Search

ObjectivesThe Manchester Acute Coronary Syndromes ECG (MACS-ECG) prediction model calculates a score based on objective ECG measurements to give the probability of a non-ST elevation myocardial infarction (NSTEMI). The model showed good performance in the emergency department (ED), but its accuracy in the pre-hospital setting is unknown. We aimed to externally validate MACS-ECG in the pre-hospital environment.MethodsWe undertook a secondary analysis from the Pre-hospital Evaluation of Sensitive Troponin (PRESTO) study, a multi-centre prospective study to validate decision aids in the pre-hospital setting (26 February 2019 to 23 March 2020). Patients with chest pain where the treating paramedic suspected acute coronary syndrome were included. Paramedics collected demographic and historical data and interpreted ECGs contemporaneously (as ‘normal’ or ‘abnormal’). After completing recruitment, we analysed ECGs to calculate the MACS-ECG score, using both a pre-defined threshold and a novel threshold that optimises sensitivity to differentiate AMI from non-AMI. This was compared with subjective ECG interpretation by paramedics. The diagnosis of AMI was adjudicated by two investigators based on serial troponin testing in hospital.ResultsOf 691 participants, 87 had type 1 AMI and 687 had complete data for paramedic ECG interpretation. The MACS-ECG model had a C-index of 0.68 (95% CI: 0.61 to 0.75). At the pre-determined cut-off, MACS-ECG had 2.3% (95% CI: 0.3% to 8.1%) sensitivity, 99.5% (95% CI: 98.6% to 99.9%) specificity, 40.0% (95% CI: 10.2% to 79.3%) positive predictive value (PPV) and 87.6% (87.3% to 88.0%) negative predictive value (NPV). At the optimal threshold for sensitivity, MACS-ECG had 50.6% sensitivity (39.6% to 61.5%), 83.1% specificity (79.9% to 86.0%), 30.1% PPV (24.7% to 36.2%) and 92.1% NPV (90.4% to 93.5%). In comparison, paramedics had a sensitivity of 71.3% (95% CI: 60.8% to 80.5%) with 53.8% (95% CI: 53.8% to 61.8%) specificity, 19.7% (17.2% to 22.45%) PPV and 93.3% (90.8% to 95.1%) NPV.ConclusionNeither MACS-ECG nor paramedic ECG interpretation had a sufficiently high PPV or NPV to ‘rule in’ or ‘rule out’ NSTEMI alone.

Preeclampsia (PE) is a pregnancy-specific hypertensive disorder with end-organ damage that presents after 20 wk of gestation. PE pathophysiology often includes vascular dysfunction and increased inflammation that continues to damage patient health even after PE resolves. Currently, there is no cure for PE beyond delivery of the fetal-placental unit. Previous clinical studies have identified elevated placental NLRP3 expression in patients with PE and suggest NLRP3 as a potential therapeutic target. In this study, we examined the effect of NLRP3 inhibition on PE pathophysiology in the reduced uterine perfusion pressure (RUPP) model rat using MCC950 (20 mg/kg/day) or esomeprazole (3.5 mg/kg/day). We hypothesized that increased NLRP3 in response to placental ischemia impairs anti-inflammatory IL-33 signaling to induce T-helper 17 cell (TH17) and cytolytic NK cell (cNK) activation, which is known to mediate oxidative stress and vascular dysfunction leading to maternal HTN and intrauterine growth restriction. RUPP rats had significantly higher placental NLRP3 expression, maternal blood pressure, fetal reabsorption rate, vascular resistance, oxidative stress, cNKs and TH17s, and decreased IL-33 compared with normal pregnant (NP) rats. NLRP3 inhibition, with either treatment, significantly reduced placental NLRP3 expression, maternal blood pressure, fetal reabsorption rates, vascular resistance, oxidative stress, cNK, and TH17 populations in RUPP rats. Based on our findings, NLRP3 inhibition reduces PE pathophysiology and esomeprazole may be a potential therapeutic for PE treatment.

BackgroundTemporary lower limb immobilisation following injury is a risk factor for symptomatic venous thromboembolism (VTE). Pharmacological thromboprophylaxis can mitigate this risk but it is unclear which patients benefit from this intervention. The Aberdeen VTE risk tool was developed to tailor thromboprophylaxis decisions in these patients and this evaluation aimed to describe its performance in clinical practice. Secondarily, diagnostic metrics were compared with other risk assessment methods (RAMs).MethodsA prospective cohort service evaluation was conducted. Adult patients (≥16 years) managed with lower limb immobilisation for injury who were evaluated with the Aberdeen VTE risk tool prior to discharge from the ED were identified contemporaneously between February 2014 and December 2020. Electronic patient records were scrutinised up to 3 months after removal of immobilisation for the development of symptomatic VTE or sudden death due to pulmonary embolism (PE). Other RAMs, including the Thrombosis Risk Prediction for Patients with cast immobilisation (TRiP(cast)) and Plymouth scores, were assimilated retrospectively and diagnostic performance compared.ResultsOf 1763 patients (mean age 46 (SD 18) years, 51% women), 15 (0.85%, 95% CI 0.52% to 1.40%) suffered a symptomatic VTE or death due to PE. The Aberdeen VTE tool identified 1053 (59.7%) patients for thromboprophylaxis with a sensitivity of 80.0% (95% CI 54.8% to 93.0%) and specificity of 40.4% (95% CI 38.1% to 42.6%) for the primary outcome. In 1695 patients, fewer were identified as high risk by the TRiP(cast) (33.3%) and Plymouth (24.4%) scores, but with greater specificity, 67.0% and 75.6%, respectively, than dichotomous RAMs, including the Aberdeen VTE tool.ConclusionRoutine use of the Aberdeen VTE tool in our population resulted in an incidence of symptomatic VTE of less than 1%. Ordinal RAMs, such as the TRiP(cast) score, may more accurately reflect VTE risk and permit more individually tailored thromboprophylaxis decisions but prospective comparison is needed.

No Abstract Available.

Papua New Guinea is a Pacific country that remains an enigma to the world at large. Despite massive geographical challenges due to mountainous terrain, remote islands, poverty, and with 80% of the population of over eight million living in rural villages, Papua New Guinea has managed to develop national medical and postgraduate specialty training. The first recorded anaesthetic was administered in Papua New Guinea in 1880 and the first anaesthetist trained in 1968. The University of Papua New Guinea graduated its first diploma in anaesthesia candidate in 1986 and its first master of medicine candidate in anaesthesiology in 1991. As of December 2021, there have been 82 diplomas and 40 masters of medicine awarded. We review the factors and influences bearing on the development of physician anaesthesia training in Papua New Guinea over this period. Many of the people involved have contributed information used in this article.

Until very recently, the major focus of research in the field of consumer behavior has been on the selection of products, brands and decision choices primarily in the sphere of marketing. The purpose of this paper was to modify a model developed to measure market share to account for the variables that enter into the selection of a political candidate and predict voting behavior.

The production of meltwater from glacier ice, which is exposed at the margins of land ice during the summer, is responsible for a large proportion of glacier mass loss. The rate of meltwater production from glacier ice is especially sensitive to its physical structure and chemical composition which combine to determine the albedo of glacier ice. However, the optical properties of near-surface glacier ice are not well known since most prior work has focused on laboratory-grown ice or deep cores. Here, we demonstrate a measurement technique based on diffuse propagation of nanosecond-duration laser pulses in near-surface glacier ice that enables the independent measurement of the scattering and absorption coefficients, allowing for a complete description of the processes governing radiative transfer. We employ a photon-counting detector to overcome the high losses associated with diffuse optics. The instrument is highly portable and rugged, making it optimally suited for deployment in remote regions. A set of measurements taken on Crook and Collier Glaciers, Oregon, serves as a demonstration of the technique. These measurements provide insight into both physical structure and composition of near-surface glacier ice and open new avenues for the analysis of light-absorbing impurities and remote sensing of the cryosphere.

Multiple intertidal barred systems (MITB) are complex coastal features observed under specific conditions including low to moderate energy waves and macrotidal forcing. Although primarily tide-dominated, MITBs can undergo significant morphological changes under storms and extreme events. In December 2021, storm Barra crossed the U.K. and was the 2nd most energetic event in the past 25 years, to occur on Northern Ireland’s east coast. At the MITB site in Dundrum Bay, offshore waves reached a maximum significant wave height of 5.5 m on December 7th, 2021 and were associated with a peak period and wave direction of 10s and 179°N-oriented respectively. Pre- and post-Barra intertidal DGPS surveys were conducted at Dundrum Bay on the 6th and 9th of December to identify beach morphological changes on MITBs. Despite direct onshore waves reaching the bay, a strong alongshore variability was recorded in the response to Murlough and Ballykinler beaches to Storm Barra. Indeed, according to preliminary results, the western end of the bay shows an elevation of the beach profile, the central area presents onshore migrations of the bars to no significant changes, while the eastern side of the bay (Ballykinler) displays bar crests flattening and linear post-storm profiles.Although storm Barra was the most energetic event recorded during the winter 2021/2022, smaller storm events had modified the morphology of Murlough and Ballykinler beaches throughout the preceding season, leading to some already low pre-Barra beach profiles. Secondly, at the peak of Barra’s energy, the waves were southeast oriented. But the direction of the waves rapidly shifted from onshore to offshore, possibly modifying the impact of Barra on the system. Finally, the shape of the bay, the location of the different profiles and the complex nearshore bathymetry and local geology must have also played a key role dictating the alongshore pattern shown. Previous studies of Dundrum Bay have shown that physical processes driven by waves/tide and geomorphology interactions can undergo significant local modification, leading to a strong alongshore variability in the profiles’ response to seasonal events. Nearshore SWAN simulations will help highlight the role of nearshore hydrodynamics including wave dissipation and re-orientation, wave-driven sediment transport and the impact of storm surge on MITB during an extreme event.

Shoreline change analysis of the entire coast of Northern Ireland was conducted for the period from 1830 to 2021. Even with its 790Km length (including the main offshore islands) the Northern Ireland coastline is remarkably diverse, comprising several notable coastal typologies (cliffs, rocky coasts, sandy beaches, sand dunes, etc.) as well as a number of commercial and industrial activities. Human pressure co-exists with the natural coast and each impacts the other in many ways.Shorelines were digitised using multiple temporal and spatial datasets (historical maps, aerial photos and orthophotos). The average temporal interval of shorelines ranges from 7.8 to 37 years, depending on location and data availability. The seaward vegetation line was selected as the primary shoreline proxy, whereas cliff edge, rock-water line or anthropogenic structures were chosen subordinately or if deemed more appropriate. Shoreline uncertainty was assessed using various errors inherent from each dataset from which the shoreline was digitised. The ArcMap® tool DSAS 5.0 was used to calculate shoreline rates and distances along 25 m spaced transects covering the entire coastline.Over the last two centuries the maximum retreat value was highlighted in Lough Foyle between the Roe River mouth and Magilligan Point where the shoreline progressively retreated up to -250 m. The largest shoreline advancement (+3.500 m) was recorded in Belfast following its port expansion.Sandy coastlines were shown to have the larger natural changes. Magilligan point, after an advancement phase toward its northern extremity between 1830 and 1919, underwent a constant retreat phase that has now extended to its eastern side up. Benone Beach, Castlerock and Portstewart Strand are the only vegetated coastal dune sites along Northern Ireland’s north coast that are advancing in the last 190 years(190-270m) Significant shoreline retreat was recorded at White Rocks (-85 m), Ballycastle (-65 m), Runkerry (-25 m) and White Park Bay (-65 m). In Dundrum Bay, Co. Down, the largest retreat values (-75 m) occurred at Murlough and maximum advancements greater than 200 m at Ballykinler.The largest shoreline advancements were all attributed to human activities such as land reclamation in the loughs (mainly during the 19th century), seaward expansions of ports (e.g., Belfast, Bangor, Carrickfergus, Portavogie and Warren Point) or construction of power stations and wastewater treatment areas. Shoreline advancements recorded for the salt marshes of Larne and Foyle Loughs and White Water River mouth also followed human interventions. High rocky coasts, apart from limited rockfalls, were less subject to shoreline changes. The work will contribute to better define coastal cells along the Northern Ireland coastline and inform coastal managers for future development plans of the coast.