Risk stratification in non-ST elevation acute coronary syndromes: risk scores, biomarkers and clinical judgment

Undifferentiated chest pain is one of the most common reasons for emergency department attendance and admission to hospitals. Non-ST elevation acute coronary syndrome (NSTE-ACS) is an important cause of chest pain, and accurate diagnosis and risk stratification in the emergency department must be a clinical priority. In the future, the incidence of NSTE-ACS will rise further as higher sensitivity troponin assays are implemented in clinical practice. In this article, we review contemporary approaches for the diagnosis and risk stratification of NSTE-ACS during emergency care. We consider the limitations of current practices and potential improvements. Clinical guidelines recommend an early invasive strategy in higher risk NSTE-ACS. The Global Registry of Acute Coronary Events (GRACE) risk score is a validated risk stratification tool which has incremental prognostic value for risk stratification compared with clinical assessment or troponin testing alone. In emergency medicine, there has been a limited adoption of the GRACE score in some countries (e.g. United Kingdom), in part related to a delay in obtaining timely blood biochemistry results. Age makes an exponential contribution to the GRACE score, and on an individual patient basis, the risk of younger patients with a flow-limiting culprit coronary artery lesion may be underestimated. The future incorporation of novel cardiac biomarkers into this diagnostic pathway may allow for earlier treatment stratification. The cost-effectiveness of the new diagnostic pathways based on high-sensitivity troponin and copeptin must also be established. Finally, diagnostic tests and risk scores may optimize patient care but they cannot replace patient-focused good clinical judgment

Sin and human responsibility in the theology of Emil Brunner

Brunner's theology is one of reaction and reformulation; reaction against the "objectivism" of Orthodoxy and Roman Catholicism, and against the "subjectivism" of liberal theology, and a reformulation of the basic tenets of the Christian faith in accordance with the sola gratia perspective of the Reformers. The reformulation contrasts the competing tendencies in philosophy, psychology and ethics, and relates these to the basic contradiction of human life, which the Christian faith calls 'sin', with the aid of Kantian criticism, and particularly Kantian moral theory, the Kierkegaardian dialectic of time and eternity, and the I-Thou framework developed by Ebner and Buber. Within this comprehensive formulation, our concern is the question of sin and human responsibility.Theologically, the issue is the seriousness of sin, and has been answered traditionally by contrasting man's creation in the image of God with the loss of that image through sin. Brunner's contention that Scripture presents two concepts of the image is most plausible, but his designation of these as a formal and a material concept of the image seems to set the distinction within man himself, whereas the Scriptural distinction seems to be between an Old Testament image which is predicated of man and a New Testament image which is Christ. We must also question his contention that Irenaeus distinguished between imago and similitudo in a manner similar to the medieval natural-supernatural distinction, but his summation of the Reformers' predicament, that their equation of the image with the justitia originalis and corresponding doctrine of total depravity renders their concept of a 'relic' of the image illegitimate, is essentially plausible. Brunner's solution to this predicament is not greatly clarified in the controversy with Barth, although Barth's subsequent charge, that Brunner teaches a neutral freedom, is instructive. Brunner's insistence on a concept of an analogia entis involving an analogy of proportionality, likeness in basic unlikeness, is understandable, but his relational interpretation of this suggests that his distinction between a formal and a material sense of the image is facilitated by an ambiguity in the term 'responsibility'.The term 'responsibility' seems to have at least three basic meanings in Brunner's theology - responsiveness, accountability, and ability to respond. Behind this is the more basic question of the distinction between moral and religious responsibility. His enthusiasm for Kant's development of the concept suggests that he overlooks the basically rational nature of the Kantian Imperative, and his content- -ion that Kant was torn between autonomy and theonomy suggests that he minimises the rational perspective from which Kant viewed Christianity. Kierkegaard's teleological suspension of the ethical, with its inseparability of command and commanded, reveals the difficulty in the formal Kantian Imperative which Brunner applauds. Further, Brunner's contention that Kant's concept of 'radical evil' is rationally discerned, and his appreciation for Schelling's treatment of evil, cast doubt on the seriousness of his affirmation of the irrationality of sin, and also illuminate the ambiguity in the moral and religious uses of the term 'responsibility' in his writings. There seem to be two strands in Brunner's presentation - a basic allegiance to the Reformers, and a certain sympathy with moral idealism.The conflict is climaxed in Brunner's treatment of the Fall and Original Sin. His rejection of a literal interpretation of Genesis III is understandable, but his contention that there is no real conflict here with modem science indicates an oversimplification of the problem. His rejection of a causal explanation of sin is understandable, but his rejection of every temporal explanation suggests a confusion between causal and temporal. His late admission that he taught a Platonic doctrine of the Fall suggests that he never really came to grips with the basic problems of the doctrine. His concern has been with the fallenness of man, in which he attempts to correct the one-sidedness of the Augustinian doctrine with an emphasis on responsibility. Here the conflict between the two strands in Brunner's theology is pronounced. His reversal of Kierkegaard's formula for the relation between individuals and humanity, whereby the special term 'Individual' is subordinated to an individualistic concept of 'each of us', conflicts with his concern for solidarity and his appreciation for the I-Thou framework, but agrees with his emphasis on responsibility and his refusal to consider a temporal origin of sin. Ultimately it is the universality of sin, and not solidarity in sin, which prevails in Brunner's theology. As this fails to provide an adequate statement of the totality of sin in terms of the race, so his emphasis on sin as 'act' fails to give adequate account of the totality of sin in terms of the individual. The concern to emphasise responsibility for sin suggests that this is a total responsibility which is predicated of men in general, and thus indicates a violation of the Reformation perspective.In his basic allegiance to the Reformation perspective, Brunner's development of the sola gratia principle involves an opposition to synergism in Orthodoxy, Roman Catholicism and liberal theology, and to passivism in the Reformers themselves. His defence of the personal over against the rational, in terms of the I-Thou framework, raises questions as to the significance of the 'It'dimension of life and the nature of the relation between I and Thou. The two questions are answered in Brunner's presentation of the respective roles of the imperative and the indicative in the relation. The former reveals a basic divergence between Brunner and Luther on 'Law' in that Brunner divests Luther's Law of all content and reintroduces it as the formal Imperative, thus indicating that Law is an 'It' which has no integral place in the I-Thou framework. The indicative of the once-for-all act of God in Christ is equally embarrassing to the I-Thou, although it represents a constant emphasis in Brunner's theology. Luther's concern for the man who stands between the demand of the Law and the comfort of the Gospel becomes, in Brunner, the concern to relate this dialectic to the self-understanding of natural man. He accomplishes this with the relatively modern word 'responsibility' which can refer both to man as an independent moral agent and to man's ultimate obligation to God. In so far as man is addressed as a moral agent, and called to account prior to the proclamation of grace, the Reformation perspective is violated. It is strange that Brunner has not applied his recognition of the profound gulf separating modern man from former ages to this relatively modern concept of 'responsibility'

Farming profitably in a changing climate: a risk management approach

Climate science has made enormous progress over the last two decades in understanding the nature of earth's climate and the changes that are taking place. Under climate change projections, we can say with some confidence that the Australian climate will continue to become hotter, and temperature-related extreme events are likely to increase in frequency. However, we cannot yet project with any reasonable level of confidence changes to rainfall and the occurrence of drought. So although there is strong evidence for the reality of climate change, there is still considerable uncertainty associated with projections of precisely how climate change will unfold in the future, particularly at regional and local scales where most farming management decisions are made. Adapting to such an uncertain future demands a flexible approach based on assessing, analysing and responding to the risks posed by a changing climate. This paper examines a risk management approach to farming in a variable and changing climate, based on experience gained in the insurance industry which is one of the first major industries to be impacted by climate change losses. Governments, businesses and individuals must consider the implications of a variable and changing climate as a normal part of decision-making based on risk, just as they would for other risks, such as market price and fuel price movements, labour costs etc. The paper also discusses briefly how advances in information technology have enabled information to be accessed and widely distributed, and showcases four best practice spatial IT website tools developed by the BRS to assist farmers and policy makers to manage risk - the National Agricultural Monitoring System (NAMS), the Meat and Livestock Australia (MLA) Rainfall to Pasture Growth Outlook Tool, the Multi-Criteria Analysis Shell (MCAS-S), and the Rainfall Reliability Wizard. There are also several tools under current development in BRS which continue with this theme. These are Water 2010 - National Water Balance and Information for Policy and Planning, the Climate Change Wizard and Climate Change Impacted Data Sets.Climate change, risk management, Environmental Economics and Policy, Risk and Uncertainty,

Modelling and Refinement in CODA

This paper provides an overview of the CODA framework for modelling and refinement of component-based embedded systems. CODA is an extension of Event-B and UML-B and is supported by a plug-in for the Rodin toolset. CODA augments Event-B with constructs for component-based modelling including components, communications ports, port connectors, timed communications and timing triggers. Component behaviour is specified through a combination of UML-B state machines and Event-B. CODA communications and timing are given an Event-B semantics through translation rules. Refinement is based on Event-B refinement and allows layered construction of CODA models in a consistent way.Comment: In Proceedings Refine 2013, arXiv:1305.563

Temperature dependent stiffness and visco-elastic behaviour of lipid coated microbubbles using atomic force microscopy.

yesThe compression stiffness of a phospholipid microbubble was determined using force-spectroscopy as a function of temperature. The stiffness was found to decrease by approximately a factor of three from 0.08 N m 1, at 10 C, down to 0.03 N m 1 at 37 C. This temperature dependence indicates that the surface tension of lipid coating is the dominant contribution to the microbubble stiffness. The timedependent material properties, e.g. creep, increased non-linearly with temperature, showing a factor of two increase in creep-displacement, from 24 nm, at 10 C, to 50 nm, at 37 C. The standard linear solid model was used to extract the visco-elastic parameters and their determination at different temperatures allowed the first determination of the activation energy for creep, for a microbubble, to be determined.EPSR

From single steps to mass migration: the problem of scale in the movement ecology of the Serengeti wildebeest

A central question in ecology is how to link processes that occur over different scales. The daily interactions of individual organisms ultimately determine community dynamics, population fluctuations and the functioning of entire ecosystems. Observations of these multiscale ecological processes are constrained by various technological, biological or logistical issues, and there are often vast discrepancies between the scale at which observation is possible and the scale of the question of interest. Animal movement is characterized by processes that act over multiple spatial and temporal scales. Second-by-second decisions accumulate to produce annual movement patterns. Individuals influence, and are influenced by, collective movement decisions, which then govern the spatial distribution of populations and the connectivity of meta-populations. While the field of movement ecology is experiencing unprecedented growth in the availability of movement data, there remain challenges in integrating observations with questions of ecological interest. In this article, we present the major challenges of addressing these issues within the context of the Serengeti wildebeest migration, a keystone ecological phenomena that crosses multiple scales of space, time and biological complexity. This article is part of the theme issue ’Collective movement ecology’

Can a native rodent species limit the invasive potential of a non-native rodent species in tropical agroforest habitats?

BACKGROUND Little is known about native and non-native rodent species interactions in complex tropical agro-ecosystems. We hypothesised that the native non-pest rodent Rattus everetti may be competitively dominant over the invasive pest rodent Rattus tanezumi within agroforests. We tested this experimentally by using pulse removal for three consecutive months to reduce populations of R. everetti in agroforest habitat and assessed over 6-months the response of R. tanezumi and other rodent species. RESULTS Following removal, R. everetti individuals rapidly immigrated into removal sites. At the end of the study period, R. tanezumi were larger and there was a significant shift in their microhabitat use with respect to the use of ground vegetation cover following the perturbation of R. everetti. Irrespective of treatment, R. tanezumi selected microhabitat with less tree canopy cover, indicative of severely disturbed habitat, whereas, R. everetti selected microhabitat with a dense canopy. CONCLUSION Our results suggest that sustained habitat disturbance in agroforests favours R. tanezumi, whilst the regeneration of agroforests towards a more natural state would favour native species and may reduce pest pressure in adjacent crops. In addition, the rapid recolonisation of R. everetti suggests this species would be able to recover from non-target impacts of short-term rodent pest control