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Objective: Creatine kinase MB isoenzyme (CK-MB) mass and rate of change of CK-MB have been proposed as superior to cardiac troponin measurement for very early exclusion of acute myocardial infarction (AMI). All three markers were examined prospectively in patients presenting to the Emergency Department (ED) for rule out of AMI. Methods: Consecutive admissions to the ED with undifferentiated chest pain were initially assessed clinically and by electrocardiography. A total of 786 patients (490 male, median age 52.5 years) considered at low risk of AMI had blood drawn on admission. If the first sample was less than 12 h from onset of chest pain, a second sample was then drawn at least 2 h later and at least 6 h from onset of chest pain. CK-MB mass was measured on the first sample and CK-MB mass and cardiac troponin T (cTnT) were measured on the second sample. Measurement of cTnT was using an Elecsys 2010 with the third generation assay (Roche Diagnostics, Lewes, UK). Assay coefficient of variation (CV) was 5.8% and 5.7% at 0.47 and 11.5 µg/L, respectively, with measuring range 0.01-25.0 µg/L; analytical sensitivity of 0.01 µg/L and functional sensitivity of 0.03 µg/L. CK-MB (mass) was measured by electrochemiluminesence using an Elecsys 2010 (Roche Diagnostics). The assay CV was 4.0% at 5.89 µg/L and 4.1% at 60.5 µg/L, with a detection limit of 0.1 µg/L and an upper measuring limit of 500 µg/L. Myocardial infarction was diagnosed if either sample had a CK-MB of more than 5 µg/L, if there was a change in CK-MB (∆CK-MB) of more than 1.5 µg/L or if the cTnT was more than 0.05 µg/L. When AMI was excluded, patients proceeded to stress electrocardiography and reattended 72 h from presentation for follow up phlebotomy for cTnT measurement. A final diagnosis of AMI was made according to American College of Cardiology/ European Society of Cardiology criteria using a cut-off of 0.05 μg/L cTnT in any of the samples. Diagnostic efficiency was compared by receiver operator characteristic (ROC) curve analysis with comparison of area under the curve (AUC) for four strategies: admission CK-MB measurement; 6-h post-pain CK-MB measurement; ∆CK-MB; and 6-h post-pain cTnT measurement. Results: On admission the AUC for CK-MB was 0.830 (95% confidence interval [CI] 0.757-0.904). At 6 h post pain the respective values were: CK-MB 0.939 (95% CI 0.889-0.988); -CK-MB 0.948 (95% CI 0.906-0.990); and cTnT 0.989 (95% CI 0.966-1.0). Conclusion: cTnT at 6 h has high diagnostic sensitivity for AMI and is superior to CK-MB mass and ∆CK-MB even using a low cut-off value.

Background: Surgical intervention in patients with malignant hematological disorders is a major undertaking due to the expected risks of bleeding, infection and poor wound healing. Methods and materials: A retrospective study of patients treated at the Riyadh Armed Forces Hospital, Saudi Arabia between January 1991 and December 2002 was conducted. The results of patients with acute leukemia and lymphoma who underwent surgical procedures (study group) were compared with those of a control group composed of patients with the same spectrum of disorders treated over the same period of time and given the same treatment protocols but never required any surgery. Results: No single death occurred intraoperatively or in the immediate postoperative period due to surgical therapy per se. However, follow up of both groups of patients revealed a shorter long-term survival and higher rates of relapse and severe invasive infections in the surgical group compared to the control group of patients. The mean survival for the study group was 1871 ± 307 days versus 3094 ± 279 days for the control group of patients (P = 0.0027). Thirty (75%) study patients suffered relapses of their malignant hematological disorders versus 23 (37.1%) control patients. Forty-five relapses were encountered in the study group of patients (1.5 relapses per relapsed patient) versus 26 relapses in the control group (1.13 relapses per relapsed patient). Various infections occurred in 37 (92.5%) study patients and 32 (51.6%) control patients. Recurrent infections developed in 30 (75%) study patients and 22 (35.5%) control patients (P = 0.00008). Infections causing tissue invasion were encountered in 29 (72.5%) study patients and 22 (35.5%) control patients. Conclusion: Even major surgical procedures can be performed in patients with leukemia or lymphoma provided enough preparatory measures are made to minimize bleeding and infectious complications. Surgery may, however, be associated with long-term complications such as a high incidence of relapse of the primary malignant hematological disorder and an increased rate of severe and invasive infections.

The authors of Adventurous Learning: A Pedagogy for a Changing World are extensively published in the fields of outdoor learning and place responsive pedagogy. Dr Simon Beames is a senior lecturer ...

BACKGROUND Surgical resection is the recognised treatment of choice for patients with stage I or II non-small cell lung cancer (NSCLC). In the UK surgical resection rates have remained far lower ( 20%), despite the recent introduction of fast access investigation units. It remains unclear therefore why UK surgical resection rates lag so far behind those of other countries. METHODS A new quick access two stop investigation service was established at Papworth in November 1995 to investigate all patients presenting to any of three surrounding health districts with suspected lung cancer. Once staging was complete, all patients with confirmed lung cancer were reviewed by a multidisciplinary team which included an oncologist and a thoracic surgeon. Time from presentation to definitive treatment and surgical resection rates were reviewed. RESULTS Two hundred and nine (76%) of a total of 275 consecutive patients investigated had confirmed lung cancer (28 small cell, 181 non-small cell). Of the remainder, eight patients (2%) had metastatic disease, four (1%) had other thoracic malignancy (thymoma, mesothelioma), four patients (1%) had benign thoracic tumours, and 50 (18%) had other non-malignant diseases. Of the 181 patients with non-small cell primary lung cancer, 47 (25%) underwent successful surgical resection, of whom 59% had stage I and 21% stage II disease. The failed thoracotomy rate was 11%. Median time from presentation at the peripheral clinic to surgical resection was 5 weeks (range 1–13). CONCLUSION Quick access investigation, high histological confirmation rates, routine CT scanning, and review of every patient with confirmed lung cancer by a thoracic surgeon led to a substantial increase in the successful surgical resection rate. These results support the growing concern that many patients with operable tumours are being denied the chance of curative surgery in our present system.

Each chapter in Human Resource Development provides the reader with commentary, activities and review sections in an integrated approach. The action-oriented approach is vital for practicing managers but increasingly for postgraduate and final year undergraduates who have work experience. It is this aspect of the book that fills a gap that currently exists in the market. This text reflects organizational realities and balances and integrates the coverage of individuals, teams and organizational learning.The book is written in a straightforward manner and explains concepts and key issues in a lucid style. The activities are focused and are better suited to encouraging readers to learn.

Our research explores the use of real-time computer vision techniques and a pair of standard computer cameras to provide 3D human body awareness in an inexpensive, immersive environment system, Fig. 1. The goal is to enhance the user experience of immersion in a virtual scene that is displayed by a 3D screen. We combine stereo vision and stereo projection to allow for both the user and the virtual scene to become aware of each others 3D presence as part of a single, integrated 3D space.

While our Y2K worries about old computers "retiring" at midnight captured the television and news media attention, a more significant "old age" phenomenon snuck onto the scene with hardly a headline: the dawn of the age of the aged. (1) The over burdened health care system will face a worldwide wave of retirees who will live longer, cost more to treat, and demand new goods and services to help them stay healthy, active, and independent. Research in persuasive technologies and the associated usage of a computing system, device, or application intentionally designed to change a person's attitude or behavior in a predetermined way is showing the potential to assist in improving healthy living, reduce the costs on the health care system, and allow the aged to maintain a more independent life. This article gives a deeper insight into the evolution of persuasive technologies and presents a framework that can guide a researcher or practitioner in comprehending more effectively the work being done in this novel research field. It also provides categories of domains within health care in which these technologies are used and surveys exemplars from published literature. The article's goal is to provide greater understanding by addressing the challenges that lie ahead for all key stakeholders that design and/or use persuasive technologies in health care.

(1991). Edith Wharton at War with the American Red Cross: The end of Noblesse Oblige. Women's Studies: Vol. 20, Reading the Letters of Edith Wharton, pp. 121-131.

Background Tuberculous infections in patients with hematological disorders and hematopoietic stem cell transplant vary in incidence, complications and response to treatment. Methods and materials A retrospective study of patients with various benign and malignant hematological disorders and recipients of hematopoietic stem cell transplant who were treated at Riyadh Armed Forces Hospital, Saudi Arabia between January 1991 and December 2002 and who developed tuberculous infections was conducted. Results Tuberculous infections occurred in eighteen patients with hematological disorders and hematopoietic stem cell transplant. The main associated factors were: reduced immunity due to the primary hematological disorder, age more than 50 years and the administration of cytotoxic chemotherapy, steroids or radiotherapy. These infections frequently involved the lungs and predominantly occurred in males and in patients with chronic myeloproliferative disorders, myelodysplastic syndrome and acute myeloid leukemia. In patients treated with intravenous cytotoxic chemotherapy, tuberculous infections tended to occur earlier and also tended to be more disseminated compared to infections occurring in patients treated with oral chemotherapy. Anti-tuberculous treatment was given to 16 patients and it was successful in 15 of these patients. Conclusion Tuberculous infections cause significant morbidity and mortality in patients with various hematological disorders and in recipients of hematopoietic stem cell transplant. The early administration of anti-tuberculous therapy and compliance with drug treatment are associated with successful outcomes while delayed management, drug resistance and the presence of miliary infections are associated with poor prognosis and high mortality rates.

Background: Most viral infections are known to exert adverse effects on bone marrow function. However, certain viruses have recently been found to be therapeutically beneficial in the treatment of some malignant disorders. Methods and materials: A retrospective study was conducted at the Armed Forces Hospital, Riyadh, Saudi Arabia. The changes in the hemalological parameters following varicella-zoster virus (VZV) infection in patients with a variety of hematological disorders were compared with those in a control group having the same spectrum of disorders and treated in the same unit over the same period of time but never had VZV inspection. Both groups of patients received the same treatment protocols for their primary hematological disorders. Definitive treatment (DT) such as chemotherapy alone, anti-thymocyte globulin or bone marrow transplant was also employed in the management of patients belonging to both groups. Results: White blood cell counts, platelet counts and hemoglobin concentrations in the study group started to increase 40 d after chickenpox or herpes zoster infection and these increases lasted for periods as long as 1050 d. The changes in platelet counts were more pronounced than those in other hematological parameters. There was a significant difference (P < 0.0001) between the two groups of patients in the values of platelet counts achieved between 280 and 1050 d after DT (mean platelet count: 262 x 10 9 /L in the study group vs. 180 x 10 9 /L in the control group, median: 288.17 x 10 9 /L in the study group vs. 180 x 10 9 /L in the control group, range: 102 to 415 x 10 9 /L in the study group vs. 26 to 365 x 10 9 /L in the control group of patients). Compared to the control group, the study group of patients achieved their maximum blood counts much earlier after DT. The maximum leucocytic count was achieved at a mean duration of 269.21 d in the study group and 349.61 d in the control group. The maximum hemoglobin level was achieved at a mean duration of 319.5 d in the study group and 402.6 d in the control group. The maximum platelet count was achieved at a mean duration of 271.4 d in the study group and 318.9 d in the control group of patients. Conclusion: VZV may behave differently from other members of the herpes group of viruses e.g. human cytomegalovirus and Epstein-Barr virus. Our observations suggest that VZV infection causes stimulation of bone marrow activity.

This sketch presents how the real-time 3D interactive simulation, "The Virtual Tour of the Cone Sisters' Apartments", from the SIGGRAPH 02 Art Gallery exhibition was designed, authored and produced by the Imaging Research Center (IRC) at UMBC for two installations at the Baltimore Museum of Art (BMA).

Vygotsky and special needs education: rethinking support for children and schools, edited by Harry Daniels and Mariane Hedegaard, London, Continuum, 2011, 230 pp., £24.99 (paperback), ISBN: 978-1-4...

the year 1916 did not begin auspiciously for edith wharton’s war work. In late December of 1915, the French Ministry of Public Education requisitioned the building where her sewing workroom was located, displacing its ninety women. Wharton closed the workroom for a lengthened Christmas vacation and took her fight to the French bureaucracy. She spent the week between Christmas and New Year’s Day in the offices of the ministry, trying first to arrange a delay and then to secure a new building. Finally the government, “realizing they have made a ‘gaffe,’ have ordered me an ‘amende honourable’ by hiring & putting at my disposal ‘pour la duree de la guerre’ a whole floor in a big building of the Boulevard St. Germain, in wh[ich] I hope to be installed at the end of next week.”1 Relieved but exhausted, Wharton spent New Year’s Day at the Children of Flanders refugee center in St Ouen and at the Bureau de la Sante.2

edith wharton started the year 1914 poised for new beginnings. she had recently divorced Teddy Wharton after twenty-eight years of an increasingly painful marriage. Teddy’s mood swings between manic highs and depressive lows became more pronounced after 1910. Wharton’s attempts to distract her husband with travel became less and less successful after their move to Paris in 1907. She arranged for Teddy to be treated at a sanitarium in Switzerland, but he returned to her Paris doorstep little improved. The final break came after Wharton discovered that her husband had been speculating with money from her trust funds.

the war was over, but its effects would be with edith wharton for the rest of her life. Through the months following the Armistice, she gradually disengaged herself from the remaining charities. She was able to return to her first love—writing. She established a rhythm: St. Brice during the summer and fall and Hyeres during the winter and spring, and a book every year. The noise and human bustle of Paris during the peace conference and into the 1920s with the arrival of Americans from “the lost generation” poisoned the city for her. She made her separate peace with the world and withdrew to her homes and gardens and friends.

edith wharton had spent the autumn and the winter of 1914 organizing war charities and raising money for the refugees flooding Paris. She told Mary Berenson, who had been staying with her during the creation of the American Hostels for Refugees and who had asked how the new organization was getting along, that the hostels took “a lot of nursing, & reams of letter writing.”1 The writing was of a kind, however, that did not lend itself to producing fiction. In a New Year’s greeting excusing “put[ting] off even the letters one most wanted to write” she said she wished she could write “when evening came, [if] my brain were not too sodden & my hand too tired to pick up a pen.”2 She confided to Charles Scribner that while she had managed to raise $100,000 during the previous five months, the daily demands of fund raising had left her “absolutely pen-tied.”3 Her literary production had fallen off so sharply that for 1914 she filed taxes on an income of only $900.4

the morning of the fourth of july, 1918, dawned overcast in paris, with a threat of rain that could spoil the elaborate schedule of ceremonies planned for the day.1 Raymond Poincare, the president of France, had sent a formal greeting to Woodrow Wilson proclaiming that America’s Independence Day would for that year become a day of national celebration in France as well. Later in the morning, in what might have been taken as a metaphor for the Allies’ military progress during the previous six months, the sky cleared.

edith wharton entered the third year of the war, 1917, exhausted. Part of her fatigue was due to hurried preparations for a recent auction of art objects, which netted over 300,000 francs for the tuberculosis hospitals. Excusing several weeks of silence, she explained to Sara Norton, “They have rushed by in such a torrent of dull work that I have lost all sense of time, and only know that long ago I used to have friends, and time to write to them.”1 When Minnie Jones wrote about the death of Frederick Whitridge, husband of Wharton’s friend Lucy Arnold Whitridge, Wharton, toughened by the loss of several friends the previous year, responded vaguely that she frequently heard of the deaths of American friends only weeks later.

the final year of the war, 1918, found wharton withdrawing more and more from administrative and fund-raising duties with the charities. Several of the relief organizations (for example, the American Hostels for Refugees) had been turned over to the American Red Cross. Those that remained under her direction—the convalescent homes—were increasingly looked after by Elisina Tyler. Wharton insulated herself from petitioners by turning all of her correspondence over to secretaries, who pleaded Mrs. Wharton’s latest illness to excuse her from public appearances or her injured wrist to explain unanswered letters. Meanwhile she sought closer emotional ties with Bernard Berenson and a new friend, Ronald Simmons. Even before the Armistice she had decided to move from Paris to the suburbs. And with the arrival of the delegates to the Peace Conference and many Americans in Paris, she retreated further and further into a private emotional and geographical space.

Horace Judson’s new historical commentary, The great betrayal: fraud in science, is a stimulating and thoughtful book for readers interested in science, publication ethics, and research misconduct. He writes with his typical flair, drawing on interviews with famous scientists. His premise is that scrutiny of the nature of fraud and other misconduct will reach to the pulse of what the sciences are and what scientists do. The book offers little, however, for readers whose principal interest is clinical research. Judson is a respected modern historian of science, perhaps best known for his history of molecular biology, The eighth day of creation: makers of the revolution in biology (S1). Most of the citations in this new book precede 1996, except for references to stories of misconduct among businessmen, historians, and journalists that have filled the press since 2000. In fact, the 35 “Recent Cases” are almost the same set of cases (late 1800s-late 1900s) previously described in Betrayers of the truth (S2) and False prophets (S3), neither of which is referenced in this new book. The newest cases cited in Judson’s book involve major scandals in a German and an American laboratory, heavily covered in the recent science press. Nonetheless, Judson does profitably draw on the classical cases noted in these earlier books, drawing analogies with cases of scientific fraud during the past decade. Also missing is a discussion of the findings of scientific misconduct in clinical cases made between 1992 and 2004 by the Office of Research Integrity (ORI), part of the United States Public Health Service (PHS) in the Department of Health and Human Services (HHS), which would have been of interest to JCI readers. About 40 of the 150 findings have involved clinical or related nonclinical research with human subjects (S4, S5). The only such case described by Judson is a clinical trial on the use of mastectomy versus lumpectomy to treat breast cancer, conducted at St. Luc’s Hospital, Montreal, and coordinated by the University of Pittsburgh, in which the investigator falsified records to make more patients eligible for the study. However, Judson includes a long, solid chapter on “The Baltimore Affair,” dealing with the allegations of falsification of data on the part of a Massachusetts Institute of Technology scientist and the overturning of the ORI’s 1994 finding against her in 1996 by the HHS appeals board. This case had been discussed in detail in 2 previous books, Science on trial: the whistle blower, the accused, and the Nobel laureate (S6), and The Baltimore case: a trial of politics, science, and character (S7), which also are not cited in Judson’s new book. To his credit, Judson personally reviewed records and interviewed witnesses, describing both in much the same style as he used in The eighth day of creation (S1), which makes the new book a fascinating read. Also striking is Judson’s initial chapter, “A Culture of Fraud,” describing public cases of fraud by businessmen, social scientists, clergy, and others. The conclusion is obvious: a few scientists are likely no better and no worse than the few members of the general population who are crooks and charlatans. His epilogue includes a plea to restore high standards to the conduct of scientific research. Several interesting chapters, titled “The problems of peer review,” “Authorship, ownership: problems of credit, plagiarism, and intellectual property,” and “Laboratory to law: the problems of institutions when misconduct is charged” will be enlightening and challenging to readers who deal with such problems and try to teach students how to avoid them in the responsible conduct of research. Judson examines self-governance in science and whether officials, editors, and peers can deal effectively, without conflicts of interest, with deviations from appropriate standards in conducting, reporting, and reviewing research. He focuses as well on the important role of whistle-blowers or complainants in challenging some reports for reasons of integrity. Judson’s book is accurate and timely, in that in 2000, the US Office of Science and Technology developed a uniform policy for dealing with allegations and investigations for all federal agencies. Each agency has since been publishing new policies or regulations; the revised HHS regulation should soon be finalized. In response, universities, research hospitals, and institutes are updating their policies and procedures, at least to address the federal government’s new definition: “Research misconduct is defined as fabrication, falsification, or plagiarism in proposing, performing, or reviewing research, or in reporting research results . . . [A] finding . . . requires that: there be a significant departure from accepted practices of the relevant research community; and the misconduct be committed intentionally, or knowingly, or recklessly; and the allegation be proven by a preponderance of evidence.” Judson has provided a nice history of the public debate over this definition through the 1990s and the creation of the ORI. His book accomplishes its goal, to describe and analyze the history of fraud in science and its impact on the scientific and public communities, and he examines what contributes to fraud. The book is recommended to readers interested in fundamental research ethics and their historical and political context in the new millennium. This review represents the personal views of the author and not necessarily any position of the ORI, PHS, or HHS. References are available online with this article; doi:10.1172/JCI200524343DS1.