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Early identification of acute coronary syndrome (ACS) is important to guide therapy at a time when it is most likely to be of value. In addition, predicting future risk helps identify those most likely to benefit from ongoing therapy. Cardiac troponin T (cTnT) is useful for both purposes although cannot reliably rule out ACS until 12 hours after pain onset and does not fully define future risk. In this review article we summarize our previously published research, which assessed the value of myocyte injury, vascular inflammation, hemostatic, and neurohormonal markers in the early diagnosis of ACS and risk stratification of patients with ACS. In addition to cTnT, we measured heart fatty acid binding protein (H-FABP), glycogen phosphorylase-BB, high-sensitivity C-reactive protein, myeloperoxidase, matrix metalloproteinase 9, pregnancy-associated plasma protein-A, D-dimer, soluble CD40 ligand, and N-terminal pro-brain natriuretic peptide (NT-proBNP). Of the 664 patients enrolled, 415 met inclusion criteria for the early diagnosis of acute myocardial infarction (MI) analysis; 555 were included in the risk stratification analysis and were followed for 1 year from admission. In patients presenting

Objective To assess the impact of mobile Automated External Defibrillators (AEDs) on Out-of-Hospital Cardiac Arrests (OHCAs) in urban and rural populations. Design Prospective before and after intervention, population study. Setting Urban and rural areas of 160,000 each. Patients, interventions and main outcome measures In 2004 to 2006 the demographics of OHCA were assessed. In 2005/6 AEDs were deployed (29 urban, 53 rural): 335 urban First Responders (FRs) and 493 rural FRs were trained in AED use and dispatched to OHCAs. Call-to-Response Interval (CRI), resuscitation and survival-to-discharge rates for OHCA were compared. Results In 2004 there were 163 urban OHCAs and the Emergency Medical Services (EMS) attended 158 (Ventricular Fibrillation (VF) 27/158(17.1%)). In 2005/6 there were 226 OHCAs, EMS attended 216 (VF 30/216(13.9%)). In 2005/6 FRs were paged to 128 OHCAs (56.6%), FRs attended 88/128(68.7%): 18/128(14%) reached before the EMS. The best combined FR/EMS mean CRI in 2005/6 (5min56s(SD4)) was better than the EMS-alone in 2004 (7min(SD3), (p=0.002). Survival rate was 5.1% in 2004, 1.4% in 2005/6 (p=NS). In 2004 there were 131 rural OHCAs, EMS attended 121 (VF 19/121(15.7%)). In 2005/2006 there were 122 OHCAs, EMS attended 114 (VF 19/114(16.7%)). In 2005/6 FRs were paged to 49 OHCAs, FRs attended 42/49(85.7%): 23/49(46.9%) reached before the EMS. The best combined FR/EMS mean CRI in 2005/6 (9min22s(SD6)) was better than the EMS-alone in 2004 (11min02s(SD6), (p=0.018). Survival rate was 2.5% in 2004, 3.5% in 2005/6 (p=NS). Conclusions Despite improvement in CRI there was no impact on survival (witnessed arrest 32.8%, VF 15.6%).

To compare the efficacy and safety of an escalating energy protocol with a non-escalating energy protocol using an impedance compensated biphasic defibrillator for direct current cardioversion of atrial fibrillation (AF).This prospective multicentre randomised trial enrolled 380 patients (248 male, mean (SD) age 67 (10) years) with AF. Patients were randomised to either an escalating energy protocol (protocol A: 100 J, 150 J, 200 J, 200 J), or a non-escalating energy protocol (protocol B: 200 J, 200 J, 200 J). Cardioversion was performed using an impedance compensated biphasic waveform. First-shock success was significantly higher for those randomised to 200 J than 100 J (71% vs 48%; p0.01) and for patients with a body mass index (BMI)25 kg/m(2) (75% vs 44%; p = 0.01). In patients with a normal BMI there was no significant difference in first-shock success. There was also no significant difference between subsequent shocks or overall success. The use of a non-escalating protocol (protocol B) resulted in fewer shocks but with a higher cumulative energy. There was no difference in duration of procedure, amount of sedation administered or post-shock erythema between the groups.First-shock success was significantly higher, particularly in patients with a BMI25 kg/m(2), when a non-escalating initial 200 J energy was selected. The overall success, duration of procedure and amount of sedation administered, however, did not differ significantly between the two protocols.

Objectives: To determine the diagnostic accuracy of advanced medical priority dispatch system (AMPDS) software used to dispatch public access defibrillation first responders to out-of-hospital cardiac arrests (OHCA). Design: All true OHCA events in North and West Belfast in 2004 were prospectively collated. This was achieved by a comprehensive search of all manually completed Patient Report Forms compiled by paramedics, together with autopsy reports, death certificates and medical records. The dispatch coding of all emergency calls by AMPDS software was also obtained for the same time period and region, and a comparison was made between these two datasets. Setting: A single urban ambulance control centre in Northern Ireland. Population: All 238 individuals with a presumed or actual OHCA in the North and West Belfast Health and Social Services Trust population of 138 591 (2001 Census), as defined by the Utstein Criteria. Main outcome measures: The accurate dispatch of an emergency ambulance to a true OHCA. Results: The sensitivity of the dispatch mechanism for detecting OHCA was 68.9% (115/167, 95% confidence interval (CI) 61.3% to 75.8%). However, the sensitivity for arrests with ventricular fibrillation (VF) was 44.4% (12/27) with sensitivity for witnessed VF of 47.1% (8/17). The positive predictive value was 63.5% (115/181, 95% CI 56.1% to 70.6%). Conclusions: The sensitivity of this dispatch process for cardiac arrest is moderate and will constrain the effectiveness of Public Access Defibrillation (PAD) schemes which utilise it. Trial registration: controlled-trials.com ISRCTN 07286796.

Objective: To determine the epidemiology of out of hospital sudden cardiac death (OHSCD) in Belfast from 1 August 2003 to 31 July 2004.Design: Prospective examination of out of hospital cardiac arrests by using the Utstein style and necropsy reports. World Health Organization criteria were applied to determine the number of sudden cardiac deaths.Results: Of 300 OHSCDs, 197 (66%) in men, mean age (SD) 68 (14) years, 234 (78%) occurred at home. The emergency medical services (EMS) attended 279 (93%). Rhythm on EMS arrival was ventricular fibrillation (VF) in 75 (27%). The call to response interval (CRI) was mean (SD) 8 (3) minutes. Among patients attended by the EMS, 9.7% were resuscitated and 7.2% survived to leave hospital alive. The CRI for survivors was mean (SD) 5 (2) minutes and for non-survivors, 8 (3) minutes (p < 0.001). Ninety one (30%) OHSCDs were witnessed; of these 91 patients 48 (53%) had VF on EMS arrival. The survival rate for witnessed VF arrests was 20 of 48 (41.7%): all 20 survivors had VF as the presenting rhythm and CRI ? 7 minutes. The European age standardised incidence for OHSCD was 122/100 000 (95% confidence interval 111 to 133) for men and 41/100 000 (95% confidence interval 36 to 46) for women.Conclusion: Despite a 37% reduction in heart attack mortality in Ireland over the past 20 years, the incidence of OHSCD in Belfast has not fallen. In this study, 78% of OHSCDs occurred at home.

This paper describes the development of a model to assess the distribution of response times for mobile volunteers of a Public Access Defibrillation (PAD) scheme in Northern Ireland. Using parameters based on a trial period, the model predicts that a PAD volunteer would arrive before the Emergency Medical Services (EMS) to 18.8% of events to which they are paged in a given year period. This is in agreement with what has actually been observed during the trial period (where volunteers have actually reached 15% of events before the EMS), and thus assisting validation of the model. Results from this model illustrate how ongoing volunteer commitment is key to the success of the scheme.

Confocal microscopy combined with cellular labeling techniques can be an effective method for imaging the morphology of a cell as well as various functional characteristics in vivo. Current analysis methods are manual, and therefore, time-consuming and prone to error. Through the development of custom algorithms and application design, the analysis process can be improved to decrease analysis time and increase reproducibility. Utilizing off-the-self PC hardware and software, a custom application was designed that would provide useful three-dimensional (3D) segmentation and analysis tools to analyze confocal image data of neurons. Techniques such as dynamic thresholding, adaptive filtering, and morphological processing were implemented to provide a robust and efficient analysis package. The automated method was compared with the standard manual method using two metrics - reproducibility and overall time necessary for analysis. The semi-automated method was more time efficient with very high reproducibility. Additional studies are necessary to further assess and improve upon the automated technique.

A rule-based approach to designing time-critical flight software is presented. The intent is to provide program design language synthesizers, which help the user to shape the requirements into a form suitable for automatic synthesis. This approach attempts to produce a deterministic scheduler design. Events are mapped, where possible, into a cyclic scheme. When events cannot be handled cyclically, they are handled as interrupts. The technique attempts to balance processing load across frames. An attributed form of IDEF (integrated computer-aided manufacturing definition) is used to express the requirements from which designs can be synthesized. IDEF information is stored in a PROLOG knowledge base and is organized hierarchically. The tool set and its associated IDEF-based methodology, is called the Systems Analysis Logical Design Technique (SALDT). >

A methodology is proposed that supports reasoning in terms of functional, temporal, and resource domains. It is intended to support the complete life cycle of an avionics system. The basis of the method is the Systems Analysis and Design Technique (SADT) defined by D. Ross. The basic SADT is augmented with a means for specifying how activities become active and for specifying timing requirements once they become active. A tool has been implemented which assists a user with the construction and verification of these temporal SADT descriptions. The result is a knowledge base amenable to temporal logic and Petri net analysis tools. The goal of the project is to demonstrate practical rooms for building verifiable real-time system designs and automated documentation. The basic temporal SADT tool has recently been complete and is being evaluated. Experience to date is encouraging. >

PURPOSE: Gemcitabine plus cisplatin (GC) and methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) were compared in patients with locally advanced or metastatic transitional-cell carcinoma (TCC) of the urothelium. PATIENTS AND METHODS: Patients with stage IV TCC and no prior systemic chemotherapy were randomized to GC (gemcitabine 1,000 mg/m2 days 1, 8, and 15; cisplatin 70 mg/m2 day 2) or standard MVAC every 28 days for a maximum of six cycles. RESULTS: Four hundred five patients were randomized (GC, n = 203; MVAC, n = 202). The groups were well-balanced with respect to prognostic factors. Overall survival was similar on both arms (hazards ratio [HR], 1.04; 95% confidence interval [CI], 0.82 to 1.32; P = .75), as were time to progressive disease (HR, 1.05; 95% CI, 0.85 to 1.30), time to treatment failure (HR, 0.89; 95% CI, 0.72 to 1.10), and response rate (GC, 49%; MVAC, 46%). More GC patients completed six cycles of therapy, with fewer dose adjustments. The toxic death rate was 1% on the GC arm and 3% on the MVAC arm. More GC than MVAC patients had grade 3/4 anemia (27% v 18%, respectively) and thrombocytopenia (57% v 21%, respectively). On both arms, the RBC transfusion rate was 13 of 100 cycles and grade 3/4 hemorrhage or hematuria was 2%; the platelet transfusion rate was four patients per 100 cycles and two patients per 100 cycles on GC and MVAC, respectively. More MVAC patients, compared with GC patients, had grade 3/4 neutropenia (82% v 71%, respectively), neutropenic fever (14% v 2%, respectively), neutropenic sepsis (12% v 1%, respectively), and grade 3/4 mucositis (22% v 1%, respectively) and alopecia (55% v 11%, respectively). Quality of life was maintained during treatment on both arms; however, more patients on GC fared better regarding weight, performance status, and fatigue. CONCLUSION: GC provides a similar survival advantage to MVAC with a better safety profile and tolerability. This better-risk benefit ratio should change the standard of care for patients with locally advanced and metastatic TCC from MVAC to GC.

Large-scale experiments, conducted by the CEGB, to investigate the development of propagating explosions of flowing coal dust/air suspensions in ducts have produced flame speeds and pressures up to detonation levels. These results provide perhaps the clearest evidence to date that detonations can develop in coal dust/air suspensions by way of deflagration to detonation transition (DDT). The experimental facility comprised a 0.6m diameter instrumented test duct supplied with mixture from an air blower and coal dust feeder installation, and was equipped with appropriate ignition source devices. The tests were performed in two distinct phases: Phase 1 comprised tests in a 30 m straight duct, and produced deflagrations with modest flame speeds and pressure rises up to little more than 1 bar. Phase 2 involved the inclusion in the test line of an explosion chamber of volume 20 m 3 and an extension of test duct length to 42m. These changes produced much-enhanced flame speeds and pressure rises which, under particularly favourable conditions of mixture composition, reached detonation values with pressures up to 81.5 bar and clear evidence of DDT. Data are presented which illustrate the dependence of explosion strength on system geometry, ignition source, coal type and mixture parameters, and the relationship between measured values of maximum flame speed and pressure rise is compared with those derived from other related research.

In order to study the effect of SO2 emissions from power stations on the formation of acid rain, cloud water sampled in the presence of the effluent gases is required for analysis. A small axial flow cyclone is described for separating the liquid water from cloud sampled by aircraft to provide these samples. The description covers structural aspects, the installation in the aircraft and a theoretical prediction of its service performance. It is shown that the separator will remove all droplets of greater than 5-μm diameter under the action only of the ram pressure generated by the forward speed of the aircraft. The optimisation of the design in a simple ground based cloud tunnel is then described and test results are given which indicate that adequate cloud water samples for chemical analyses should be obtained when the liquid water content of the sampled cloud exceeds 0.35 g m−3. This is supported by the results of early flight tests and it is concluded that the separator will provide useful cloud water samples in most homogeneous cloud conditions.

This paper is a study of the comparative efficacy of Priscoline, Regitine, and Roniacol in relaxing vasospasm in the extremities of normal human subjects. A total of 60 studies were performed on 14 subjects. Severe cutaneous vasospasm was induced by exposure of the lightly clad subject to an environmental temperature of 20 C. for one hour or more. In half the tests the severe vasospasm was reduced to moderate vasospasm by application of heat to the torso of the chilled subjects. The effectiveness of the drugs was tested by giving them by intravenous infusion after the appropriate state of vasospasm had been obtained. The degree of relaxation of vasospasm was estimated from the resulting changes in cutaneous temperature recorded with thermocouples.