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Introduction: Acute coronary syndrome (ACS) is a common, sometimes difficult to diagnose spectrum of diseases. Given the diagnostic challenge, it is sensible for emergency physicians to have an approach to prognosticate patients with possible ACS. The objective of this review was to investigate the ability of the HEART score to predict major adverse cardiac events (MACE) in patients presenting to the ED with possible ACS. Methods: Eleven databases and other sources identified 468 potentially relevant studies. Sixty-seven studies underwent full text review with 25 studies meeting eligibility criteria. Main outcome measures were pooled prevalence, risk ratio (RR), and absolute risk reduction (ARR) for MACE within six weeks of ED evaluation, comparing HEART score 0–3 versus 4–10. Model discrimination (sensitivity, specificity, concordance statistic) and calibration (observed to expected events ratio) were also evaluated. Results: Data from 25 studies including 41,397 patients were combined in the meta-analysis. In total, 4815 patients (11.6%) developed MACE. Among 18,866 patients with HEART score 0–3, 396 (2.1%) developed MACE (RR 0.08; ARR 0.20). Outcome measures were consistent across planned subgroup and sensitivity analyses. Among studies with secondary outcome data for patients with HEART score 0–3, 5 of 6461 (0.1%) died and 75 of 7556 (1.0%) had a myocardial infarction. Conclusion: The HEART score provides a reliable quantitative risk assessment of MACE in ED patients with possible ACS. Emergency clinicians should consider using the HEART score to facilitate risk communication and shared decision making with patients and other care providers.
Effective treatment of maternal antenatal depression may ameliorate adverse neurodevelopmental outcomes in offspring. We performed two follow-up rounds of children at age 2 and age 5 whose mothers had received either specialized cognitive-behavioural therapy or routine care for depression while pregnant. Of the original cohort of 54 women, renewed consent was given by 28 women for 2-year follow-up and by 24 women for 5-year follow-up. Child assessments at the 2-year follow-up included the Parenting Stress Index (PSI), Bayley Scales of Infant Development (BSID-III) and the Child Behaviour Checklist (CBCL). The 5-year follow-up included the Wechsler Preschool and Primary Scales of Intelligence (WPPSI-III) and again the CBCL. Treatment during pregnancy showed significant benefits for children’s development at age 2, but not at age 5. At 2 years, intervention effects were found with lower scores on the PSI Total score, Parent Domain and Child domain (d=1.44, 1.47, 0.96 respectively). A non-significant trend favoured the intervention group on most subscales of the CBCL and the BSID-III (most notably motor development: d =0.52). In contrast, at 5-year follow-up, no intervention effects were found. Also, irrespective of treatment allocation, higher depression or anxiety during pregnancy was associated with higher CBCL and lower WPPSI-III scores at 5 years. This is one of the first controlled studies to evaluate the long-term effect of antenatal depression treatment on infant neurodevelopmental outcomes, showing some benefit. Nevertheless, caution should be taken interpreting the results because of a small sample size, and larger studies are warranted.
The subaqueous margins of calving glaciers have the potential to make significant contributions to glacier mass loss. However, to date, very little is known about the morphology and development of subaqueous margins. A unique combination of sub-bottom profile and bathymetric data collected between 2008 and 2010 in proglacial lakes at Mueller, Hooker and Tasman glaciers in New Zealand’s Southern Alps reveal subaqueous ice ramps extending up to 510 m from the terminus of each glacier. Ice ramp surfaces are undulating and covered with a thick layer (up to 10 m) of unsorted sediment derived from supraglacial and englacial debris, lateral moraines and deltaic deposits. A cyclic calving pattern, relatively stable lake level and the debris cover appear to control the development and maintenance of these ice ramps. High subaerial retreat rates generally correspond to high subaqueous calving rates, although the highest subaerial retreat rates are not associated with the largest ice ramp. Debris mantling the subaqueous ice ramp surfaces insulates the ice from melting and also reduces buoyant forces acting on the terminus. Comparisons with previous studies show that the ice ramps evolve over time with changes in glacier dynamics and water-body properties.
HEAO 1 A2 and Einstein SSS spectral observations of Seyfert galaxies and BL Lac objects suggest that in both cases, the X-ray emission is due to relativistic particles. The five BL Lac objects have very soft spectra and at higher energies (above 10 keV) may have hard tails. Combining our X-ray data with radio, infrared, optical, and ultraviolet observations, we can fit the BL Lac spectra with the familiar synchrotron self-Compton model if we allow for relativistic beaming (Urry and Mushotzky 1982, Urry et al. 1982). We show that Doppler beaming of an underlying (Seyfert-like) source population flattens the observed luminosity function, and we emphasize that the relative numbers of BL Lacs and quasars in given spectral intervals are strong functions of selection effects, the degree of Doppler beaming, and the form of the intrinsic luminosity function.
Relationships between stable isotopes (δD–δ18O), ice facies and glacier structures have hitherto gone untested in the mid-latitude maritime glaciers of the Southern Hemisphere. Here, we present δD–δ18O values as part of a broader study of the structural glaciology of Fox Glacier, New Zealand. We analyzed 94 samples of δD–δ18O from a range of ice facies to investigate whether isotopes have potential for structural glaciological studies of a rapidly deforming glacier. The δD–δ18O measurements were aided by structural mapping and imagery from terminus time-lapse cameras. The current retreat phase was preceded by an advance of 1 km between 1984 and 2009, with the isotopic sampling and analysis undertaken at the end of that advance (2010/11). Stable isotopes from debris-bearing shear planes near the terminus, interpreted as thrust faults, are isotopically enriched compared with the surrounding ice. When plotted on co-isotopic diagrams (δD–δ18O), ice sampled from the shear planes appears to show a subtle, but distinctive isotopic signal compared with the surrounding clean ice on the lower glacier. Hence, stable isotopes (δD–δ18O) have potential within the structural glaciology field, but larger sample numbers than reported here may be required to establish isotopic contrasts between a broad range of ice facies and glacier structures.
The radiation environment of space poses a challenge for electronic systems, in particular flash memory, which contains multiple radiation-sensitive parts. Resistive memory (RRAM) devices have the potential to replace flash memory, functioning as an inherently radiation resistant memory device. Several studies indicate significant radiation resistance in RRAM devices to a broad range of radiation types and doses. In this study, we focus on the effect of displacement damage on tantalum oxide-based RRAM devices, as this form of damage is likely a worst-case scenario. An Ar+ (170 keV) ion beam was used to minimize any contribution from ionization damage, maximizing the effect of displacement damage. Fluence levels were chosen to generate enough oxygen vacancies such that devices in the high resistance state (HRS) would likely switch to the low resistance state (LRS). More than half of devices tested at the highest fluence level (1.43E13 ions/cm2) switched from HRS to LRS. The devices were then switched for 50 set/reset cycles, after which the radiation-induced resistance shift disappeared. These results suggest that device switching may mitigate radiation damage by accelerating oxygen vacancy-interstitial recombination.
We present a summary of our recent results on gas outflows in radio galaxies. Fast outflows (up to 2000 km s−1) have been detected both in ionized and neutral gas. The latter is particularly surprising as it shows that, despite the extremely energetic phenomena occurring near an AGN, some of the outflowing gas remains, or becomes again, neutral. These results are giving new and important insights on the physical conditions of the gaseous medium around an AGN.
Resistive Random Access Memory (RRAM) is a novel form of non-volatile memory that is expected to play a major role in future computing and memory solutions. It has been shown that the resistance of RRAM devices can be precisely tuned by modulating switching voltages, by limiting peak current, and by adjusting the switching pulse duration. This enables the realization of novel applications such as memristive neuromorphic computing and neural network computing. The RRAM devices described in this work utilize an inert tungsten bottom electrode, hafnium oxide based active switching layer, a titanium oxygen exchange layer, and an inert titanium nitride top electrode. Linear sweep and controlled pulse (down to 10 ns) based electrical characterization of RRAM devices was performed in a 1 transistor 1 RRAM (1T1R) configuration to determine endurance, reliability, retention and threshold voltage parameters. We demonstrated endurance values above 108 cycles with an average on/off ratio of 15 and pulse voltages for set/reset operation of ±1.5V. The on-chip 1T1R structures show an excellent controllability with respect to the low and high resistive state by manipulating the peak current from 75 up to 350µA we were able to achieve 10 discrete resistive states. Our results demonstrate that the set operation (which shifts the RRAM device from the high to the low resistance state) is only dependent on the voltage of the switching pulse and the peak current limit. The reset operation, however, occurs in an analog fashion and appears to be dependent on the total energy of the applied switching pulse. Pulse energy was modulated by varying the peak voltage which resulted in a larger relative change of the RRAM device resistance.
The subsurface exploration of other planetary bodies can be used to unravel their geological history and assess their habitability. On Mars in particular, present-day habitable conditions may be restricted to the subsurface. Using a deep subsurface mine, we carried out a program of extraterrestrial analog research – MINe Analog Research (MINAR). MINAR aims to carry out the scientific study of the deep subsurface and test instrumentation designed for planetary surface exploration by investigating deep subsurface geology, whilst establishing the potential this technology has to be transferred into the mining industry. An integrated multi-instrument suite was used to investigate samples of representative evaporite minerals from a subsurface Permian evaporite sequence, in particular to assess mineral and elemental variations which provide small-scale regions of enhanced habitability. The instruments used were the Panoramic Camera emulator, Close-Up Imager, Raman spectrometer, Small Planetary Linear Impulse Tool, Ultrasonic drill and handheld X-ray diffraction (XRD). We present science results from the analog research and show that these instruments can be used to investigate in situ the geological context and mineralogical variations of a deep subsurface environment, and thus habitability, from millimetre to metre scales. We also show that these instruments are complementary. For example, the identification of primary evaporite minerals such as NaCl and KCl, which are difficult to detect by portable Raman spectrometers, can be accomplished with XRD. By contrast, Raman is highly effective at locating and detecting mineral inclusions in primary evaporite minerals. MINAR demonstrates the effective use of a deep subsurface environment for planetary instrument development, understanding the habitability of extreme deep subsurface environments on Earth and other planetary bodies, and advancing the use of space technology in economic mining.
Impetigo is common in remote Indigenous children of northern Australia, with the primary driver in this context being Streptococcus pyogenes [or group A Streptococcus (GAS)]. To reduce the high burden of impetigo, the transmission dynamics of GAS must be more clearly elucidated. We performed whole genome sequencing on 31 GAS isolates collected in a single community from children in 11 households with ⩾2 GAS-infected children. We aimed to determine whether transmission was occurring principally within households or across the community. The 31 isolates were represented by nine multilocus sequence types and isolates within each sequence type differed from one another by only 0–3 single nucleotide polymorphisms. There was evidence of extensive transmission both within households and across the community. Our findings suggest that strategies to reduce the burden of impetigo in this setting will need to extend beyond individual households, and incorporate multi-faceted, community-wide approaches.
This study identified factors that influenced physical activity (PA) participation among older adults from rural settings in Nova Scotia Canada and explored how the rural context may influence PA participation and promotion. Data were collected via individual semistructured interviews with 20 older adults (Mage = 77.5 years) from rural areas of Cape Breton and subjected to thematic analysis procedures (Braun & Clarke, 2006). Four themes representing factors that influence the prioritization of PA were identified: (1) historical context of activity, work, and productivity; (2) already busy with day-to-day activities; (3) being/staying on the go; and (4) cautionary approach. These findings suggest that PA promotion should be contextually salient, and highlight the need for a shared understanding between rural older adults and PA promoters regarding what constitutes being “physically active”. Effective promotion of PA among rural older adults may require a shift away from contemporary methods of PA promotion.
Although the incidence of invasive group A streptococcal disease in northern Australia is very high, little is known of the regional epidemiology and molecular characteristics. We conducted a case series of Northern Territory residents reported between 2011 and 2013 with Streptococcus pyogenes isolates from a normally sterile site. Of the 128 reported episodes, the incidence was disproportionately high in the Indigenous population at 69·7/100 000 compared to 8·8/100 000 in the non-Indigenous population. Novel to the Northern Territory is the extremely high incidence in haemodialysis patients of 2205·9/100 000 population; and for whom targeted infection control measures could prevent transmission. The incidences in the tropical north and semi-arid Central Australian regions were similar. Case fatality was 8% (10/128) and streptococcal toxic shock syndrome occurred in 14 (11%) episodes. Molecular typing of 82 isolates identified 28 emm types, of which 63 (77%) were represented by four emm clusters. Typing confirmed transmission between infant twins. While the diverse range of emm types presents a challenge for effective coverage by vaccine formulations, the limited number of emm clusters raises optimism should cluster-specific cross-protection prove efficacious. Further studies are required to determine effectiveness of chemoprophylaxis for contacts and to inform public health response.
Southern California grasslands have largely been type-converted to dominance by exotic annual grasses, leading to displacement of many native grass and forb species. Crimson fountaingrass, Pennisetum setaceum, an exotic perennial C4 species and a relatively new invader to California, is expanding to areas currently occupied by purple needlegrass, Stipa pulchra, a C3 native. We predicted that fountaingrass seedlings might withstand cool season competition in California's Mediterranean-type climate and establish in Stipa pulchra grasslands due to less competition during the warm, dry summer season, and that interactions might be influenced by density. A field experiment was conducted to examine competitive interactions of the two species from the cool winter season to the warm summer season. As predicted, Stipa produced greater aboveground biomass in the cool season and showed strong intraspecific competition, as well as interspecific suppression of Pennisetum growth, whereas Pennisetum showed no suppression of Stipa. In the warm season, Stipa showed relatively less suppression of Pennisetum, erasing significant differences, and Pennisetum showed increased growth. Results of this study show that C3Stipa can suppress initial growth of C4Pennisetum in the cool season, but in warmer months, Pennisetum can overcome this initial suppression at both low and high densities, even within a Mediterranean-type climate with little to no summer rainfall. Thus, in southern California, temporal niche partitioning due to photosynthetic pathway in these two species can allow Pennisetum invasion. Given the similarity in life history and growth form of Stipa and Pennisetum, few options exist for controlling Pennisetum in habitats where Stipa occurs. In these cases, restoration plantings of desirable species are essential in order to reestablish competitive vegetation that will be more resistant to invasion.
A surprising number of the documents of 1215 survive in Anglo-Norman translations. These include the Charter itself, the writ of 27 June directed to the sheriffs and twelve elected knights of each county authorizing them to distrain on those who refused the oath to the Twenty-Five, and versions of the charters of liberties of Henry I, Stephen and Henry II. The first two are included in the cartulary of the leper Hospital of St. Giles at Pont- Audemer, Normandy (Rouen, Bibliothèque Municipale, MS y 200). The charters of liberties constitute Harleian MS 458 in the British Library.
The first two were published under the title of ‘A vernacular-French text of Magna Carta, 1215’. It is now clear that they are in fact in Anglo- Norman. The writ, unlike the enrolled version on the Patent roll, was addressed to the sheriff of Hampshire. It is therefore reasonable to suppose that this vernacular version of the charter was intended for proclamation in the county court of Hampshire in 1215. If so, it lies at or near the origin of the public proclamation of the charters and other documents in both French and English, which was certainly being practised by the 1250s. That leaves some obvious questions – were there other translations? Where and how were they made? To these the Harleian MS suggests some possible answers.
Harleian MS 458 is only a bifolium. Liebermann used it in his work on the text of the charter of Henry I, but he did not appreciate its importance and misdated the translations on the second folio. It has escaped attention since. It is written in a careful, indeed handsome, business hand, or probably more than one. These are not scrappy notes or hasty transcripts but texts clearly and spaciously arranged. Nothing is known of its history except that it passed through the hands of the antiquary Peter Le Neve in the late seventeenth, or early eighteenth, century. It may be significant that Le Neve did much work on the records in the Rolls Chapel.
(1) Agreement between King John and Robert fitz Walter, Marshal of the Army of God, and others concerning the custody of London (P.R.O. Chancery Miscellanea, 34/1/1)(see pl. 10).
Hec est conventio facta inter dominum Johannem regem Anglie, ex una parte, et Robertum filium Walteri, marescallum exercitus Dei et sancte ecclesie in Anglia, et Ricardum comitem de Clara, Gaufridum comitem Essex' [et] Glouc', Rogerum Bigot comitem Northfolc' et Suthfolc', Saherum comitem Wint', Robertum comitem Oxon', Henricum comitem Hereford', et barones subscriptos, scilicet Willielmum Mariscallum juniorem, Eustachium de Vescy, Willielmum de Mobray, Johannem filium Roberti, Rogerum de Monte Begonis, Willielmum de Lanvalai, et alios comites et barones et liberos homines totius regni, ex altera parte, videlicet quod ipsi comites et barones et alii prescripti tenebunt civitatem London' de ballio domini regis, salvis interim domino regi firmis, redditibus et claris debitis suis, usque ad assumptionem beate Marie anno regni ipsius regis xviimo, et dominus Cantuar' tenebit similiter de ballio domini regis turrim London' usque ad predictum terminum, salvis civitati London' libertatibus suis et liberis consuetudinibus suis, et salvo cuilibet jure suo in custodia turris London', et ita quod interim non ponat dominus rex munitionem vel vires alias in civitate predicta vel in turri London'. Fiant etiam infra predictum terminum sacramenta per totam Angliam viginti quinque baronibus sicut continetur in carta de libertatibus et securitate regno concessis vel attornatis viginti quinque baronum sicut continetur in literis de duodecim militibus eligendis ad delendum malas consuetudines de forestis et aliis. Et preterea infra eundem terminum omnia que comites et barones et alii liberi hominess petunt a domino rege que ipse dixerit esse reddenda vel que per xxv barones aut per majorem partem eorum judicata fuerint esse reddenda reddantur secundum formam predicte carte. Et si hec facta fuerint vel per dominum regem non steterit quo minus ista facta fuerint infra predictum terminum tunc civitas et turris London' ad eundem terminum statim reddantur domino regi salvis predicte civitati libertatibus suis et liberis consuetudinibus suis sicut prescriptum est. Et si hec facta non fuerint et per dominum regem steterit quod ista non fiant infra predictum terminum barones tenebunt civitatem predictam et dominus archiepiscopus turrim London' donec predicta compleantur. Et interim omnes ex utraque parte recuperabunt castra, terras et villas quas habuerunt in initio guerre orte inter dominum regem et barones.
Dr Antonia Gransden and Dr R. M. Thomson are more inclined than I am to accept the evidence of Roger of Wendover that a great baronial gathering occurred at Bury St Edmunds late in 1214 at which the barons swore on the high altar that they would fight, if necessary, in order to compel the king to confirm the charter of liberties of Henry I. We are all agreed that the difficulty arises from the abrupt termination of the Annales S. Edmundi in 1212; but it seems to me to carry speculation too far to suppose that the story of the meeting appeared in the lost continuation of the Annales or its source. Indeed Dr Thomson provides strong grounds for thinking that this was not the case, for the author of the later Cronica Buriensis used John of Wallingford, not the Bury annals, as the source for his account of the meeting. In Bury histories the story first appears in a condensed form in a chronicle of Bury composed by Bury monks at St Benet of Hulme in or after 1327.
The matter therefore depends on the evidence or lack of it, in the Electio Hugonis. Now the Electio mentions no such meeting, and, given its subjectmatter, it may reasonably be asked – why should it? Dr Gransden relies in some degree on this argument. However, both she and Dr Thomson go further by maintaining that the Electio does, in fact, contain veiled references to incipient rebellion which are consistent with Wendover's story.
Before examining these it is well to bear some dates in mind. First, John was at La Rochelle on 2 October and at Dartmouth on 15 October. He probably arrived in England about 7 October. Secondly, he visited Bury on 4 November, when he attempted to settle the disputed election. Thirdly, the most likely date for a baronial meeting would be 20 November, the feast of St Edmund, when there was a good excuse for an assembly at Bury; and indeed Wendover states that the barons gathered ‘as if for prayer’.