Influence of case definition on incidence and outcome of acute coronary syndromes

© 2016, BMJ Publishing Group. All rights reserved. Objective: Acute coronary syndromes (ACS) are common, but their incidence and outcome might depend greatly on how data are collected. We compared case ascertainment rates for ACS and myocardial infarction (MI) in a single institution using several different strategies. Methods: The Hull and East Yorkshire Hospitals serve a population of ∼560 000. Patients admitted with ACS to cardiology or general medical wards were identified prospectively by trained nurses during 2005. Patients with a death or discharge code of MI were also identified by the hospital information department and, independently, from Myocardial Infarction National Audit Project (MINAP) records. The hospital laboratory identified all patients with an elevated serum troponin-T (TnT) by contemporary criteria ( > 0.03 μg/L in 2005). Results: The prospective survey identified 1731 admissions (1439 patients) with ACS, including 764 admissions (704 patients) with MIs. The hospital information department reported only 552 admissions (544 patients) with MI and only 206 admissions (203 patients) were reported to the MINAP. Using all 3 strategies, 934 admissions (873 patients) for MI were identified, for which TnT was > 1 μg/L in 443, 0.04-1.0 μg/L in 435, =0.03 μg/L in 19 and not recorded in 37. A further 823 patients had TnT > 0.03 μg/L, but did not have ACS ascertained by any survey method. Of the 873 patients with MI, 146 (16.7%) died during admission and 218 (25.0%) by 1 year, but ranging from 9% for patients enrolled in the MINAP to 27% for those identified by the hospital information department. Conclusions: MINAP and hospital statistics grossly underestimated the incidence of MI managed by our hospital. The 1-year mortality was highly dependent on the method of ascertainment

Interplay between right ventricular function and cardiac resynchronization therapy : an analysis of the CARE-HF trial (cardiac resynchronization–heart failure)

Objectives: The aim of this study was to investigate the impact of cardiac resynchronization therapy (CRT) on right ventricular (RV) function and the influence of RV dysfunction on the echocardiographic and clinical response to CRT among patients enrolled in the CARE-HF (Cardiac Resynchronization-Heart Failure) trial. Background: Cardiac resynchronization therapy prolongs survival in appropriately selected patients with heart failure but the benefit might be diminished in patients with RV dysfunction. Methods: Of 813 patients enrolled in the CARE-HF study, 688 had tricuspid plane systolic excursion (TAPSE) measured at baseline, and 345 of these were assigned to CRT. Their median (interquartile range) age was 66 (58 to 71) years, left ventricular (LV) ejection fraction was 24% (21% to 28%), and TAPSE was 19 (16 to 22) mm. Baseline LV function and size and QRS duration were similar among TAPSE tertiles, but those in the worst tertile (TAPSE < 17.4 mm) were more likely to have ischemic heart disease. Results: Overall, CRT improved LV but not RV structure and function with little evidence of an interaction with TAPSE. During a median (interquartile range) follow-up of 748 (582 to 950) days, 213 deaths occurred. Patients with lower TAPSE had a higher mortality, regardless of assigned treatment (p < 0.001). Greater inter-ventricular mechanical delay, New York Heart Association functional class, mitral regurgitation, and N-terminal pro-B-type natriuretic peptide, lower TAPSE, and assignment to the control group were independently associated with higher mortality. Reduction in mortality with CRT was similar in each tertile of TAPSE. Conclusions: Right ventricular dysfunction is a powerful determinant of prognosis among candidates for CRT, regardless of treatment assigned, but did not diminish the prognostic benefits of CRT among patients enrolled in the CARE-HF trial. (Care-HF CArdiac Resynchronization in Heart Failure; NCT00170300) © 2013 American College of Cardiology Foundation

Development of a human model for the study of effects of hypoxia, exercise, and sildenafil on cardiac and vascular function in chronic heart failure

Background: Pulmonary hypertension is associated with poor outcome in patients with chronic heart failure (CHF) and may be a therapeutic target. Our aims were to develop a noninvasive model for studying pulmonary vasoreactivity in CHF and characterize sildenafil's acute cardiovascular effects. Methods and Results: In a crossover study, 18 patients with CHF participated 4 times [sildenafil (2 × 20 mg)/or placebo (double-blind) while breathing air or 15% oxygen] at rest and during exercise. Oxygen saturation (SaO2) and systemic vascular resistance were recorded. Left and right ventricular (RV) function and transtricuspid systolic pressure gradient (RVTG) were measured echocardiographically. At rest, hypoxia caused SaO2 (P = 0.001) to fall and RVTG to rise (5 ± 4 mm Hg; P = 0.001). Sildenafil reduced SaO2 (−1 ± 2%; P = 0.043), systemic vascular resistance (−87 ± 156 dyn·s−1·cm−2; P = 0.034), and RVTG (−2 ± 5 mm Hg; P = 0.05). Exercise caused cardiac output (2.1 ± 1.8 L/min; P &lt; 0.001) and RVTG (19 ± 11 mm Hg; P &lt; 0.0001) to rise. The reduction in RVTG with sildenafil was not attenuated by hypoxia. The rise in RVTG with exercise was not substantially reduced by sildenafil. Conclusions: Sildenafil reduces SaO2 at rest while breathing air, this was not exacerbated by hypoxia, suggesting increased ventilation–perfusion mismatching due to pulmonary vasodilation in poorly ventilated lung regions. Sildenafil reduces RVTG at rest and prevents increases caused by hypoxia but not by exercise. This study shows the usefulness of this model to evaluate new therapeutics in pulmonary hypertension

Developing a learning environment that encourages deep learning outcomes

In this paper we report on the development of an authentic learning environment, the tropical island of Lys, that we used to facilitate high quality student learning in a third year subject designed for environmental and ecological scientists (NRB572 ‘Terrestrial Ecosystems’). Lys provided the conceptual framework around which students engaged with web-based learning resources, lectures, practicals, paper-based resources (such as study guides and handouts), as well as a virtual tour of the island, and most importantly an integrated set of assessment tasks that obliged students to develop a critical understanding of fundamental ecosystem processes. Our students expressed conspicuous levels of satisfaction, enjoyment, interest and engagement from their learning experience together with significantly enhanced learning outcomes, which were both self- and formally identified. In this paper, we report on how we used several ‘principles’ of curriculum design so that others, irrespective of discipline, could use similar approaches to achieve similar learning outcomes with their students

Towards an understanding of the rapid decline of the cosmic star formation rate

We present a first analysis of deep 24 micron observations with the Spitzer Space Telescope of a sample of nearly 1500 galaxies in a thin redshift slice, 0.65<z<0.75. We combine the infrared data with redshifts, rest-frame luminosities, and colors from COMBO-17, and with morphologies from Hubble Space Telescope images collected by the GEMS and GOODS projects. To characterize the decline in star-formation rate (SFR) since z~0.7, we estimate the total thermal infrared (IR) luminosities, SFRs, and stellar masses for the galaxies in this sample. At z~0.7, nearly 40% of intermediate and high-mass galaxies (with stellar masses >2x10^10 solar masses) are undergoing a period of intense star formation above their past-averaged SFR. In contrast, less than 1% of equally-massive galaxies in the local universe have similarly intense star formation activity. Morphologically-undisturbed galaxies dominate the total infrared luminosity density and SFR density: at z~0.7, more than half of the intensely star-forming galaxies have spiral morphologies, whereas less than \~30% are strongly interacting. Thus, a decline in major-merger rate is not the underlying cause of the rapid decline in cosmic SFR since z~0.7. Physical properties that do not strongly affect galaxy morphology - for example, gas consumption and weak interactions with small satellite galaxies - appear to be responsible.Comment: To appear in the Astrophysical Journal 1 June 2005. 14 pages with 8 embedded figure

Spitzer view on the evolution of star-forming galaxies from z=0 to z~3

We use a 24 micron selected sample containing more than 8,000 sources to study the evolution of star-forming galaxies in the redshift range from z=0 to z~3. We obtain photometric redshifts for most of the sources in our survey using a method based on empirically-built templates spanning from ultraviolet to mid-infrared wavelengths. The accuracy of these redshifts is better than 10% for 80% of the sample. The derived redshift distribution of the sources detected by our survey peaks at around z=0.6-1.0 (the location of the peak being affected by cosmic variance), and decays monotonically from z~1 to z~3. We have fitted infrared luminosity functions in several redshift bins in the range 0<z<~3. Our results constrain the density and/or luminosity evolution of infrared-bright star-forming galaxies. The typical infrared luminosity (L*) decreases by an order of magnitude from z~2 to the present. The cosmic star formation rate (SFR) density goes as (1+z)^{4.0\pm0.2} from z=0 to z=0.8. From z=0.8 to z~1.2, the SFR density continues rising with a smaller slope. At 1.2<z<3, the cosmic SFR density remains roughly constant. The SFR density is dominated at low redshift (z<0.5) by galaxies which are not very luminous in the infrared (L_TIR<1.e11 L_sun, where L_TIR is the total infrared luminosity, integrated from 8 to 1000 micron). The contribution from luminous and ultraluminous infrared galaxies (L_TIR>1.e11 L_sun) to the total SFR density increases steadily from z~0 up to z~2.5, forming at least half of the newly-born stars by z~1.5. Ultraluminous infrared galaxies (L_TIR>1.e12 L_sun) play a rapidly increasing role for z>~1.3.Comment: 28 pages, 17 figures, accepted for publication in Ap

14th Annual Seminar on Estate Planning

Outlines of speaker presentations from the 14th Annual Seminar on Estate Planning held by UK/CLE on July 17-18, 1987

Conservation successes and challenges for wide-ranging sharks and rays

Overfishing is the most significant threat facing sharks and rays. Given the growth in consumption of seafood, combined with the compounding effects of habitat loss, climate change, and pollution, there is a need to identify recovery paths, particularly in poorly managed and poorly monitored fisheries. Here, we document conservation through fisheries management success for 11 coastal sharks in US waters by comparing population trends through a Bayesian state-space model before and after the implementation of the 1993 Fisheries Management Plan for Sharks. We took advantage of the spatial and temporal gradients in fishing exposure and fisheries management in the Western Atlantic to analyze the effect on the Red List status of all 26 wide-ranging coastal sharks and rays. We show that extinction risk was greater where fishing pressure was higher, but this was offset by the strength of management engagement (indicated by strength of National and Regional Plan of Action for sharks and rays). The regional Red List Index (which tracks changes in extinction risk through time) declined in all regions until the 1980s but then improved in the North and Central Atlantic such that the average extinction risk is currently half that in the Southwest. Many sharks and rays are wide ranging, and successful fisheries management in one country can be undone by poorly regulated or unregulated fishing elsewhere. Our study underscores that well-enforced, science-based management of carefully monitored fisheries can achieve conservation success, even for slow-growing species

A Physical Model for z~2 Dust Obscured Galaxies

We present a physical model for the origin of z~2 Dust-Obscured Galaxies (DOGs), a class of high-redshift ULIRGs selected at 24 micron which are particularly optically faint (24/R>1000). By combining N-body/SPH simulations of high redshift galaxy evolution with 3D polychromatic dust radiative transfer models, we find that luminous DOGs (with F24 > 0.3 mJy at z~2 are well-modeled as extreme gas-rich mergers in massive (~5x10^12-10^13 Msun) halos, with elevated star formation rates (~500-1000 Msun/yr) and/or significant AGN growth (Mdot > 0.5 Msun/yr), whereas less luminous DOGs are more diverse in nature. At final coalescence, merger-driven DOGs transition from being starburst dominated to AGN dominated, evolving from a "bump" to a power-law shaped mid-IR (IRAC) spectral energy distribution (SED). After the DOG phase, the galaxy settles back to exhibiting a "bump" SED with bluer colors and lower star formation rates. While canonically power-law galaxies are associated with being AGN-dominated, we find that the power-law mid-IR SED can owe both to direct AGN contribution, as well as to a heavily dust obscured stellar bump at times that the galaxy is starburst dominated. Thus power-law galaxies can be either starburst or AGN dominated. Less luminous DOGs can be well-represented either by mergers, or by massive ($M_{\rm baryon} ~5x10^11 Msun) secularly evolving gas-rich disc galaxies (with SFR > 50 Msun/yr). By utilising similar models as those employed in the SMG formation study of Narayanan et al. (2010), we investigate the connection between DOGs and SMGs. We find that the most heavily star-forming merger driven DOGs can be selected as Submillimetre Galaxies (SMGs), while both merger-driven and secularly evolving DOGs typically satisfy the BzK selection criteria.Comment: Accepted by MNRAS; major changes include better description of dependency on ISM specification and updated models allowing dust to evolve with metallicity