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Aims The clinical usefulness of historical concentrations of high-sensitivity cardiac troponin T (hs-cTnT) is unknown. This study investigated the ability to rule out myocardial infarction (MI) with the use of historical hs-cTnT concentrations among patients with chest pain in the emergency department (ED). Methods and results The derivation cohort consisted of patients presenting with chest pain to nine different EDs (n = 60 071), where we included those with ≥1 hs-cTnT analysed at the index visit and ≥1 hs-cTnT results prior to the visit. We developed an algorithm to rule out MI within 30 days with a pre-specified target negative predictive value (NPV) of ≥99.5%. The performance was then validated in a separate cohort of ED chest pain patients (n = 10 994). A historical hs-cTnT Conclusion Combining a historical hs-cTnT with a single new hs-cTnT may safely rule out MI and thereby reduce the need for serial hs-cTnT measurements in ED patients with chest pain.

BACKGROUND The 2020 European Society of Cardiology (ESC) guidelines recommend using the 0/1-hour and 0/2-hour algorithms over the 0/3-hour algorithm as the first and second choices of high-sensitivity cardiac troponin (hs-cTn)-based strategies for triage of patients with suspected acute myocardial infarction (AMI). PURPOSE To evaluate the diagnostic accuracies of the ESC 0/1-hour, 0/2-hour, and 0/3-hour algorithms. DATA SOURCES PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus from 1 January 2011 to 31 December 2020. (PROSPERO: CRD42020216479). STUDY SELECTION Prospective studies that evaluated the ESC 0/1-hour, 0/2-hour, or 0/3-hour algorithms in adult patients presenting with suspected AMI. DATA EXTRACTION The primary outcome was index AMI. Twenty unique cohorts were identified. Primary data were obtained from investigators of 16 cohorts and aggregate data were extracted from 4 cohorts. Two independent authors assessed each study for methodological quality. DATA SYNTHESIS A total of 32 studies (20 cohorts) with 30 066 patients were analyzed. The 0/1-hour algorithm had a pooled sensitivity of 99.1% (95% CI, 98.5% to 99.5%) and negative predictive value (NPV) of 99.8% (CI, 99.6% to 99.9%) for ruling out AMI. The 0/2-hour algorithm had a pooled sensitivity of 98.6% (CI, 97.2% to 99.3%) and NPV of 99.6% (CI, 99.4% to 99.8%). The 0/3-hour algorithm had a pooled sensitivity of 93.7% (CI, 87.4% to 97.0%) and NPV of 98.7% (CI, 97.7% to 99.3%). Sensitivity of the 0/3-hour algorithm was attenuated in studies that did not use clinical criteria (GRACE score

BACKGROUND: Influenza vaccination early after myocardial infarction (MI) improves prognosis but vaccine effectiveness may differ dependent on type of MI.METHODS: A total of 2,571 participants were prospectively enrolled in the Influenza vaccination after myocardial infarction (IAMI) trial and randomly assigned to receive in-hospital inactivated influenza vaccine or saline placebo. The trial was conducted at 30 centers in eight countries from October 1, 2016 to March 1, 2020. Here we report vaccine effectiveness in the 2,467 participants with ST-segment elevation MI (STEMI, n = 1,348) or non-ST-segment elevation MI (NSTEMI, n = 1,119). The primary endpoint was the composite of all-cause death, MI, or stent thrombosis at 12 months. Cumulative incidence of the primary and key secondary endpoints by randomized treatment and NSTEMI/STEMI was estimated using the Kaplan-Meier method. Treatment effects were evaluated with formal interaction testing to assess for effect modification.RESULTS: Baseline risk was higher in participants with NSTEMI. In the NSTEMI group the primary endpoint occurred in 6.5% of participants assigned to influenza vaccine and 10.5% assigned to placebo (hazard ratio [HR], 0.60; 95% CI, 0.39-0.91), compared to 4.1% assigned to influenza vaccine and 4.5% assigned to placebo in the STEMI group (HR, 0.90; 95% CI, 0.54-1.50, P = .237 for interaction). Similar findings were seen for the key secondary endpoints of all-cause death and cardiovascular death. The Kaplan-Meier risk difference in all-cause death at one year was more pronounced in participants with NSTEMI (NSTEMI: HR, 0.47; 95% CI 0.28-0.80, STEMI: HR, 0.86; 95% CI, 0.43-1.70, interaction P = .028).CONCLUSIONS: The beneficial effect of influenza vaccination on adverse cardiovascular events may be enhanced in patients with NSTEMI compared to those with STEMI.

A novel and efficient Fabry-Perot biosensor on the tip of a dual-core single-mode optical fiber is proposed. The incident light emerges from one of the cores and is coupled to the second core via high-contrast silicon nitride slanted grating couplers (SGCs), separated by a silicon nitride waveguide segment disposed along the fiber tip. The challenges in designing high-contrast SGCs of very short length were overcome using an efficient analytical design approach augmented by simulations in 2D, resulting in grating designs that produce core-to-core coupling efficiencies of up to 29%. The waveguide segment separating the SGCs acts as a Fabry-Perot sensing cavity producing narrow Fabry-Perot fringes in the transmittance spectrum of the structure. Monitoring these fringes leads to bulk sensitivity and figure of merit of 50 – 100 nm/RIU and 16.67 – 33.34 (RIU $^{-1}$ ), for sensing a large range of biomaterials. The structure operates in transmission, thus eliminating the need to separate the reflected light from the incident light at the input of the fiber, which simplifies the interrogation system. Properly packaged, the fiber tip can be dipped or inserted directly into the sensing medium, which removes the need for microfluidics. The scheme enables robust, flexible, compact, and remotely-interrogated biosensors.

Background: The Second Primary Angioplasty in Myocardial Infarction (PAMI-II) risk score is recommended by guidelines to identify low-risk patients with ST-elevation myocardial infarction (STEMI) for an early discharge strategy. Aims: We aimed to assess the safety of early discharge (≤2 days) for low-risk STEMI patients treated with primary percutaneous coronary intervention (PCI). Methods: Using nationwide data from the SWEDEHEART registry, we identified patients with STEMI treated with primary PCI during the period 2009-2017, of whom 8,092 (26.4%) were identified as low risk with the PAMI-II score. Low-risk patients were stratified according to their length of hospital stay (≤2 days vs >2 days). The primary endpoint was major adverse cardiovascular events (MACE, including death, reinfarction treated with PCI, stroke or heart failure hospitalisation) at one year, assessed using a Cox proportional hazards model with propensity score as well as an inverse probability weighting propensity score of average treatment effect to adjust for confounders. Results: A total of 1,449 (17.9%) patients were discharged ≤2 days from admission. After adjustment, the one-year MACE rate was not higher for patients discharged at >2 days from admission than for patients discharged ≤2 days (4.3% vs 3.2%; adjusted HR 1.31, 95% confidence interval [CI]: 0.92-1.87, p=0.14), and no difference was observed regarding any of the individual components of the main outcome. Results were consistent across all subgroups with no difference in MACE between early and late discharge patients. Conclusions: Nationwide observational data suggest that early discharge of low-risk patients with STEMI treated with PCI is not associated with an increase in one-year MACE.

Background. Glucose is emerging as a biomarker for early and safe rule-out of acute myocardial infarction in emergency department (ED) chest pain patients. We evaluated the diagnostic accuracy of dual testing with high sensitivity TnT (hs-cTnT) and glucose for prediction of major adverse cardiac events (MACE) within 30 days. Methods. This was a secondary analysis of a single-center prospective observational study of 1167 ED chest-pain patients with hs-cTnT and glucose testing at presentation (0 h), and hs-cTnT 1 h later. We tested the addition of glucose 14 ng/L. The outcomes were 30-day MACE and 30-day MACE without UA. Results. Two dual-testing approaches reached our target NPV for rule-out: A 0 h hs-cTnT ≤14 ng/L and glucose

Background Machine learning approaches are increasingly being explored for use in healthcare systems, but there is a trade-off between increased accuracy and decreased explainability with more complex models. We aimed to evaluate the diagnostic performance for acute myocardial infarction (AMI) or death within 30 days of index visit. Machine learning models were trained using demographic factors, ECG and blood markers, and to compare them to a single high sensitivity TnT (hs-cTnT) value. Methods Using records from 9519 ED patients from two hospitals in Skåne, Sweden, we created machine learning models based on both logistic regression and artificial neural networks. Inputs in the models varied and included sex and age, first hs-cTnT value at the ED, glucose, creatinine, hemoglobin, and ECG signal data. The models were adapted to meet the following criteria for safe rule-out of 30-day myocardial infarction or death: Negative predictive value (NPV) >99.5% and sensitivity >99%. For rule-in of myocardial infarction or death, a positive predictive value (PPV) of >70% was set. The models were then compared to the performance of a first hs-cTnT 51 ng/L for rule-in. The patient population was split by arrival date and models were trained on the initial 50% of patients. Thresholds were selected from the subsequent 25%, and tests were performed on the final 25% (2379 patients). Results The best model, a convolutional neural network, identified 1309 (55%) patients for rule-out and 125 (5.3%) for rule-in, with the required NPV, sensitivity and PPV. In comparison, a single hs-cTnT value identified 1123 (47.2%) patients for rule-out and 158 (6.6%) for rule-in, but failed to reach the required sensitivity and PPV levels. Conclusions These results indicate that more complex models are able to safely identify a large proportion of patients for early rule-out or rule-in without the need for serial troponin tests. In future studies attempts should be made to improve the explainability of these models. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): VR; grant no. 2019-00198

Background The cornerstones in the assessment of emergency department (ED) patients with suspected acute coronary syndrome (ACS) are patient history and physical examination, electrocardiogram, and cardiac troponins. Although there are several prior studies on this subject, they have in some cases produced inconsistent results. Objective The aim of this study was to evaluate the diagnostic and prognostic accuracy of elements of patient history and the physical examination in ED chest pain patients for predicting major adverse cardiac events (MACE) within 30 days. Methods: This was a prospective observational study that included 1167 ED patients with nontraumatic chest pain. We collected clinical data during the initial ED assessment of the patients. Our primary outcome was 30-day MACE. Results Pain radiating to both arms increased the probability of 30-day MACE (positive likelihood ratio [LR+] 2.7), whereas episodic chest pain lasting seconds (LR+ 0.0) and >24 h (LR+ 0.1) markedly decreased the risk. In the physical examination, pulmonary rales (LR+ 3.0) increased the risk of 30-day MACE, while pain reproduced by palpation (LR+ 0.3) decreased the risk. Among cardiac risk factors, a history of diabetes (LR+ 3.0) and peripheral arterial disease (LR+ 2.7) were the most predictive factors. Conclusions No clinical findings reliably ruled in 30-day MACE, whereas episodic chest pain lasting seconds and pain lasting more than 24 h markedly decreased the risk of 30-day MACE. Consequently, these two findings can be adjuncts in ruling out 30-day MACE.

Background: Data regarding high-sensitivity troponin concentrations in patients presenting to the emergency department with symptoms suggestive of myocardial infarction may be useful in determining the probability of myocardial infarction and subsequent 30-day outcomes.Methods: In 15 international cohorts of patients presenting to the emergency department with symptoms suggestive of myocardial infarction, we determined the concentrations of high-sensitivity troponin I or high-sensitivity troponin T at presentation and after early or late serial sampling. The diagnostic and prognostic performance of multiple high-sensitivity troponin cutoff combinations was assessed with the use of a derivation–validation design. A risk-assessment tool that was based on these data was developed to estimate the risk of index myocardial infarction and of subsequent myocardial infarction or death at 30 days.Results: Among 22,651 patients (9604 in the derivation data set and 13,047 in the validation data set), the prevalence of myocardial infarction was 15.3%. Lower high-sensitivity troponin concentrations at presentation and smaller absolute changes during serial sampling were associated with a lower likelihood of myocardial infarction and a lower short-term risk of cardiovascular events. For example, high-sensitivity troponin I concentrations of less than 6 ng per liter and an absolute change of less than 4 ng per liter after 45 to 120 minutes (early serial sampling) resulted in a negative predictive value of 99.5% for myocardial infarction, with an associated 30-day risk of subsequent myocardial infarction or death of 0.2%; a total of 56.5% of the patients would be classified as being at low risk. These findings were confirmed in an external validation data set.Conclusions: A risk-assessment tool, which we developed to integrate the high-sensitivity troponin I or troponin T concentration at emergency department presentation, its dynamic change during serial sampling, and the time between the obtaining of samples, was used to estimate the probability of myocardial infarction on emergency department presentation and 30-day outcomes. (Funded by the German Center for Cardiovascular Research [DZHK]; ClinicalTrials.gov numbers, NCT00470587, NCT02355457, NCT01852123, NCT01994577, and NCT03227159; and Australian New Zealand Clinical Trials Registry numbers, ACTRN12611001069943, ACTRN12610000766011, ACTRN12613000745741, and ACTRN12611000206921.)

Increasing peak amplitude of THz signals plays a key role in applications such as biomedical imaging, biological applications, and security screening. Improving peak amplitude of photoconductive antenna (PCA) has been investigated in this work. The peak amplitude of a PCA depends on several parameters such as electrode material, transmission through photoconductive material, thickness of photoconductive material, and electrode bias voltage. A dielectric with improved periodic nanoslit structure has been suggested and optimized in order that it improves the transmission of incident optical wave through the photoconductive material in both TE and TM polarizations up to %23 and %8.65 respectively. Then a mixed graphene-gold electrodes have been used so as to it may enhance the detected THz signal peak amplitude up to %14.31. Also, the effect of varying the chemical potential, photoconductive thickness, and electrode bias voltage on peak amplitude of the detected THz signal has been investigated. Finally, a design process for improving peak amplitude of the detected THz signal has been mentioned.

Ultrasound plays an important role in several medical fields. The heart was the first organ for which ultrasound gained clinical utility, followed by obstetric and gynecological applications. Shortly thereafter, abdominal organs and blood vessels became targets for ultrasound examination. The lung was long considered inaccessible for ultrasound due to its high air content. Work since the 1990s has however established a role for lung ultrasound, in leveraging several technical artefacts generated in the normal lung and in conditions with reduced air content, to allow rapid diagnosis of interstitial fluid accumulation, pneumothorax, pneumonia among others. In this article, we provide an overview of the potential of lung ultrasound, particularly as a promising method for assessment of patients presenting with acute dyspnea in the emergency department and for monitoring residual fluid in patients with decompensated heart failure. We also discuss limitations and caveats of the method.

Objectives The augmented inflammatory response to cardiac surgery is a recognized cause of postoperative acute kidney injury. The present study aimed to investigate the effects of preoperative cyclosporine treatment on cytokine production and delineate factors associated with postoperative kidney impairment. Design Randomized, double-blind, placebo-controlled, single-center study. Setting Tertiary care, university hospital Participants Patients eligible for elective coronary artery bypass grafting surgery, 67 patients were enrolled. Interventions Patients were randomized to receive 2.5 mg/kg cyclosporine or placebo before surgery. Cytokine levels were measured after induction of anesthesia and four hours after the end of cardiopulmonary bypass. Measurements and Main Results Tissue-aggressive (IL-1β, MIP-1β, G-CSF, IL-6, IL-8, IL-17, MCP-1) as well tissue-lenient (IL-4) cytokines were significantly elevated in response to surgery. Changes in cytokine levels were not affected by cyclosporine pretreatment. Conclusions Elective coronary artery bypass grafting surgery with cardiopulmonary bypass triggers cytokine activation. This activation was not impacted by preoperative cyclosporine treatment.

Objective Computerized decision‐support tools may improve diagnosis of acute myocardial infarction (AMI) among patients presenting with chest pain at the emergency department (ED). The primary aim was to assess the predictive accuracy of machine learning algorithms based on paired high‐sensitivity cardiac troponin T (hs‐cTnT) concentrations with varying sampling times, age, and sex in order to rule in or out AMI. Methods In this register‐based, cross‐sectional diagnostic study conducted retrospectively based on 5695 chest pain patients at 2 hospitals in Sweden 2013–2014 we used 5‐fold cross‐validation 200 times in order to compare the performance of an artificial neural network (ANN) with European guideline‐recommended 0/1‐ and 0/3‐hour algorithms for hs‐cTnT and with logistic regression without interaction terms. Primary outcome was the size of the intermediate risk group where AMI could not be ruled in or out, while holding the sensitivity (rule‐out) and specificity (rule‐in) constant across models. Results ANN and logistic regression had similar (95%) areas under the receiver operating characteristics curve. In patients (n = 4171) where the timing requirements (0/1 or 0/3 hour) for the sampling were met, using ANN led to a relative decrease of 9.2% (95% confidence interval 4.4% to 13.8%; from 24.5% to 22.2% of all tested patients) in the size of the intermediate group compared to the recommended algorithms. By contrast, using logistic regression did not substantially decrease the size of the intermediate group. Conclusion Machine learning algorithms allow for flexibility in sampling and have the potential to improve risk assessment among chest pain patients at the ED.

Background: Observational and small, randomized studies suggest that influenza vaccine may reduce future cardiovascular events in patients with cardiovascular disease. Methods: We conducted an investigator-initiated, randomized, double-blind trial to compare inactivated influenza vaccine with saline placebo administered shortly after myocardial infarction (MI; 99.7% of patients) or high-risk stable coronary heart disease (0.3%). The primary end point was the composite of all-cause death, MI, or stent thrombosis at 12 months. A hierarchical testing strategy was used for the key secondary end points: all-cause death, cardiovascular death, MI, and stent thrombosis. Results: Because of the COVID-19 pandemic, the data safety and monitoring board recommended to halt the trial before attaining the prespecified sample size. Between October 1, 2016, and March 1, 2020, 2571 participants were randomized at 30 centers across 8 countries. Participants assigned to influenza vaccine totaled 1290 and individuals assigned to placebo equaled 1281; of these, 2532 received the study treatment (1272 influenza vaccine and 1260 placebo) and were included in the modified intention to treat analysis. Over the 12-month follow-up, the primary outcome occurred in 67 participants (5.3%) assigned influenza vaccine and 91 participants (7.2%) assigned placebo (hazard ratio, 0.72 [95% CI, 0.52–0.99]; P =0.040). Rates of all-cause death were 2.9% and 4.9% (hazard ratio, 0.59 [95% CI, 0.39–0.89]; P =0.010), rates of cardiovascular death were 2.7% and 4.5%, (hazard ratio, 0.59 [95% CI, 0.39–0.90]; P =0.014), and rates of MI were 2.0% and 2.4% (hazard ratio, 0.86 [95% CI, 0.50–1.46]; P =0.57) in the influenza vaccine and placebo groups, respectively. Conclusions: Influenza vaccination early after an MI or in high-risk coronary heart disease resulted in a lower risk of a composite of all-cause death, MI, or stent thrombosis, and a lower risk of all-cause death and cardiovascular death, as well, at 12 months compared with placebo. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02831608.

Background/aimIn ED chest pain patients, a 0-hour/1-hour protocol based on high sensitivity cardiac troponin T (hs-cTnT) tests combined with clinical risk stratification in diagnosing acute coronary syndrome is recommended. Two of the most promising risk stratification tools are the History, ECG, Age, Risk Factors and Troponin (HEART) and Emergency Department Assessment of Chest Pain (EDAC) scores. Few studies have assessed the diagnostic accuracy of the 0-hour/1-hour hs-cTnT protocol when combined with HEART score, and none with EDACS. In ED chest pain patients, we aimed to evaluate the diagnostic accuracy of a 0-hour/1-hour hs-cTnT protocol combined the HEART Pathway, or the EDACS accelerated diagnostic pathway (EDACS-ADP).MethodsThis was a secondary analysis of data from a prospective observational study enrolling 1167 ED chest pain patients who visited the ED at Skåne University Hospital in Lund, Sweden in the period between February 2013 and April 2014. HEART and EDAC scores were assessed together with hs-cTnT at 0 and 1 hour and compared with HEART score alone. Sensitivity, specificity, negative predictive value (NPV) and likelihood ratios were evaluated. The primary outcome was major adverse cardiac events (MACE) including unstable angina within 30 days. The secondary outcome was index visit acute myocardial infarction (AMI).ResultsA total of 939 patients were included in the final analysis. When combined with 0-hour/1-hour hs-cTnT testing, the HEART Pathway and EDACS-ADP identified 49.8% and 49.6% of the patients for rule-out, with NPVs for 30-day MACE of 99.8% and 99.1%, compared with the HEART score alone that identified 53.4% of the patients for rule-out with NPV of 99.2%. The NPV for index visit AMI were 100%, 99.8% and 99.2%, respectively.ConclusionThe combination of the HEART Pathway or the EDACS-ADP with a 0-hour/1-hour hs-cTnT protocol allows safe and early rule-out in a large proportion of ED chest pain patients.

Solar cells entailing multi-coloring capability can pave the way for solar-powered colorful displays. Therefore, the energy that is usually wasted in color displays could be harvested to produce useful electrical power. On the other hand, introduction of color filters with capability of active control on the output color results in more compact and efficient optical devices. In this work, we have proposed a chromatic electrode in which the transmitted light has been employed as a source for the solar energy device while the reflected light generates polarization-tuned colors, simultaneously. Aiming to design such a chromatic electrode, a hybrid nanostructure of graphene and aluminum nanocross arrays has been employed for the first time. In addition to replacing ITO in organic solar cells by a novel electrode and achieving performance enhancement of organic solar cells, mapping the polarization of the incident light to visible color results in solar-powered chromatic polarizers with potential applications including active color displays, security tags, and polarization imaging. Using finite-difference time-domain numerical simulations, it has been shown that the proposed nanostructured electrode leads to enhanced photocurrent densities in the range of 11.82–17.05 (mA/cm2) due to the light trapping plasmonic properties of the nanocross arrays. Additionally, replacing ITO, suffering from poor mechanical properties and cost-ineffectiveness, offers a promising approach for large-area growth of organic photovoltaics.

Despite the crucial role of plasmonic nanostructures in enhancing the performance of organic solar cells, the actual absorption of the active layer in these cells is restricted by the parasitic metal absorption loss limiting their efficiencies. In this paper, a bilayer of Al-TiN nanosquare array has been proposed as a novel plasmonic scheme in order to improve the photocurrent and the solar absorption of organic solar cells. The hybrid design of Al and TiN materials reduces the parasitic loss issue offering extended application of plasmonic light-harvesting structures. Engineering the energy band diagram of the cell and concentrating the electrical field distribution inside the active layer result in boosting the absorption as well as the optical current densities for each layer. Utilization of TiN in the proposed design also benefits from the cost effectiveness, abundance, and CMOS compatibility of this material compared to noble metals as well as featuring appropriate light trapping properties. In addition, the symmetric scheme of the proposed structure makes it polarization insensitive under the normal incidence. The numerical simulations of this study based on the finite-difference time-domain (FDTD) method show an enhanced absorption of 70–88% over the spectral range of 300–625 nm and the maximum enhancement factor of 2.16 at the wavelength of about 665 nm. Moreover, an improved photocurrent density of 13.7082 (mA/cm2) has also been achieved despite the usage of an ultrathin active layer. The proposed design can also be developed to achieve performance enhancement of other thin film solar cells in the future.

Background Acute kidney injury is a common complication after cardiac surgery, leading to increased morbidity and mortality. One suggested cause for acute kidney injury is extracorporeal circulation–induced ischemia–reperfusion injury. In animal studies, cyclosporine has been shown to reduce ischemia–reperfusion injury in the kidneys. We hypothesized that administering cyclosporine before extracorporeal circulation could protect the kidneys in patients undergoing cardiac surgery. Methods The Cyclosporine to Protect Renal Function in Cardiac Surgery (CiPRICS) study was an investigator-initiated, double-blind, randomized, placebo-controlled, single-center study. The primary objective was to assess if cyclosporine could reduce acute kidney injury in patients undergoing coronary artery bypass grafting surgery with extracorporeal circulation. In the study, 154 patients with an estimated glomerular filtration rate of 15 to 90 ml · min–1 · 1.73 m–2 were enrolled. Study patients were randomized to receive 2.5 mg/kg cyclosporine or placebo intravenously before surgery. The primary endpoint was relative plasma cystatin C changes from the preoperative day to postoperative day 3. Secondary endpoints included biomarkers of kidney, heart, and brain injury. Results All enrolled patients were analyzed. The cyclosporine group (136.4 ± 35.6%) showed a more pronounced increase from baseline plasma cystatin C to day 3 compared to placebo (115.9 ± 30.8%), difference, 20.6% (95% CI, 10.2 to 31.2%, P < 0.001). The same pattern was observed for the other renal markers. The cyclosporine group had more patients in Risk Injury Failure Loss End-stage (RIFLE) groups R (risk), I (injury), or F (failure; 31% vs. 8%, P < 0.001). There were no differences in safety parameter distribution between groups. Conclusions Administration of cyclosporine did not protect coronary artery bypass grafting patients from acute kidney injury. Instead, cyclosporine caused a decrease in renal function compared to placebo that resolved after 1 month.

Objective. Oxygen (O2) have been a cornerstone in the treatment of acute myocardial infarction. Studies have been inconclusive regarding the cardiovascular and analgesic effects of oxygen in these patients. In the SOCCER trial, we compared the effects of oxygen treatment versus room air in patients with ST-elevation myocardial infarction (STEMI). There was no difference in myocardial salvage index or infarct size assessed with cardiac magnetic resonance imaging. In the present subanalysis, we wanted to evaluate the effect of O2 on chest pain in patients with STEMI. Design. Normoxic patients with first time STEMI were randomized in the ambulance to standard care with 10 l/min O2 or room air until the end of the percutaneous coronary intervention (PCI). The ambulance personnel noted the patients´ chest pain on a visual analog scale (VAS; 1-10) before randomization and after the transport but before the start of the PCI, and also registered the amount of morphine given. Results. 160 patients were randomized to O2 (n = 85) or room air (n = 75). The O2 group had a higher median VAS at randomization than the air group (7.0 ± 2.3 vs 6.0 ± 2.9; p = .02) and also received a higher median total dose of morphine (5.0 mg ± 4.4 vs 4.0 mg ± 3.7; p = .02). There was no difference between the O2 and air groups in VAS at the start of the PCI (4.0 ± 2.4 vs 3.0 ± 2.5; p = .05) or in the median VAS decrease from randomization to the start of the PCI (−2.0 ± 2.2 vs −1.0 ± 2.9; p = .18). Conclusion. Taken together with previously published data, these results do not support a significant analgesic effect of oxygen in patients with STEMI. European Clinical Trials Database (EudraCT): 2011-001452-11. ClinicalTrials.gov Identifier: NCT01423929

A graphene microstrip patch antenna is designed to operate in the three bands of the atmospheric windows promising for the future wireless communications. The graphene has a reconfigurable surface conductivity that can be tuned to operate at the desired frequencies. This paper studies the role of chemical potential ( μ c ) of the graphene to tune the resonant frequency of a microstrip antenna. The results show that the resonant frequency of a microstrip antenna increases as the chemical potential grows that can be employed to realize a reconfigurable antenna. The proposed resonances for the low-loss 300 GHz, 350 GHz and 410 GHz atmospheric windows can be achieved for μ c = 0.21 eV, μ c = 0.4 eV and μ c = 1.5 eV respectively. Finally, a design process for a multi-band graphene-based antenna has been presented.

Guidelines recommend a 0-hour/1-hour high-sensitivity cardiac troponin T (hs-cTnT) diagnostic strategy in acute chest pain patients. There are, however, little data on the performance of this strategy when combined with clinical risk stratification. We aimed to evaluate the diagnostic accuracy of an accelerated diagnostic protocol (ADP) using the 0-hour/1-hour hs-cTnT strategy together with an adapted Thrombolysis In Myocardial Infarction (TIMI) score and electrocardiogram (ECG) for ruling out major adverse cardiac events (MACE) within 30 days.This prospective observational study enrolled consecutive emergency department (ED) chest pain patients. TIMI score variables, ED physicians' assessments of the ECG, and 0- and 1-hour hs-cTnT were collected. Thirty-day MACE was defined as acute myocardial infarction (AMI), unstable angina (UA), cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of cardiac or unknown cause.A total of 1,020 patients were included in the final analysis. The combination of an adapted TIMI score ≤1, a nonischemic ECG, and either a 0-hour hs-cTnT 5 ng/L or a 0-hour hs-cTnT 12 ng/L combined with a 1-hour increase 3 ng/L identified 432 (42.4%) patients as very low risk with a negative predictive value of 99.5% (95% confidence interval [CI] = 98.3%-99.9%) and a negative likelihood ratio of 0.04 (95% CI = 0.01-0.14) for 30-day MACE. The ADP missed only two patients with UA and no patients with AMI or other forms of MACE.An ADP using the guideline recommended 0-hour/1-hour hs-cTnT strategy rapidly identified patients with a very low risk of 30-day MACE including UA where no further cardiac testing would be needed. This could potentially allow safe early discharge of about 40% of ED chest pain patients.

Background: Although oxygen (O2) is routinely used in patients with acute myocardial infarction (AMI), it may have negative effects. In this substudy of the SOCCER trial, we aimed to evaluate the effects of O2-treatment on myocardial function in patients with ST elevation myocardial infarction (STEMI). Methods: Normoxic (≥94%) STEMI patients were randomized in the ambulance to either supplemental O2 or room air until the end of the percutaneous coronary intervention (PCI). The patients underwent echocardiography on day 2-3 after the PCI and once again after 6 months. The study endpoints were wall-motion score index (WMSI) and left ventricular ejection fraction (LVEF). Results: Forty-six patients in the O2 group and 41 in the air group were included in the analysis. The index echocardiography showed no significant differences between the groups in WMSI (1.32±0.27 for O2 group vs 1.28±0.28 for air group) or LVEF (47.0±8.5% vs 49.2±8.1%). Nor were there differences at 6 months in WMSI (1.16±0.25 vs 1.14±0.24) or LVEF (53.5±5.8% vs 53.5±6.9%). Conclusion: The present findings indicate no harm or benefit of supplemental O2 on myocardial function in STEMI patients. Our results support that it is safe to withhold supplemental O2 in normoxic STEMI patients. (Less)

Chest pain is one of the most common complaints at the emergency department (ED), and it is commonly the perceived likelihood of acute coronary syndrome (ACS) that drives management. Guidelines from the European Society of Cardiology (ESC) recommend the use of a 0-/1-h high-sensitivity cardiac troponin T (hs-cTnT) protocol to rule out or in ACS, but this is mostly based on observational studies. The aim of the ESC-TROP trial is to determine the safety and effectiveness of the ESC 0-/1-h hs-cTnT protocol when implemented in routine care. Adult chest pain patients at 5 EDs in the Skåne Region, Sweden, are included in the trial. The 0-/1-h hs-cTnT ESC protocol supplemented with clinical assessment and electrocardiography (ECG) is implemented at 3 EDs, and the other 2 EDs act as concurrent controls. Outcomes will be evaluated during the 10 months after the implementation and the corresponding 10 months of the previous year. The 2 co-primary outcomes are (a) acute myocardial infarction (AMI) and all-cause death within 30 days in patients discharged from the ED, and (b) ED length of stay of the same patients. Secondary outcomes include the proportion of chest pain patients discharged from the ED and the number of ruled-out patients undergoing objective testing within 30 days. The ESC-TROP trial will determine the performance and applicability of the 0-/1-h hs-cTnT ESC protocol supplemented with clinical assessment and ECG when implemented in routine ED care. It will provide evidence whether 0-/1-h hs-cTnT testing is safe, effective, and feasible, and whether widespread implementation as recommended by ESC guidelines should be supported.

Background In emergency department (ED) chest pain patients, it is believed that the diagnostic accuracy of the electrocardiogram (ECG) for acute coronary syndrome (ACS) is higher during ongoing than abated chest pain. Objectives We compared patient characteristics and the diagnostic performance of the ECG in ED patients presenting with ongoing, vs. abated, chest pain. Methods In total, 1132 unselected ED chest pain patients were analyzed. The patient characteristics and diagnostic accuracy for index visit ACS of the emergency physicians’ interpretation of the ECG was compared in patients with and without ongoing chest pain. Logistic regression analysis was performed to control for possible confounders. Results Patients with abated chest pain (n = 508) were older, had more comorbidities, and had double the risk of index visit ACS (15%) and major adverse cardiac events (MACE) at 30 days (15.6%) compared with patients with ongoing pain (n = 631; ACS 7.3%, 30-day MACE 7.4%). Sensitivity of the ECG for ACS was 24% in patients with ongoing pain and 35% in those without, specificity was 97% in both groups, negative predictive value was 94% and 89%, respectively, and positive likelihood ratio 10.6 and 7.8, respectively. When the diagnostic performance was controlled for confounders, there was no significant difference between the groups. Conclusion Our results indicate that ED chest pain patients with ongoing pain at arrival are younger, healthier, and have less ACS and 30-day MACE than patients with abated pain, but that there is no difference in the diagnostic accuracy of the ECG for ACS between the two groups.

In this paper, a bi-layer of silver-SiO 2 nanodisk array has been employed aiming to realize efficient plasmonic sensors within the visible spectrum. Utilization of silver nanodisk arrays results in narrow and enhanced extinction spectra while the SiO 2 layer enhances the extraordinary optical transmission (EOT) of light and protects the silver surface from oxidation. Using numerical simulations, it has been demonstrated that the designed sensor shows high refractive index sensitivities as large as 390nm/RIU with a figure of merit of 10.5 RIU−1 proving the efficacy of the design. The proposed scheme is polarization insensitive thanks to it symmetric configuration taking advantage of low cost compared with gold-based sensors. The designed nanostructure provides a good reliability using the SiO 2 layer offering potential applications for chemical and biological sensing.

A 1-h algorithm based on high-sensitivity cardiac troponin T (hs-cTnT) testing at presentation and again 1 h thereafter has been shown to accurately rule out acute myocardial infarction.The goal of the study was to evaluate the diagnostic accuracy of the 1-h algorithm when supplemented with patient history and an electrocardiogram (ECG) (the extended algorithm) for predicting 30-day major adverse cardiac events (MACE) and to compare it with the algorithm using hs-cTnT alone (the troponin algorithm).This prospective observational study enrolled consecutive patients presenting to the emergency department (ED) with chest pain, for whom hs-cTnT testing was ordered at presentation. Hs-cTnT results at 1 h and the ED physician's assessments of patient history and ECG were collected. The primary outcome was an adjudicated diagnosis of 30-day MACE defined as acute myocardial infarction, unstable angina, cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of a cardiac or unknown cause.In the final analysis, 1,038 patients were included. The extended algorithm identified 60% of all patients for rule-out and had a higher sensitivity than the troponin algorithm (97.5% vs. 87.6%; p 0.001). The negative predictive value was 99.5% and the likelihood ratio was 0.04 with the extended algorithm versus 97.8% and 0.17, respectively, with the troponin algorithm. The extended algorithm ruled-in 14% of patients with a higher sensitivity (75.2% vs. 56.2%; p 0.001) but a slightly lower specificity (94.0% vs. 96.4%; p 0.001) than the troponin algorithm. The rule-in arms of both algorithms had a likelihood ratio10.A 1-h combination algorithm allowed fast rule-out and rule-in of 30-day MACE in a majority of ED patients with chest pain and performed better than the troponin-alone algorithm.

In this work, a gas sensor based on the plasmonic double-layer graphene nanograting (GNG) structure with an enhanced figure of merit (FoM) is presented in the near-infrared region. This structure includes double periodic graphene nanoribbon arrays, separated by a dielectric. The wavelength interrogation method is employed to accurately investigate the behavior of the proposed structure for various physical and geometrical parameters, including the array pitch, graphene nanoribbon width, refractive index of the intermediate dielectric between the GNGs, and the chemical potential of the graphene. A sharp dip is achieved by the guided-mode resonance between the two GNG layers, due to their near-field coupling. For the optimized design, obtained sensitivity and FoM are 430.91 nm/RIU and 174.68 R I U − 1 , respectively, when the finite-element method is used for the simulations. The high FoM is a result of the field enhancement at the edges of the graphene nanoribbons, as well as the narrow resonance linewidth achieved by the sharp transmission dip. In addition to the high performance and FoM, the structure is robust to the misalignment of two GNG layers, offering a solution for practical gas sensing applications. To the best of our knowledge, the proposed GNG-based structure enjoys a boosted FoM compared to the previously proposed integrated gas sensors, as well as a practically feasible design for fabrication.

We have designed a new class of single-stage Faraday isolators that employs two sheets of graphene. Using nonreciprocal optical materials such as InSb boosts plasmonic coupling between the graphene layers, which leads to a 45 deg polarization rotation as well as increased transmission through the structure. More than 91% transmission is achieved in the THz band (1 THz–7 THz). This design opens up the way in ultrafast integrated magneto-optical nanophotonic devices to realize single-stage isolators with enhanced transmittance in the THz band.

Objectives: Guidelines recommend a single high-sensitivity cardiac troponin T (hs-cTnT) ≤14 ng/L measured ≥6 h after chest pain onset combined with a GRACE score Design: This was a secondary analysis of a prospective observational study, which enrolled emergency department (ED) chest pain patients. The hs-cTnT strategy was combined with HEART, TIMI, EDACS, GRACE score and ED physician’s overall assessment of patient history and ECG. The primary outcome was MI, and the secondary outcome was 30-day major adverse cardiac events (MACE). Results: All tested diagnostic strategies were shown to have a negative predictive value (NPV) ≥99.5% for ruling out MI. Using HEART, TIMI, EDACS or ECG + patient history also resulted in a NPV ≥98% for ruling out 30-day MACE. An isolated hs-cTnT ≤14 ng/L measured ≥6 h after chest pain onset and the combination with GRACE score both had a NPV Conclusion: A single hs-cTnT ≤14 ng/L obtained ≥6 h from chest pain onset, with and without GRACE score, reliably ruled out MI but did not perform well for ruling out 30-day MACE. These results question current guideline recommendations, and indicate that HEART, EDACS, TIMI, or ECG + patient history strategies should be the preferred risk stratification tools.

Objectives. Chest pain is a common complaint in the emergency department (ED), and it is a challenge to identify low-risk chest pain patients eligible for early discharge. We aimed to develop a simple objective decision rule to exclude 30-day major adverse cardiac events (MACE) in ED chest pain patients. Design. We analyzed prospectively included patients presenting with chest pain. Low risk patients were identified with the clinical objective rule-out evaluation (CORE). CORE was based on high sensitivity cardiac troponin T (hs-cTnT) tests at ED presentation (0 h) and 2 h later together with a simplified risk score consisting of four objective variables: age ≥65 years and a history of arterial disease, hypertension or diabetes. For the patient to be classified as low risk in the CORE rule, hs-cTnT had to be ≤14 ng/L both at 0 and 2 h, and the sum of the risk score had to be 0. The primary outcome was MACE within 30 days. Results. Among the 751 patients in the final analysis, 90 (11.9%) had a MACE. CORE identified 248 (33%) of patients as low risk with a sensitivity of 98.9% (CI 93.1–99.9) and a negative predictive value of 99.6% (95% CI 97.4–100) for 30-day MACE. Adding the ED physician’s interpretation of the ECG to CORE did not improve diagnostic performance. Conclusion. A simple objective decision rule (CORE) identified one-third of all patients as having a very low 30-day risk of MACE. These patients may potentially be discharged without additional investigations for acute coronary syndrome. (Less)

Utilization of moth eye anti-reflection coatings has attracted significant interest to achieve broadband anti-reflective properties. In this study, particle swarm optimization has been employed aiming to improve the performance of thin film solar cells. Numerical simulations based upon the finite-difference time-domain method have been used for extracting the optical properties of the structure. The shape and dimensions of silicon-based moth eye nanostructures have been optimized in the wavelength range from 350 to 850 nm. A low reflectance factor less than 4% has been obtained resulting in a great broadband solar absorption of more than 96% over the mentioned wavelength span. The results prove the efficacy of the proposed method for performance enhancement of similar structures, as well.

Acute kidney injury is a common complication after cardiac surgery, leading to increased morbidity and mortality. One suggested cause for acute kidney injury is extracorporeal circulation-induced ischemia-reperfusion injury. In animal studies, cyclosporine has been shown to reduce ischemia-reperfusion injury in the kidneys. We hypothesized that administering cyclosporine before extracorporeal circulation could protect the kidneys in patients undergoing cardiac surgery.The Cyclosporine to Protect Renal Function in Cardiac Surgery (CiPRICS) study was an investigator-initiated, double-blind, randomized, placebo-controlled, single-center study. The primary objective was to assess if cyclosporine could reduce acute kidney injury in patients undergoing coronary artery bypass grafting surgery with extracorporeal circulation. In the study, 154 patients with an estimated glomerular filtration rate of 15 to 90 ml · min · 1.73 m were enrolled. Study patients were randomized to receive 2.5 mg/kg cyclosporine or placebo intravenously before surgery. The primary endpoint was relative plasma cystatin C changes from the preoperative day to postoperative day 3. Secondary endpoints included biomarkers of kidney, heart, and brain injury.All enrolled patients were analyzed. The cyclosporine group (136.4 ± 35.6%) showed a more pronounced increase from baseline plasma cystatin C to day 3 compared to placebo (115.9 ± 30.8%), difference, 20.6% (95% CI, 10.2 to 31.2%, P0.001). The same pattern was observed for the other renal markers. The cyclosporine group had more patients in Risk Injury Failure Loss End-stage (RIFLE) groups R (risk), I (injury), or F (failure; 31% vs. 8%, P0.001). There were no differences in safety parameter distribution between groups.Administration of cyclosporine did not protect coronary artery bypass grafting patients from acute kidney injury. Instead, cyclosporine caused a decrease in renal function compared to placebo that resolved after 1 month.

Taking advantage of nanostructured metal films as plasmonic colour filters (PCFs) has been evolved remarkably as an alternative to the conventional technologies of chemical colour filtering. However, most of the proposed PCFs depict a poor colour purity focusing on generating either the additive or subtractive colours. In this paper, we present dual mode operation PCFs employing an opaque aluminium film patterned with sub-wavelength holes. Subtractive colours like cyan, magenta, and yellow are the results of reflection mode of these filters yielding optical efficiencies as high as 70%–80% and full width at half maximum of the stop-bands up to 40–50 nm. The colour selectivity of the transmission mode for the additive colours is also significant due to their enhanced performance through the utilization of a relatively thick aluminium film in contact with a modified dielectric environment. These filters provide a simple design with one-step lithography in addition to compatibility with the conventional CMOS processes. Moreover, they are polarization insensitive due to their symmetric geometry. A complete palette of pure subtractive and additive colours has been realized with potential applications, such as multispectral imaging, CMOS image sensors, displays, and colour printing.

Background: High-sensitivity assays for cardiac troponin T (hs-cTnT) are sometimes used to rapidly rule out acute myocardial infarction (AMI).Purpose: To estimate the ability of a single hs-cTnT concentration below the limit of detection (Data Sources: EMBASE and MEDLINE without language restrictions (1 January 2008 to 14 December 2016).Study Selection: Cohort studies involving adults presenting to the ED with possible acute coronary syndrome in whom an ECG and hs-cTnT measurements were obtained and AMI outcomes adjudicated during initial hospitalization.Data Extraction: Investigators of studies provided data on the number of low-risk patients (no new ischemia on ECG and hs-cTnT measurements Data Synthesis: Of 9241 patients in 11 cohort studies, 2825 (30.6%) were classified as low risk. Fourteen (0.5%) low-risk patients had AMI. Sensitivity of the risk classification for AMI ranged from 87.5% to 100% in individual studies. Pooled estimated sensitivity was 98.7% (95% CI, 96.6% to 99.5%). Sensitivity for 30-day MACEs ranged from 87.9% to 100%; pooled sensitivity was 98.0% (CI, 94.7% to 99.3%). No low-risk patients died.Limitation: Few studies, variation in timing and methods of reference standard troponin tests, and heterogeneity of risk and prevalence of AMI across studies.Conclusion: A single hs-cTnT concentration below the limit of detection in combination with a nonischemic ECG may successfully rule out AMI in patients presenting to EDs with possible emergency acute coronary syndrome.Primary Funding Source: Emergency Care Foundation.

Utilization of a plasmonic nanohole array as a color filter, proposes important advantages like the compatibility with CMOS processes. A color filter is an important component for applications, such as LCDs, LEDs, CMOS image sensors, etc. In this article, a set of primary color filters (red, green and blue) are designed by an optimization procedure, employing genetic algorithm integrated with Lumerical FDTD software. The filters consist of a square lattice of nanoholes in an aluminum film on a silicon dioxide substrate. They are suitable for using in CMOS image sensors. Despite the practical restrictions to simplify the fabrication, the optical response of the filters have shown a transmission peak of 30–43 percent with a FWHM of 40 (nm), 50 (nm) and 80 (nm) in accurate resonant wavelengths of red, green, and blue filters, respectively. These results demonstrate the efficacy of the proposed optimization method.