Comparison of clinical and angiographic prognostic risk scores in elderly patients presenting with acute coronary syndrome and referred for percutaneous coronary intervention.

BACKGROUND: Multiple risk prediction models have been validated in all-age patients presenting with acute coronary syndrome (ACS) and treated with percutaneous coronary intervention (PCI); however, they have not been validated specifically in the elderly. METHODS: We calculated the GRACE (Global Registry of Acute Coronary Events) score, the logistic EuroSCORE, the AMIS (Acute Myocardial Infarction Swiss registry) score, and the SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) score in a consecutive series of 114 patients ≥75 years presenting with ACS and treated with PCI within 24 hours of hospital admission. Patients were stratified according to score tertiles and analysed retrospectively by comparing the lower/mid tertiles as an aggregate group with the higher tertile group. The primary endpoint was 30-day mortality. Secondary endpoints were the composite of death and major adverse cardiovascular events (MACE) at 30 days, and 1-year MACE-free survival. Model discrimination ability was assessed using the area under receiver operating characteristic curve (AUC). RESULTS: Thirty-day mortality was higher in the upper tertile compared with the aggregate lower/mid tertiles according to the logistic EuroSCORE (42% vs 5%; odds ratio [OR] = 14, 95% confidence interval [CI] = 4-48; p <0.001; AUC = 0.79), the GRACE score (40% vs 4%; OR = 17, 95% CI = 4-64; p <0.001; AUC = 0.80), the AMIS score (40% vs 4%; OR = 16, 95% CI = 4-63; p <0.001; AUC = 0.80), and the SYNTAX score (37% vs 5%; OR = 11, 95% CI = 3-37; p <0.001; AUC = 0.77). CONCLUSIONS: In elderly patients presenting with ACS and referred to PCI within 24 hours of admission, the GRACE score, the EuroSCORE, the AMIS score, and the SYNTAX score predicted 30 day mortality. The predictive value of clinical scores was improved by using them in combination

GRB 081028 and its late-time afterglow re-brightening

‘The definitive version is available at www3.interscience.wiley.com '. Copyright Royal Astronomical SocietySwift captured for the first time a smoothly rising X-ray re-brightening of clear non-flaring origin after the steep decay in a long gamma-ray burst (GRB): GRB 081028. A rising phase is likely present in all GRBs but is usually hidden by the prompt tail emission and constitutes the first manifestation of what is later to give rise to the shallow decay phase. Contemporaneous optical observations reveal a rapid evolution of the injection frequency of a fast cooling synchrotron spectrum through the optical band, which disfavours the afterglow onset (start of the forward shock emission along our line of sight when the outflow is decelerated) as the origin of the observed re-brightening. We investigate alternative scenarios and find that the observations are consistent with the predictions for a narrow jet viewed off-axis. The high on-axis energy budget implied by this interpretation suggests different physical origins of the prompt and (late) afterglow emission. Strong spectral softening takes place from the prompt to the steep decay phase: we track the evolution of the spectral peak energy from the γ-rays to the X-rays and highlight the problems of the high latitude and adiabatic cooling interpretations. Notably, a softening of both the high and low spectral slopes with time is also observed. We discuss the low on-axis radiative efficiency of GRB 081028 comparing its properties against a sample of Swift long GRBs with secure Eγ,iso measurements.Peer reviewe

The intrapreneurial state: Singapore's emergence in the smart and sustainable urban solutions field

The East Asian developmental state model and the Anglo-American entrepreneurial state model profile varied ways in which the state continues to intervene in economic development. These models are developed by different disciplines and against diverse contexts to capture extrasocietal state responses to neoliberalism and globalization but leave the intrasocietal preconditions for state evolution little explored. We elaborate the concept of state intrapreneurialism as one way of understanding the interrelationship between economic and state transformation – one ingredient of the intrasocietal preconditions underpinning the responses to extrasocietal changes emphasized in the post-developmental state literature. Drawing on the case of Singapore's emergence in the field of smart/sustainable urban solutions, the subsidiary contributions of this paper are to suggest intrapreneurship as a specific and enduring advantage within the developmental state model, especially when set against its limitations signalled in the post-developmental state literature

Lag-luminosity relation in gamma-ray burst X-ray flares: a direct link to the prompt emission

The temporal and spectral analysis of 9 bright X-ray flares out of a sample of 113 flares observed by Swift reveals that the flare phenomenology is strictly analogous to the prompt gamma-ray emission: high energy flare profiles rise faster, decay faster and peak before the low energy emission. However, flares and prompt pulses differ in one crucial aspect: flares evolve with time. As time proceeds flares become wider, with larger peak lag, lower luminosities and softer emission. The flare spectral peak energy E_{p,i} evolves to lower values following an exponential decay which tracks the decay of the flare flux. The two flares with best statistics show higher than expected isotropic energy E_{iso} and peak luminosity L_{p,iso} when compared to the E_{p,i}-E_{iso} and E_{p,i}-L_{iso} prompt correlations. E_{p,i} is found to correlate with L_{iso} within single flares, giving rise to a time resolved E_{p,i}(t)-L_{iso}(t). Like prompt pulses, flares define a lag-luminosity relation: L_{p,iso}^{0.3-10 keV} t_{lag}^{-0.95+/-0.23}. The lag-luminosity is proven to be a fundamental law extending 5 decades in time and 5 in energy. Moreover, this is direct evidence that GRB X-ray flares and prompt gamma-ray pulses are produced by the same mechanism. Finally we establish a flare-afterglow morphology connection: flares are preferentially detected superimposed to one-break or canonical X-ray afterglows.Comment: MNRAS accepte

Unveiling the origin of X-ray flares in Gamma-Ray Bursts

We present an updated catalog of 113 X-ray flares detected by Swift in the ~33% of the X-ray afterglows of Gamma-Ray Bursts (GRB). 43 flares have a measured redshift. For the first time the analysis is performed in 4 different X-ray energy bands, allowing us to constrain the evolution of the flare temporal properties with energy. We find that flares are narrower at higher energies: their width follows a power-law relation w~E^{-0.5} reminiscent of the prompt emission. Flares are asymmetric structures, with a decay time which is twice the rise time on average. Both time scales linearly evolve with time, giving rise to a constant rise-to-decay ratio: this implies that both time scales are stretched by the same factor. As a consequence, the flare width linearly evolves with time to larger values: this is a key point that clearly distinguishes the flare from the GRB prompt emission. The flare 0.3-10 keV peak luminosity decreases with time, following a power-law behaviour with large scatter: L_{pk}~ t_{pk}^{-2.7}. When multiple flares are present, a global softening trend is established: each flare is on average softer than the previous one. The 0.3-10 keV isotropic energy distribution is a log-normal peaked at 10^{51} erg, with a possible excess at low energies. The flare average spectral energy distribution (SED) is found to be a power-law with spectral energy index beta~1.1. These results confirmed that the flares are tightly linked to the prompt emission. However, after considering various models we conclude that no model is currently able to account for the entire set of observations.Comment: MNRAS submitte

Intramyocardial hemorrhage and microvascular obstruction after primary percutaneous coronary intervention

Reperfusion may cause intramyocardial hemorrhage (IMH) by extravasation of erythrocytes through severely damaged endothelial walls. The purpose of the study was to evaluate the clinical significance of IMH in relation to infarct size, microvascular obstruction (MVO) and function in patients after primary percutaneous intervention. Forty-five patients underwent cardiovascular MR imaging (CMR) 1 week and 4 months after primary stenting for a first acute myocardial infarction. T2-weighted spin-echo imaging (T2W) was used to assess infarct related edema and IMH, and delayed enhancement (DE) was used to assess infarct size and MVO. Cine CMR was used to assess left ventricular volumes and function at baseline and at 4 months follow-up. In 22 (49%) patients, IMH was detected as areas of attenuated signal in the core of the high signal intensity region on T2W images. Patients with IMH had larger infarcts, higher left ventricular volumes and lower ejection fraction. Contrast-to-noise ratio (CNR) between hyperintense periphery and the hypo-intense core of the T2W ischemic area correlated to peak CKMB, total infarct size and MVO size. Using univariable analysis, CNR predicted ejection fraction at baseline (β = −0.62, P = 0.003) and follow-up (β = −0.84, P < 0.001). However, after multivariable analysis, baseline ejection fraction and presence of MVO were the only parameters that predicted functional changes at follow-up. IMH was found in the majority of patients with MVO after reperfused myocardial infarction. It was closely related to markers of infarct size, MVO and function, but did not have prognostic significance beyond MVO

Anomalous X-Ray emission in GRB060904B: a Nickel line?

The detection of an extra component in GRB060904B X-ray spectra in addition to the standard single power-law behaviour has recently been reported in the literature. This component can be fit with different models; in particular the addition of a spectral line provides the best representation.In this paper we investigate the physical properties that the surrounding medium must have in order to produce a spectral feature that can explain the detected emission. We analyse and discuss how and if the detected spectral excess fits in different theoretical models developed to explain the nature of line emission during the afterglow phase of Gamma-Ray Bursts (GRBs). Trasmission and reflection models have been considered. Given the high value (>>1) of the Thomson optical depth, the emission is likely to arise in a reflection scenario. Within reflection models, the external reflection geometry fails to predict the observed luminosity. On the contrary, the detected feature can be explained in a funnel scenario with typical opening angle theta of 5 degrees, Nickel mass of the order of 0.1 M_o and T=10^6 K. For theta=20 degrees, assuming the reprocessing material to be the SN shell, the detected emission implies a Nickel mass of 0.4 M_o at T=10^7 K and a metallicity 10 times the solar value. If the giant X-ray flare that dominates the early XRT light curve is identified with the ionizing source, the SN expansion began 3000 s before the GRB event.Comment: Accepted by A&