The role of the emergency department in the management of acute heart failure: an international perspective on education and research

Emergency departments are a major entry point for the initial management of acute heart failure (AHF) patients throughout the world. The initial diagnosis, management and disposition - the decision to admit or discharge - of AHF patients in the emergency department has significant downstream implications. Misdiagnosis, under or overtreatment, or inappropriate admission may place patients at increased risk for adverse events, and add costs to the healthcare system. Despite the critical importance of initial management, data are sparse regarding the impact of early AHF treatment delivered in the emergency department compared to inpatient or chronic heart failure management. Unfortunately, outcomes remain poor, with nearly a third of patients dying or re-hospitalised within 3 months post-discharge. In the absence of robust research evidence, consensus is an important source of guidance for AHF care. Thus, we convened an international group of practising emergency physicians, cardiologists and advanced practice nurses with the following goals to improve outcomes for AHF patients who present to the emergency department or other acute care setting through: (a) a better understanding of the pathophysiology, presentation and management of the initial phase of AHF care; (b) improving initial management by addressing knowledge gaps between best practices and current practice through education and research; and (c) to establish a framework for future emergency department-based international education and research

Crossover from adiabatic to sudden interaction quenches in the Hubbard model: Prethermalization and nonequilibrium dynamics

The recent experimental implementation of condensed matter models in optical lattices has motivated research on their nonequilibrium behavior. Predictions on the dynamics of superconductors following a sudden quench of the pairing interaction have been made based on the effective BCS Hamiltonian; however, their experimental verification requires the preparation of a suitable excited state of the Hubbard model along a twofold constraint: (i) a sufficiently nonadiabatic ramping scheme is essential to excite the nonequilibrium dynamics, and (ii) overheating beyond the critical temperature of superconductivity must be avoided. For commonly discussed interaction ramps there is no clear separation of the corresponding energy scales. Here we show that the matching of both conditions is simplified by the intrinsic relaxation behavior of ultracold fermionic systems: For the particular example of a linear ramp we examine the transient regime of prethermalization [M. Moeckel and S. Kehrein, Phys. Rev. Lett. 100, 175702 (2008)] under the crossover from sudden to adiabatic switching using Keldysh perturbation theory. A real-time analysis of the momentum distribution exhibits a temporal separation of an early energy relaxation and its later thermalization by scattering events. For long but finite ramping times this separation can be large. In the prethermalization regime the momentum distribution resembles a zero temperature Fermi liquid as the energy inserted by the ramp remains located in high energy modes. Thus ultracold fermions prove robust to heating which simplifies the observation of nonequilibrium BCS dynamics in optical lattices.Comment: 27 pages, 8 figures Second version with small modifications in section

Editor's Choice-The role of the emergency department in the management of acute heart failure : An international perspective on education and research

Emergency departments are a major entry point for the initial management of acute heart failure (AHF) patients throughout the world. The initial diagnosis, management and disposition - the decision to admit or discharge - of AHF patients in the emergency department has significant downstream implications. Misdiagnosis, under or overtreatment, or inappropriate admission may place patients at increased risk for adverse events, and add costs to the healthcare system. Despite the critical importance of initial management, data are sparse regarding the impact of early AHF treatment delivered in the emergency department compared to inpatient or chronic heart failure management. Unfortunately, outcomes remain poor, with nearly a third of patients dying or re-hospitalised within 3 months post-discharge. In the absence of robust research evidence, consensus is an important source of guidance for AHF care. Thus, we convened an international group of practising emergency physicians, cardiologists and advanced practice nurses with the following goals to improve outcomes for AHF patients who present to the emergency department or other acute care setting through: (a) a better understanding of the pathophysiology, presentation and management of the initial phase of AHF care; (b) improving initial management by addressing knowledge gaps between best practices and current practice through education and research; and (c) to establish a framework for future emergency department-based international education and research.Peer reviewe

Early diagnosis of acute coronary syndrome.

The diagnostic evaluation of acute chest pain has been augmented in recent years by advances in the sensitivity and precision of cardiac troponin assays, new biomarkers, improvements in imaging modalities, and release of new clinical decision algorithms. This progress has enabled physicians to diagnose or rule-out acute myocardial infarction earlier after the initial patient presentation, usually in emergency department settings, which may facilitate prompt initiation of evidence-based treatments, investigation of alternative diagnoses for chest pain, or discharge, and permit better utilization of healthcare resources. A non-trivial proportion of patients fall in an indeterminate category according to rule-out algorithms, and minimal evidence-based guidance exists for the optimal evaluation, monitoring, and treatment of these patients. The Cardiovascular Round Table of the ESC proposes approaches for the optimal application of early strategies in clinical practice to improve patient care following the review of recent advances in the early diagnosis of acute coronary syndrome. The following specific 'indeterminate' patient categories were considered: (i) patients with symptoms and high-sensitivity cardiac troponin 99th percentile but without dynamic change; and (iv) patients with symptoms and high-sensitivity troponin >99th percentile and dynamic change but without coronary plaque rupture/erosion/dissection. Definitive evidence is currently lacking to manage these patients whose early diagnosis is 'indeterminate' and these areas of uncertainty should be assigned a high priority for research

A simplified approach to analyze the space debris evolution in the low earth orbit

During the past 60 years the number of objects on Earth orbits has increased. So has the risk of collisions, which is likely to be the main driver for space debris generation in the future. This is important, for example, in densely populated regions like the sun-synchronous orbit at around 800 km altitude. In order to predict the future development of the debris environment numerical simulations can be used. These simulations are usually based on initial assumptions like the launch rate, the probability distribution of success of post mission disposal measures and the likelihood for catastrophic collisions. The computationally expensive Monte-Carlo method is employed for the random sampling of the defined events. Additionally, a propagator needs to process the objects to determine potential collision partners, increasing the demand for computing power even further. In this paper an analytical model is presented, which is based on source and sink mechanisms, like launches, collisions and explosions. In this approach different altitude shells and diameter bins, as well as four different object classes for intact objects and fragments, each on circular and eccentric orbits are considered. By using pre-computed tables for orbital lifetimes and decay rates, both the computational effort and complexity of the model are decreased. The model can be adjusted to reflect different forecasts by altering the decay and collision rates. The paper concludes by showing preliminary results and a discussion of the generic approach, which allows the model to be fitted against more computationally expensive Monte-Carlo simulations

Dynamics of a Quantum Phase Transition and Relaxation to a Steady State

We review recent theoretical work on two closely related issues: excitation of an isolated quantum condensed matter system driven adiabatically across a continuous quantum phase transition or a gapless phase, and apparent relaxation of an excited system after a sudden quench of a parameter in its Hamiltonian. Accordingly the review is divided into two parts. The first part revolves around a quantum version of the Kibble-Zurek mechanism including also phenomena that go beyond this simple paradigm. What they have in common is that excitation of a gapless many-body system scales with a power of the driving rate. The second part attempts a systematic presentation of recent results and conjectures on apparent relaxation of a pure state of an isolated quantum many-body system after its excitation by a sudden quench. This research is motivated in part by recent experimental developments in the physics of ultracold atoms with potential applications in the adiabatic quantum state preparation and quantum computation.Comment: 117 pages; review accepted in Advances in Physic

Effectiveness of neonatal pulse oximetry screening for detection of critical congenital heart disease in daily clinical routine—results from a prospective multicenter study

Pulse oximetry screening (POS) has been proposed as an effective, noninvasive, inexpensive tool allowing earlier diagnosis of critical congenital heart disease (cCHD). Our aim was to test the hypothesis that POS can reduce the diagnostic gap in cCHD in daily clinical routine in the setting of tertiary, secondary and primary care centres. We conducted a prospective multicenter trial in Saxony, Germany. POS was performed in healthy term and post-term newborns at the age of 24–72 h. If an oxygen saturation (SpO2) of ≤95% was measured on lower extremities and confirmed after 1 h, complete clinical examination and echocardiography were performed. POS was defined as false-negative when a diagnosis of cCHD was made after POS in the participating hospitals/at our centre. From July 2006–June 2008, 42,240 newborns from 34 institutions have been included. Seventy-two children were excluded due to prenatal diagnosis (n = 54) or clinical signs of cCHD (n = 18) before POS. Seven hundred ninety-five newborns did not receive POS, mainly due to early discharge after birth (n = 727; 91%). In 41,445 newborns, POS was performed. POS was true positive in 14, false positive in 40, true negative in 41,384 and false negative in four children (three had been excluded for violation of study protocol). Sensitivity, specificity, positive and negative predictive value were 77.78%, 99.90%, 25.93% and 99.99%, respectively. With POS as an adjunct to prenatal diagnosis, physical examination and clinical observation, the percentage of newborns with late diagnosis of cCHD was 4.4%. POS can substantially reduce the postnatal diagnostic gap in cCHD, and false-positive results leading to unnecessary examinations of healthy newborns are rare. POS should be implemented in routine postnatal care

Photonic spectral density of coupled microwave cavities

We study a pair of anharmonic microwave cavities that is connected by an optical fiber. The photonic spectral density characterizes the evolution of the coupled cavities after the system has been prepared in a Fock or N00N state. We evaluate the photonic spectral density within the recursive projection method and find that the anharmonicity has no substantial effect on the spectral properties. In all cases the photonic spectral density has a Gaussian envelope for large photon numbers.Comment: 8 pages, 6 figure