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Natalie R Stokes,1 Brett W Dietz,1 Jackson J Liang2 1Perelman School of Medicine, University of Pennsylvania, 2Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USAAbstract: Dyspnea is a common chief complaint in the emergency department, with over 4 million visits annually in the US. Establishing the correct diagnosis can be challenging, because the subjective sensation of dyspnea can result from a wide array of underlying pathology, including pulmonary, cardiac, neurologic, psychiatric, toxic, and metabolic disorders. Further, the presence of dyspnea is linked with increased mortality in a variety of conditions, and misdiagnosis of the cause of dyspnea leads to poor patient-level outcomes. In combination with the history and physical, efficient, and focused use of laboratory studies, the various cardiopulmonary biomarkers can be useful in establishing the correct diagnosis and guiding treatment decisions in a timely manner. Use and interpretation of such tests must be guided by the clinical context, as well as an understanding of the current evidence supporting their use. This review discusses current standards and research regarding the use of established and emerging cardiopulmonary laboratory markers in the evaluation of acute dyspnea, focusing on recent evidence assessing the diagnostic and prognostic utility of various tests. These markers include brain natriuretic peptide (BNP) and N-terminal prohormone (NT-proBNP), mid-regional peptides proatrial NP and proadrenomedullin, cardiac troponins, D-dimer, soluble ST2, and galectin 3, and included is a discussion on the use of arterial and venous blood gases.Keywords: cardiopulmonary, emergency, heart failure, troponin, BNP, galectin 3, MR-proANP, MR-proADM

The Cambrian-Ordovician Wagonga Group contains basalts at Melville Point and Barlings Beach, 20 km south of Batemans Bay, New South Wales. At Melville Point, the succession has basal altered basalts overlain by chert and interbedded siliceous mudstone of the Wagonga Group, in turn overlain by turbidites and chert of the Adaminaby Group with a latest Cambrian to earliest Ordovician age. By contrast, at Barlings Beach, basalt is associated with highly disrupted chert (tectonic mélange), various slivers of mudstone and turbidites, and turbidites of the Adaminaby Group. Immobile elements in the basalts show consistent patterns that allow the magmatic affinity and tectonic setting to be determined in spite of pervasive hydrothermal alteration and subsequent lower greenschist facies metamorphism that accompanied strong folding and multiple foliation development. The Melville Point basalts show Ti/V ratios transitional between arc and MORB and therefore may have formed in either a forearc or backarc basin setting. However, these rocks have higher Ti/V ratios, LREE, Th and Nb than found in forearc basalts and are therefore considered to have formed in a backarc basin setting. In contrast to Melville Point, most basalts at Barlings Beach have a geochemical signature distinctive of ocean island settings like those reported from elsewhere in the Wagonga Group. We believe these rocks developed in a Cambrian backarc basin setting. In the Early to Middle Ordovician, much of the ocean basin was inundated by quartzose turbidites followed by basin destruction with accretion/underplating at a Late Ordovician-early Silurian Benambran subduction zone and formation of the Narooma Accretionary Complex.

The Cambro-Ordovican Wagonga Group rocks of the Narooma Accretionary Complex in the southeastern Lachlan Fold Belt, are well exposed at Melville Point and Barlings Head, 20 km south of Batemans Bay at Tomakin, on the New South Wales south coast. They are comprised of ocean floor turbidites and pelagic sedimentary rocks, and mafic volcanic rocks. Relationships between the volcanic rocks and the surrounding rocks are in need of more detailed examination. Detailed mapping, petrography (microscopy, XRD) and whole rock geochemistry (laboratory and hand-held XRF) of the rock units in the study area, have been used for detailed description of the lithologies. This study shows that the chaotic rocks at Barlings Head form a mélange that is not a stratigraphic sequence, like that at Melville Point. The overall assemblage at both localities is similar. An array of different facies occurs at Barlings Head, including a massive greenstone unit and several different types of mudstone, sandstone and chert units that are commonly mixed and highly deformed. The greenstone unit at Barlings Head is massive and highly altered (secondary clay minerals dominate the rock composition), and it injects along its contacts with adjacent chert and black mudstone units. At Melville Point, the greenstone occurs as a massive unit, pillow lavas and folded within the core of anticlines in the Narooma Chert. Geochemical findings indicate that greenstones at Barlings Head and Melville Point have different magmatic affinities. The Barlings Head greenstone has an ocean-island basalt affinity and is interpreted to be offscraped from a subducted seamount. The Melville Point greenstone has an island arc basalt affinity, derived from a depleted mantle source, and is interpreted to have erupted in a deep marine setting by its association with the Narooma Chert. At Barlings Head a mélange of black mudstone/sandstone is interpreted to have been diapirically injected along an early fault, with later injection of