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Introduction: ex-specific diagnostic cutoffs may improve the test characteristics of high-sensitivity troponin assays for the diagnosis of myocardial infarction. Sex-specific cutoffs for ruling in MI improve the sensitivity of the assay for MI among women, and improve the specificity of diagnosis among men. We hypothesized that the use of sex-specific high-sensitivity Troponin T (hsTnT) cutoffs for ruling out MI at the time of ED arrival would improve the classification efficiency of the assay by enabling more patients to have MI ruled out at the time of ED arrival while maintaining diagnostic sensitivity. The objective of this study was to quantify the test characteristics of sex-specific cutoffs of an hsTnT assay for acute myocardial infarction (AMI) when performed at ED arrival in patients with chest pain. Methods: This retrospective study included consecutive ED patients with suspected cardiac chest pain evaluated in four urban EDs were, excluding those with ST-elevation AMI, cardiac arrest or abnormal kidney function. The primary outcomes was AMI at 7 days. Secondary outcomes included major adverse cardiac events (MACE: all-cause mortality, AMI and revascularization) and the individual MACE components. We quantified test characteristics (sensitivity, negative predictive value, likelihood ratios and proportion of patients ruled out) for multiple combinations of sex-specific rule-out cutoffs. We calculated net reclassification improvement compared to universal rule-out cutoffs of 5ng/L (the assays limit of detection) and 6ng/L (the FDA-approved limit of quantitation for US laboratories). Results: 7130 patients, including 3931 men and 3199 women, were included. The 7-day incidence of AMI was 7.38% among men and 3.78% among women. Universal cutoffs of 5 and 6 ng/L ruled out AMI with 99.7% sensitivity in 33.6 and 42.2% of patients. The best-performing combination of sex-specific cutoffs (8g/L for men and 6ng/L for men) ruled out AMI with 98.7% sensitivity in 51.9% of patients. Conclusion: Sex-specific hsTnT cutoffs for ruling out AMI at ED arrival may achieve substantial improvement in classification performance, enabling more patients to be ruled out at ED arrival, while maintaining acceptable diagnostic sensitivity for AMI. Universal and sex-specific rule-out cutoffs differ by only small changes in hsTnT concentration. Therefore, these findings should be confirmed in other datasets.
Introduction: Patients with chronic kidney disease (CKD) are at high risk of cardiovascular events, and have worse outcomes following acute myocardial infarction (AMI). Cardiac troponin is often elevated in CKD, making the diagnosis of AMI challenging in this population. We sought to quantify test characteristics for AMI of a high-sensitivity troponin T (hsTnT) assay performed at emergency department (ED) arrival in CKD patients with chest pain, and to derive rule-out cutoffs specific to patient subgroups stratified by estimated glomerular filtration rate (eGFR). We also quantified the sensitivity and classification performance of the assays limit of detection (5 ng/L) and the FDA-approved limit of quantitation (6 ng/L) for ruling out AMI at ED arrival. Methods: Consecutive patients in four urban EDs from the 2013 calendar year with suspected cardiac chest pain who had a Roche Elecsys hsTnT assay performed on arrival were included f. This analysis was restricted to patients with an eGFR< 60 ml/min/1.73m2. The primary outcome was 7-day AMI. Secondary outcomes included major adverse cardiac events (death, AMI and revascularization). Test characteristics were calculated and ROC curves were generated for eGFR subgroups. Results: 1416 patients were included. 7-day AMI incidence was 10.1%. 73% of patients had an initial hsTnT concentration greater than the assays 99th percentile (14 ng/L). TCurrently accepted cutoffs to rule out MI at ED arrival ( 5 ng/L and 6 ng/L) had 100% sensitivity for AMI, but no patients with an eGFR less than 30 ml/min/1.73M had hsTnT concentrations below these thresholds. We derived eGFR-adjusted cutoffs to rule out MI with sensitivity >98% at ED arrival, which were able to rule out 6-42% of patients, depending on eGFR category. The proportion of patients able to be accurately ruled-in with a single hsTnT assay was substantially lower among patients with an eGFR <30 ml/min/1.73m2 (6-20% vs 25-43%). We also derived eGFR-adjusted cutoffs to rule-in AMI with specificity >90%, which accurately ruled-in up to 18% of patients. Conclusion: Cutoffs achieving acceptable diagnostic performance for AMI using single hsTnT sampling on ED arrival may have limited clinical utility, particularly among patients with very low eGFR. The ideal diagnostic strategy for AMI in patients with CKD likely involves serial high-sensitivity troponin testing with diagnostic thresholds customized to different eGFR categories.
Introduction: Chest pain and symptoms of acute coronary syndrome are responsible for a large proportion of ED visits and acute hospitalizations. However, only about 15% of patients presenting to the ED with high-risk symptoms do, in fact, have an acute coronary syndrome. The objective of this study is to derive a 2-hour high-sensitivity Troponin T (hsTnT) testing algorithm with outcome based-cutoffs to rapidly rule out acute myocardial infarction (AMI) in a large proportion of ED chest pain patients. Methods: Patients included consecutive ED patients with a chief complaint of cardiac chest pain who had an hsTnT assay performed at ED arrival and 2 hours after ED arrival. Administrative databases were queried to identify troponin results and major adverse cardiac outcomes (MACE) including death, MI, and revascularization. Test characteristics of iterative combinations of initial troponin level and absolute change in troponin level were quantified in order to identify the testing algorithm that identified the greatest proportion of patients eligible for early discharge while maintaining a target sensitivity of 98.5% for the primary outcome of 7-day AMI. Results: 755 eligible patients had hsTnT assays performed at ED arrival and at 2 hours. 91 patients (12.1%) had a 7-day AMI while 108 (14.0%) had 7-day MACE. An initial hsTnT level of less than 14 ng/L, in combination with a 2-hour absolute change of less than 10ng/L had a sensitivity of 98.9% (95% CI 94.0,99.8) and an NPV of 99.8% (95% CI 98.7, 100.0) for 7-day AMI. This identified 58.5% of all patients as being suitable for early discharge. Sensitivity and NPV for 7-day MACE were 90.0% (95% CI 83.3, 94.2) and 97.3% (95% CI 95.3,98.4) respectively. Sex-specific differences in test characteristics were not clinically important. Rule-in hsTnT cutoffs were also evaluated, with specificities ranging from 85-95%, although cutoffs with higher specificity had less ability to rapidly rule-in AMI, leaving more patients with indeterminate results after 2 hours. Conclusion: A hsTnT algorithm can safely and accurately rule out AMI in 58.5% of ED chest pain patients within 2 hours of ED arrival. The lower sensitivity of this algorithm for MACE compared to AMI speaks to the importance of clinical assessment and ECG findings in identifying patients at risk for acute coronary syndromes.
There is growing evidence that many offspring of parents with bipolar disorder (BD) will develop moderate to severe forms of psychopathology during childhood and adolescence, including thought problems. The purpose of this study was to evaluate the developmental progression of thought problems within the context of a family risk study. Repeated assessments of thought problems, spanning approximately 15 years, were conducted in offspring (N = 192 from 98 families) of parents diagnosed with BD (O-BD), unipolar depression (O-UNI), or no significant psychiatric or medical problems (O-WELL). Survival analysis showed that the O-BD group had the greatest estimated probability of developing thought problems over time, followed by O-UNI, and then O-WELL and O-BD exhibiting higher levels of persistence than O-WELL. Parent-reported thought problems in childhood and adolescence predicted a range of problems in young adulthood. Disturbances in reality testing and other atypical behaviors are likely to disrupt progression through important developmental periods and to associate with poor outcomes. These findings are likely relevant to preventing the occurrence or progression of problems in offspring of bipolar parents. The study of thought problems across development represents an important area of continued research in children at risk for development of affective disorders.
In this study, slurry formulations in the presence of self-assembled surfactant structures were investigated for Ge/SiO2 CMP applications in the absence and presence of oxidizers. Both anionic (sodium dodecyl sulfate-SDS) and cationic (cetyl trimethyl ammonium bromide-C12TAB) micelles were used in the slurry formulations as a function of pH and oxidizer concentration. CMP performances of Ge and SiO2 wafers were evaluated in terms of material removal rates, selectivity and surface quality. The material removal rate responses were also assessed through AFM wear rate tests to obtain a faster response for preliminary analyses. The surfactant adsorption characteristics were studied through surface wettability responses of the Ge and SiO2 wafers through contact angle measurements. It was observed that the self-assembled surfactant structures can help obtain selectivity on the silica/germanium system at low concentrations of the oxidizer in the slurry.
Persistent katabatic winds form widely distributed localized areas of near-zero net surface accumulation on the East Antarctic ice sheet (EAIS) plateau. These areas have been called 'glaze' surfaces due to their polished appearance. They are typically 2-200 km2 in area and are found on leeward slopes of ice-sheet undulations and megadunes. Adjacent, leeward high-accumulation regions (isolated dunes) are generally smaller and do not compensate for the local low in surface mass balance (SMB). We use a combination of satellite remote sensing and field-gathered datasets to map the extent of wind glaze in the EAIS above 1500 m elevation. Mapping criteria are derived from distinctive surface and subsurface characteristics of glaze areas resulting from many years of intense annual temperature cycling without significant burial. Our results show that 11.2 ± 1.7%, or 950 ± 143 × 103km2, of the EAIS above 1500 m is wind glaze. Studies of SMB interpolate values across glaze regions, leading to overestimates of net mass input. Using our derived wind-glaze extent, we estimate this excess in three recent models of Antarctic SMB at 46-82 Gt. The lowest-input model appears to best match the mean in regions of extensive wind glaze.
Input from molecular phylogenetics in the past five years has substantially altered concepts of systematic relationships among liverworts. While these studies have confirmed the monophyly of phylum Marchantiophyta, they have demonstrated that many previously recognised ranks within the hierarchy are unnatural and in need of modification. Changes in the ranks of suborder and above have been proposed by various workers, but modifications in the circumscription of genera and families are still required. A comprehensive, phylogenetic classification scheme that integrates morphological data with molecular hypotheses is presented. The scheme includes diagnoses and publication citations for all names above the rank of genus. All currently recognised genera are listed alphabetically in their respective families; subfamilies are not indicated. Major modifications and novel alignments of taxa are thoroughly discussed, with pertinent references provided. Jungermanniaceae is redefined and Solenostomataceae fam. nov. is formally described to accommodate some of the genera excluded from it.
Mannia controversa (Meyl.) Schill comb. nov. (Marchantiidae, Aytoniaceae), a long-forgotten European taxon, is fully redescribed and a lectotype selected. It is reported from its original localities in the Swiss Alps and new sites in the Austrian and French Alps. A series of specimens from eastern Asia are closely related and are described as Mannia controversa subsp. asiatica Schill & D.G.Long. For the species, differences with other Mannia species are summarised and for its two subspecies, descriptions, illustrations (including SEM images) and a key are provided along with notes on ecology and distribution maps.
Nano-catalysts, Au nano-particles on TiO2 (anatase), were studied by means of quantitative scanning transmission electron microcopy (Q-STEM) and high-resolution transmission electron microcopy (HRTEM). All the Au nano-catalysts were produced from an Au13 precursor, Au13[PPh3]4[S(CH2)11CH3]4, TiO2 supports, with three treatments: (1) thermal heating in the air at 400°C for 2 hours, (2) exposure to ozone (O3) at room temperature, and (3) exposure to atomic oxygen (AO, or O) with a AO dose of 7.3 ×1018 atom/cm2 at room temperature. Both reactive oxygen species O3 and AO produced significantly small sizes of Au particles as compared to those from the heating treatment in the air (2.7 ± 0.6 nm, 324 b 264 atoms). Ozone produced the smallest (1.2 ± 0.5 nm, 40 ± 49 atoms), whereas AO produced smaller (2.1 ± 0.7 nm, 72 ± 98 atoms), with a broad size distribution and a variety of shapes. HRTEM studies on the AO treated Au/TiO2 samples found that there could exist relationship between the particles size and their shapes which also affected by the interaction with TiO2 supports. The support effect of TiO2 to the shapes of Au particles was also studied.
Recent studies on molecular phylogeny of complex thalloid liverworts (Marchantiopsida) have revealed the need to recognize four new higher taxa: Family Neohodgsoniaceae, Order Neohodgsoniales, Order Lunulariales and Family Dumortieraceae. These are formally described along with notes on their differences from other complex thalloid liverworts.