. Conclusions The potential of social marketing campaigns to facilitate patient decision aid adoption in maternity care highlights the need for pragmatic trials to evaluate their effectiveness. Identifying which sub-groups of women are more or less likely to respond to these strategies will further direct implementation.

Isänmaamme keisari : Eliitin kansallisen identiteetin murros ja suomalaisen isänmaan rakentuminen autonomian ajan alussa

The emperor of our fatherland The changing national identity of the elite and the construction of the Finnish fatherland at the beginning of the autonomy This study addresses the question of changing national identity of the elite at the beginning of the autonomy (1808 1814) in Finland. Russia had conquered Finland from Sweden, but Finland was not incorporated into the Russian Empire. Instead, it was governed as separately administered area, and Finland retained its own (laws of the realm of Sweden) laws. The inclusion in the Russian Empire compelled the elite of Finland to deliberate their national identity; they had to determine whether they remained Swedes or became Finns or Russians. The elite chose to become Finns, which may seem obvious from the nowadays perspective, but it cannot be taken for granted that the Swedish speaking and noble elite converted their local Finnish identity into a new national identity. The basis of this study is constructive in a sense that identity is not seen as stable and constant. Theoretical background lies on Stuart Hall s writings on national identity, which offer good practical methods to study national identity. According to Hall identity is based mainly on difference , difference to others . In practice this means how elite began to define themselves in contrast to Swedes and Russians. The Finnish national identity was constructed in contrast to Swedes due to the political reasons. In order to avoid Russians suspicions Finns had to diverge from Sweden. Sweden had also gone trough coup d état, which was disliked by the elite of Finland. However, the attitudes of the elite towards Sweden remained somewhat ambiguous. Even if it was politically and rationally thinking wisest to draw away from Sweden, emotionally it was difficult. Russia, on the other hand, had been for centuries the archenemy of the Finns as well as all the Swedes. The fear of the Russians was mainly imaginary. Russians were seen as cruel barbarians who hated and resented Finns. The Finnish national identity was constructed above all in contrast to the Russians, for the difference to Russia was seen as a precondition for the existence of Finland. Respectively, the new position of Finland also required approaching towards Russia, which was in its nature very pragmatic. The elite contrived to get rid off its prejudice against Russians on intellectual level, but not on emotional level. At the beginning of the autonomy the primary loyalty of the elite was directed into the Finnish fatherland and its habitants. This was a radical ideological change, because traditionally the loyalty of the elite had focused on monarch and monarch s realm. However, the role of Alexander I was crucial. According to the elite the emperor had granted them a new fatherland. The former native country (Finland) was seen as a new fatherland instead of Sweden. The loyalty of the elite to the emperor generated from the reciprocal gratitude; Alexander I had treated their native country so mercifully. The elite felt strong personal responsibility for Finland s existence. The elite believed that the future of Finland rested on their shoulders. Alexander I had given them fatherland, but it was in the hands of the elite to construct the Finnish state and national spirit. The study of the Finnish national identity brings forth also that the national identity was constructed by emphasizing Finns civic rights. The civic rights were essential part of the construction of the Finnish national identity, for the difference between Finns and Russians was based on Finns own laws and privileges, which the emperor of the Russia had ensured.