Development and validation of a clinical prediction rule for chest wall syndrome in primary care.

ABSTRACT: BACKGROUND: Chest wall syndrome (CWS), the main cause of chest pain in primary care practice, is most often an exclusion diagnosis. We developed and evaluated a clinical prediction rule for CWS. METHODS: Data from a multicenter clinical cohort of consecutive primary care patients with chest pain were used (59 general practitioners, 672 patients). A final diagnosis was determined after 12 months of follow-up. We used the literature and bivariate analyses to identify candidate predictors, and multivariate logistic regression was used to develop a clinical prediction rule for CWS. We used data from a German cohort (n = 1212) for external validation. RESULTS: From bivariate analyses, we identified six variables characterizing CWS: thoracic pain (neither retrosternal nor oppressive), stabbing, well localized pain, no history of coronary heart disease, absence of general practitioner's concern, and pain reproducible by palpation. This last variable accounted for 2 points in the clinical prediction rule, the others for 1 point each; the total score ranged from 0 to 7 points. The area under the receiver operating characteristic (ROC) curve was 0.80 (95% confidence interval 0.76-0.83) in the derivation cohort (specificity: 89%; sensitivity: 45%; cut-off set at 6 points). Among all patients presenting CWS (n = 284), 71% (n = 201) had a pain reproducible by palpation and 45% (n = 127) were correctly diagnosed. For a subset (n = 43) of these correctly classified CWS patients, 65 additional investigations (30 electrocardiograms, 16 thoracic radiographies, 10 laboratory tests, eight specialist referrals, one thoracic computed tomography) had been performed to achieve diagnosis. False positives (n = 41) included three patients with stable angina (1.8% of all positives). External validation revealed the ROC curve to be 0.76 (95% confidence interval 0.73-0.79) with a sensitivity of 22% and a specificity of 93%. CONCLUSIONS: This CWS score offers a useful complement to the usual CWS exclusion diagnosing process. Indeed, for the 127 patients presenting CWS and correctly classified by our clinical prediction rule, 65 additional tests and exams could have been avoided. However, the reproduction of chest pain by palpation, the most important characteristic to diagnose CWS, is not pathognomonic.

Slits in container wall improve root structure and stem straightness of outplanted Scots pine seedlings

Abstract

Flooding tolerance and cell wall alterations in maize mesocotyl during hypoxia

This research aimed to characterize the tolerance to flooding and alterations in pectic and hemicellulose fractions from mesocotyl of maize tolerant to flooding when submitted to hypoxia. In order to characterize tolerance seeds from maize cultivars Saracura BRS-4154 and BR 107 tolerant and sensitive to low oxygen levels, respectively, were set to germinate. Plantlet survival was evaluated during five days after having been submitted to hypoxia. After fractionation with ammonium oxalate 0.5% (w/v) and KOH 2M and 4M, Saracura BRS-4154 cell wall was obtained from mesocotyl segments with different damage intensities caused by oxygen deficiency exposure. The cell wall fractions were analyzed by gel filtration and gas chromatography, and also by Infrared Spectrum with Fourrier Transformation (FTIR). The hypoxia period lasting three days or longer caused cell lysis and in advanced stages plant death. The gelic profile from pectic, hemicellulose 2M and 4M fractions from samples with translucid and constriction zone showed the appearance of low molecular weight compounds, similar to glucose. The main neutral sugars in pectic and hemicellulose fractions were arabinose, xilose and mannose. The FTIR spectrum showed a gradual decrease in pectic substances from mesocotyl with normal to translucid and constriction appearance respectively.

Agreed-upon procedures report on the City of Wall Lake, Iowa for the period July 1, 2013 through June 30, 2014

Agreed-upon procedures report on the City of Wall Lake, Iowa for the period July 1, 2013 through June 30, 2014

Impact of bulk cardiac motion on right coronary MR angiography and vessel wall imaging.

The purpose of this study was to investigate the impact of in-plane coronary artery motion on coronary magnetic resonance angiography (MRA) and coronary MR vessel wall imaging. Free-breathing, navigator-gated, 3D-segmented k-space turbo field echo ((TFE)/echo-planar imaging (EPI)) coronary MRA and 2D fast spin-echo coronary vessel wall imaging of the right coronary artery (RCA) were performed in 15 healthy adult subjects. Images were acquired at two different diastolic time periods in each subject: 1) during a subject-specific diastasis period (in-plane velocity <4 cm/second) identified from analysis of in-plane coronary artery motion, and 2) using a diastolic trigger delay based on a previously implemented heart-rate-dependent empirical formula. RCA vessel wall imaging was only feasible with subject-specific middiastolic acquisition, while the coronary wall could not be identified with the heart-rate-dependent formula. For coronary MRA, RCA border definition was improved by 13% (P < 0.001) with the use of subject-specific trigger delay (vs. heart-rate-dependent delay). Subject-specific middiastolic image acquisition improves 3D TFE/EPI coronary MRA, and is critical for RCA vessel wall imaging.

3D coronary vessel wall imaging utilizing a local inversion technique with spiral image acquisition.

Current 2D black blood coronary vessel wall imaging suffers from a relatively limited coverage of the coronary artery tree. Hence, a 3D approach facilitating more extensive coverage would be desirable. The straightforward combination of a 3D-acquisition technique together with a dual inversion prepulse can decrease the effectiveness of the black blood preparation. To minimize artifacts from insufficiently suppressed blood signal of the nearby blood pools, and to reduce residual respiratory motion artifacts from the chest wall, a novel local inversion technique was implemented. The combination of a nonselective inversion prepulse with a 2D selective local inversion prepulse allowed for suppression of unwanted signal outside a user-defined region of interest. Among 10 subjects evaluated using a 3D-spiral readout, the local inversion pulse effectively suppressed signal from ventricular blood, myocardium, and chest wall tissue in all cases. The coronary vessel wall could be visualized within the entire imaging volume.

Prenatal diagnosis of a fetal abdominal eventration: a rare congenital abdominal wall defect.

We report a case of abdominal eventration associated with cystic fibrosis, diagnosed by mid-trimester ultrasonography. The defect concerned the abdominal muscles and their aponevrotic sheath, but respected the skin. There was no associated malformation. The outcome was favorable after surgery, and the infant is well at the age of 6 months.

Investigation of Uplift Failures in Flexible Pipe Culverts, HR-306, 1990

This study was precipitated by several failures of flexible pipe culverts due to apparent inlet floatation. A survey of Iowa County Engineers revealed 31 culvert failures on pipes greater than 72" diameter in eight Iowa counties within the past five years. No special hydrologic, topography, and geotechnical environments appeared to be more susceptible to failure. However, most failures seemed to be on pipes flowing in inlet control. Geographically, most of the failures were in the southern and western sections of Iowa. The forces acting on a culvert pipe are quantified. A worst case scenario, where the pipe is completely plugged, is evaluated to determine the magnitude of forces that must be resisted by a tie down or headwall. Concrete headwalls or slope collars are recommended for most pipes over 4 feet in diameter.

Design Methodology for Corrugated Metal Pipe Tiedowns, HR-332, Phase 1, 1993

Questionnaires were sent to transportation agencies in all 50 states in the U.S., to Puerto Rico, and all provinces in Canada asking about their experiences with uplift problems of - corrugated metal pipe (CMP). Responses were received from 52 agencies who reported 9 failures within the last 5 years. Some agencies also provided design standards for tiedowns to resist uplift. There was a wide variety in restraining forces used; for example for a pipe 6 feet in diameter, the resisting force ranged from 10 kips to 66 kips. These responses verified the earlier conclusion based on responses from Iowa county engineers that a potential uplift danger exists.when end restraint is not provided for CMP and that existing designs have an unclear theoretical or experimental basis. In an effort to develop more rational design standards, the longitudinal stiffness of three CMP ranging from 4 to 8 feet in diameter were measured in the laboratory. Because only three tests were conducted, a theoretical model to evaluate the stiffness of pipes of a variety of gages and corrugation geometries was also developed. The experimental results indicated a "stiffness" EI in the range of 9.11 x 10^5 k-in^2 to 34.43 x 10^5 k-in^2 for the three pipes with the larger diameter pipes having greater stiffness. The theoretical model developed conservatively estimates these stiffnesses.

Design Methodology for Corrugated Metal Pipe Tiedowns, HR-362, Phase II, 1995

This investigation is the final phase of a three part study whose overall objectives were to determine if a restraining force is required to prevent inlet uplift failures in corrugated metal pipe (CMP) installations, and to develop a procedure for calculating the required force when restraint is required. In the initial phase of the study (HR-306), the extent of the uplift problem in Iowa was determined and the forces acting on a CMP were quantified. In the second phase of the study (HR- 332), laboratory and field tests were conducted. Laboratory tests measured the longitudinal stiffness ofCMP and a full scale field test on a 3.05 m (10 ft) diameter CMP with 0.612 m (2 ft) of cover determined the soil-structure interaction in response to uplift forces. Reported herein are the tasks that were completed in the final phase of the study. In this phase, a buried 2.44 m (8 ft) CMP was tested with and without end-restraint and with various configurations of soil at the inlet end of the pipe. A total of four different soil configurations were tested; in all tests the soil cover was constant at 0.61 m (2 ft). Data from these tests were used to verify the finite element analysis model (FEA) that was developed in this phase of the research. Both experiments and analyses indicate that the primary soil contribution to uplift resistance occurs in the foreslope and that depth of soil cover does not affect the required tiedown force. Using the FEA, design charts were developed with which engineers can determine for a given situation if restraint force is required to prevent an uplift failure. If an engineer determines restraint is needed, the design charts provide the magnitude of the required force. The design charts are applicable to six gages of CMP for four flow conditions and two types of soil.

Investigation of Plastic Pipes for Highway Applications, HR-373A, Phase II, 1997

It is generally accepted that high density polyethylene pipe (HDPE) performs well under live loads with shallow cover, provided the backfill is well compacted. Although industry standards require carefully compacted backfill, poor inspection and/or faulty construction may result in soils that provide inadequate restraint at the springlines of the pipes thereby causing failure. The objectives of this study were: 1) to experimentally define a lower limit of compaction under which the pipes perform satisfactorily, 2) to quantify the increase in soil support as compaction effort increases, 3) to evaluate pipe response for loads applied near the ends of the buried pipes, 4) to determine minimum depths of cover for a variety of pipes and soil conditions by analytically expanding the experimental results through the use of the finite element program CANDE. The test procedures used here are conservative especially for low-density fills loaded to high contact stresses. The failures observed in these tests were the combined effect of soil bearing capacity at the soil surface and localized wall bending of the pipes. Under a pavement system, the pipes' performance would be expected to be considerably better. With those caveats, the following conclusions are drawn from this study. Glacial till compacted to 50% and 80% provides insufficient support; pipe failureoccurs at surface contact stresses lower than those induced by highway trucks. On the other hand, sand backfill compacted to more than 110 pcf (17.3 kN/m3) is satisfactory. The failure mode for all pipes with all backfills is localized wall bending. At moderate tire pressures, i.e. contact stresses, deflections are reduced significantly when backfill density is increased from about 50 pcf (7.9 kN/m^3) to 90 pcf (14.1 kN/m^3). Above that unit weight, little improvement in the soil-pipe system is observed. Although pipe stiffness may vary as much as 16%, analyses show that backfill density is more important than pipe stiffness in controlling both deflections at low pipe stresses and at the ultimate capacity of the soil-pipe system. The rate of increase in ultimate strength of the system increases nearly linearly with increasing backfill density. When loads equivalent to moderate tire pressures are applied near the ends of the pipes, pipe deflections are slighly higher than when loaded at the center. Except for low density glacial till, the deflections near the ends are not excessive and the pipes perform satisfactorily. For contact stresses near the upper limit of truck tire pressures and when loaded near the end, pipes fail with localized wall bending. For flowable fill backfill, the ultimate capacity of the pipes is nearly doubled and at the upper limit of highway truck tire pressures, deflections are negligible. All pipe specimens tested at ambient laboratory room temperatures satisfied AASHTO minimum pipe stiffness requirements at 5% deflection. However, nearly all specimens tested at elevated pipe surface temperatures, approximately 122°F (50°C), failed to meet these requirements. Some HDPE pipe installations may not meet AASHTO minimum pipe stiffness requirements when installed in the summer months (i.e. if pipe surface temperatures are allowed to attain temperatures similar to those tested here). Heating of any portion of the pipe circumference reduced the load carrying capacity of specimens. The minimum soil cover depths, determined from the CANOE analysis, are controlled by the 5% deflection criterion. The minimum soil cover height is 12 in. (305 mm). Pipes with the poor silt and clay backfills with less than 85% compaction require a minimum soil cover height of 24 in. (610 mm). For the sand at 80% compaction, the A36 HDPE pipe with the lowest moment of inertia requires a minimum of 24 in. (610 mm) soil cover. The C48 HDPE pipe with the largest moment of inertia and all other pipes require a 12 in. (305 mm) minimum soil cover.

Investigation of High Density Polyethylene Pipe for Highway Applications, HR-373, Phase 1, 1996

In the past, culvert pipes were made only of corrugated metal or reinforced concrete. In recent years, several manufacturers have made pipe of lightweight plastic - for example, high density polyethylene (HDPE) - which is considered to be viscoelastic in its structural behavior. It appears that there are several highway applications in which HDPE pipe would be an economically favorable alternative. However, the newness of plastic pipe requires the evaluation of its performance, integrity, and durability; A review of the Iowa Department of Transportation Standard Specifications for Highway and Bridge Construction reveals limited information on the use of plastic pipe for state projects. The objective of this study was to review and evaluate the use of HDPE pipe in roadway applications. Structural performance, soil-structure interaction, and the sensitivity of the pipe to installation was investigated. Comprehensive computerized literature searches were undertaken to define the state-of-the-art in the design and use of HDPE pipe in highway applications. A questionnaire was developed and sent to all Iowa county engineers to learn of their use of HDPE pipe. Responses indicated that the majority of county engineers were aware of the product but were not confident in its ability to perform as well as conventional materials. Counties currently using HDPE pipe in general only use it in driveway crossings. Originally, we intended to survey states as to their usage of HDPE pipe. However, a few weeks after initiation of the project, it was learned that the Tennessee DOT was in the process of making a similar survey of state DOT's. Results of the Tennessee survey of states have been obtained and included in this report. In an effort to develop more confidence in the pipe's performance parameters, this research included laboratory tests to determine the ring and flexural stiffness of HDPE pipe provided by various manufacturers. Parallel plate tests verified all specimens were in compliance with ASTM specifications. Flexural testing revealed that pipe profile had a significant effect on the longitudinal stiffness and that strength could not be accurately predicted on the basis of diameter alone. Realizing that the soil around a buried HDPE pipe contributes to the pipe stiffness, the research team completed a limited series of tests on buried 3 ft-diameter HDPE pipe. The tests simulated the effects of truck wheel loads above the pipe and were conducted with two feet of cover. These tests indicated that the type and quality of backfill significantly influences the performance of HDPE pipe. The tests revealed that the soil envelope does significantly affect the performance of HDPE pipe in situ, and after a certain point, no additional strength is realized by increasing the quality of the backfill.

Hydraulics of Slope-Tapered Pipe Culverts, HR-398, 2001

This report updates the Iowa Department of Transportation (DOT) design procedures for circular, slope-tapered concrete culverts. The current practice is to use the design coefficients for a square-edged, circular concrete culvert with a headwall that are found in Hydraulic Series No. 5 (HDS-5). New inlet control design constants and entrance loss coefficients were calculated for the slope-tapered culverts and then compared with the HDS-5 coefficients (square edge). In addition, various reducer lengths and taper ratios were also studied to determine what impact, if any, they have on the design coefficients. All of the laboratory testing was done at the Federal Highway Administration�s Turner-Fairbank Highway Research Center located in McLean, Virginia.

Evaluation of Stainless Steel Culvert Pipe in Mahaska County, Iowa, HR-2001

Corrosion of culvert pipe in Iowa in general is not a serious problem. However, it is potentially significant in some local areas. An opportunity to make a limited durability study of stainless steel pipe was presented when a local fabricating company expressed interest in a cooperative field experiment. The potential of stainless steel pipe is to reduce maintenance costs that are incurred through replacement and upkeep. A new stainless steel material, Allegheny Metal MF-1, was used in a partial fabrication demonstration and later these demonstration sections were delivered to the selected field site for placement.

Preliminary Report on the Installation of Stainless Steel Culvert Pipe in Mahaska County, Iowa, HR-2001, 1967

At the request of Mr. Arnold E. Levine, of the Levine Company, Centerville, Iowa, the Iowa State Highway Commission was asked to observe the partial fabrication of two stainless steel culvert pipes and later the Commission was asked if they would like to study their durability. These pipes were fabricated April 12, 1967 in Des Moines, Personnel of the Design and Materials Department were at the fabrication, but no Research people were present. The idea for the installation was conceived and a site selected after which the project was turned over to the Research Engineer. The stainless steel pipes presumably contained the new Allegheny Metal, MF-1, whose composition is shown in Appendix A. The primary aim of the stainless steel pipe is to reduce long term costs that are incurred through replacement and upkeep. The MF-1 has a theoretical life of infinity.