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Background: We recently introduced the myocardial-ischemic-injury-index (MI3), a machine learning algorithm that predicts the likelihood of myocardial infarction in patients with suspected acute coronary syndrome. Whether this algorithm performs well in routine clinical practice or predicts subsequent events is unknown.Methods: MI3 was validated in a prespecified exploratory analysis from a multi-centre randomised trial that included consecutive patients with suspected acute coronary syndrome undergoing serial high-sensitivity cardiac troponin I measurement. Patients with ST-segment elevation myocardial infarction were excluded. MI3 incorporates age, sex, and two troponin measurements to compute a value (0-100) reflecting an individual’s likelihood of myocardial infarction during the index visit and estimates diagnostic performance metrics at the computed score. Model performance for an index diagnosis of myocardial infarction, and for subsequent myocardial infarction or cardiovascular death at one year was determined using previously defined low- and high-probability MI3 thresholds (1·6 and 49·7, respectively). Findings: In total, 20,761 patients (64±16 years, 46% women) were included of whom 3,272 (15·8%) had myocardial infarction. MI3 had an area under the receiver-operating-characteristic curve of 0·949 (95% confidence interval 0·946-0·952) identifying 12,983 (62·5%) patients as low-probability (sensitivity 99·3% [99·0-99·6%], negative predictive value 99·8% [99·8-99·9%]), and 2,961 (14·3%) as high-probability (specificity 95·0% [94·6-95·3%], positive predictive value 70·4% [68·7-72·0%]). At one year, subsequent myocardial infarction or cardiovascular death occurred more often in high-probability compared to low-probability patients (17·6% [520/2,961] versus 1·5% [197/12,983], PInterpretation: In consecutive patients undergoing serial cardiac troponin measurement for suspected acute coronary syndrome, the MI3 algorithm accurately estimates the likelihood of myocardial infarction and predicts subsequent adverse cardiovascular events.

Supplemental Digital Content is available in the text., Background: High-sensitivity cardiac troponin assays enable myocardial infarction to be ruled out earlier, but the safety and efficacy of this approach is uncertain. We investigated whether an early rule-out pathway is safe and effective for patients with suspected acute coronary syndrome. Methods: We performed a stepped-wedge cluster randomized controlled trial in the emergency departments of 7 acute care hospitals in Scotland. Consecutive patients presenting with suspected acute coronary syndrome between December 2014 and December 2016 were included. Sites were randomized to implement an early rule-out pathway where myocardial infarction was excluded if high-sensitivity cardiac troponin I concentrations were

Background and Purpose— We conducted a randomized exploratory study to assess safety and the probability of a favorable outcome with adjunctive argatroban, a direct thrombin-inhibitor, administered to recombinant tissue-type plasminogen activator (r-tPA)–treated ischemic stroke patients. Methods— Patients treated with standard-dose r-tPA, not receiving endovascular therapy, were randomized to receive no argatroban or argatroban (100 μg/kg bolus) followed by infusion of either 1 (low dose) or 3 μg/kg per minute (high dose) for 48 hours. Safety was incidence of symptomatic intracerebral hemorrhage. Probability of clinical benefit (modified Rankin Scale score 0–1 at 90 days) was estimated using a conservative Bayesian Poisson model (neutral prior probability centered at relative risk, 1.0 and 95% prior intervals, 0.33–3.0). Results— Ninety patients were randomized: 29 to r-tPA alone, 30 to r-tPA+low-dose argatroban, and 31 to r-tPA+high-dose argatroban. Rates of symptomatic intracerebral hemorrhage were similar among control, low-dose, and high-dose arms: 3/29 (10%), 4/30 (13%), and 2/31 (7%), respectively. At 90 days, 6 (21%) r-tPA alone, 9 (30%) low-dose, and 10 (32%) high-dose patients were with modified Rankin Scale score 0 to 1. The relative risks (95% credible interval) for modified Rankin Scale score 0 to 1 with low, high, and either low or high dose argatroban were 1.17 (0.57–2.37), 1.27 (0.63–2.53), and 1.34 (0.68–2.76), respectively. The probability that adjunctive argatroban was superior to r-tPA alone was 67%, 74%, and 79% for low, high, and low or high dose, respectively. Conclusions— In patients treated with r-tPA, adjunctive argatroban was not associated with increased risk of symptomatic intracerebral hemorrhage and provides evidence that a definitive effectiveness trial is indicated. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique Identifier: NCT01464788.

Supplemental Digital Content is available in the text., Background: The introduction of more sensitive cardiac troponin assays has led to increased recognition of myocardial injury in acute illnesses other than acute coronary syndrome. The Universal Definition of Myocardial Infarction recommends high-sensitivity cardiac troponin testing and classification of patients with myocardial injury based on pathogenesis, but the clinical implications of implementing this guideline are not well understood. Methods: In a stepped-wedge cluster randomized, controlled trial, we implemented a high-sensitivity cardiac troponin assay and the recommendations of the Universal Definition in 48 282 consecutive patients with suspected acute coronary syndrome. In a prespecified secondary analysis, we compared the primary outcome of myocardial infarction or cardiovascular death and secondary outcome of noncardiovascular death at 1 year across diagnostic categories. Results: Implementation increased the diagnosis of type 1 myocardial infarction by 11% (510/4471), type 2 myocardial infarction by 22% (205/916), and acute and chronic myocardial injury by 36% (443/1233) and 43% (389/898), respectively. Compared with those without myocardial injury, the rate of the primary outcome was highest in those with type 1 myocardial infarction (cause-specific hazard ratio [HR] 5.64 [95% CI, 5.12–6.22]), but was similar across diagnostic categories, whereas noncardiovascular deaths were highest in those with acute myocardial injury (cause specific HR 2.65 [95% CI, 2.33–3.01]). Despite modest increases in antiplatelet therapy and coronary revascularization after implementation in patients with type 1 myocardial infarction, the primary outcome was unchanged (cause specific HR 1.00 [95% CI, 0.82–1.21]). Increased recognition of type 2 myocardial infarction and myocardial injury did not lead to changes in investigation, treatment or outcomes. Conclusions: Implementation of high-sensitivity cardiac troponin assays and the recommendations of the Universal Definition of Myocardial Infarction identified patients at high-risk of cardiovascular and noncardiovascular events but was not associated with consistent increases in treatment or improved outcomes. Trials of secondary prevention are urgently required to determine whether this risk is modifiable in patients without type 1 myocardial infarction. Clinical Trial Registration: https://www.clinicaltrials.gov. Unique identifier: NCT01852123.

It is estimated that 19% of 16–24 year olds suffer from a mental health condition. There has been a fivefold increase in reported mental health problems from first year university students since 2006/07(1). Limited but consistent evidence suggests that nutritional status is linked to mental health. University students may be more vulnerable to the impact of diet on mental health due to increased food insecurity and risk of stress. The aim of this project was to determine the association between nutritional status and stress, anxiety and depression in university students.After obtaining ethical approval, university students (n = 562) aged 18–24 y were recruited. A cross-sectional design was used to measure body mass index (BMI), percent body fat (%BF), capillary blood measures of glucose and lipids and nutrient intake by validated 3-day food diary. Mental health status was determined by DASS21 questionnaire (2) and participants were grouped into 5 categories: normal, mild, moderate, severe and extremely severe for anxiety, depression or stress. Difference in nutritional status between categories was determined by a Kruskal-Wallis test and Dun-Bonferroni post-hoc tests using SPSS version 25 and significance determined as p < 0.05.Results showed that depression was associated with %BF (p = 0.025), blood glucose (p < 0.001), dietary protein (p = 0.003) and dietary sugar (p = 0.041). Anxiety was associated with blood glucose (p < 0.001) and dietary protein (p = 0.007).Stress was associated with total cholesterol (p = 0.007), HDL cholesterol (p = 0.007) and blood glucose (p < 0.001).In light of these findings, further research is required to investigate the effect of student lifestyle habits and university practices on mental health and nutritional status so that strategic interventions can be designed to improve the health of young adults at university.

Background Major disparities between women and men in the diagnosis, management, and outcomes of acute coronary syndrome are well recognized. Objectives The aim of this study was to evaluate the impact of implementing a high-sensitivity cardiac troponin I assay with sex-specific diagnostic thresholds for myocardial infarction in women and men with suspected acute coronary syndrome. Methods Consecutive patients with suspected acute coronary syndrome were enrolled in a stepped-wedge, cluster-randomized controlled trial across 10 hospitals. Myocardial injury was defined as high-sensitivity cardiac troponin I concentration >99th centile of 16 ng/l in women and 34 ng/l in men. The primary outcome was recurrent myocardial infarction or cardiovascular death at 1 year. Results A total of 48,282 patients (47% women) were included. Use of the high-sensitivity cardiac troponin I assay with sex-specific thresholds increased myocardial injury in women by 42% and in men by 6%. Following implementation, women with myocardial injury remained less likely than men to undergo coronary revascularization (15% vs. 34%) and to receive dual antiplatelet (26% vs. 43%), statin (16% vs. 26%), or other preventive therapies (p, Central Illustration

This qualitative study investigates the social justice leadership practices of three primary principals working in some of the most disadvantaged areas in Victoria, Australia. Drawing on Pierre Bourdieu’s theory of practice I explore how the principals’ understandings of social justice are shaped by the intersection of their life and work histories. I examine how their understandings are structured by and structuring of a public education system heavily influenced by neoliberal ideologies. I investigate the disjunctions between the understandings of social justice expressed by these educational leaders and their leadership practices, and implications of this leadership scholarship, policy and practice.

Background: New Zealand has a unique model of maternity care, with midwives as the predominant carers. A recently published retrospective cohort study sought to compare the experience levels of Lead Maternity Carer midwives with rates of perinatal mortality. The paper claimed that an association was found between first year of practice midwives and increased perinatal mortality. However, the study design was seriously flawed and the data do not support the conclusions that were drawn. Aim: To systematically critique the study using the principles of epidemiological research. Methods: The study design and methodology were critically analysed in terms of the three potential sources of error that occur in observational studies: bias (measurement error), confounding and chance. The potential impacts on results were considered. Findings: Four areas of misclassification bias were identified, which introduced error to the data from the design stage. Important confounders were not distinguished and therefore neither excluded in the design stage nor adjusted for in the analysis. These flaws invalidate the results. The hypothesis test for the outcome of interest indicated an extremely high likelihood that the apparent association between midwives in their first year of practice and increased perinatal mortality was due to chance. Conclusion: Because of the major methodological flaws in this research, no conclusions can be drawn from the results. This paper highlights the importance of involving members of the profession being studied in the research team to improve quality by providing crucial insight into the sector and identifying potential sources of error.

Background We describe innovations in the study design and the efficient data coordination of a randomized multicenter trial of Argatroban in Combination with Recombinant Tissue Plasminogen Activator for Acute Stroke (ARTSS-2). Methods ARTSS-2 is a 3-arm, multisite/multiregional randomized controlled trials (RCTs) of two doses of Argatroban injection (low, high) in combination with recombinant tissue plasminogen activator (rt-PA) in acute ischemic stroke patients and rt-PA alone. We developed a covariate adaptive randomization program that balanced the study arms with respect to study site as well as hemorrhage after thrombolysis (HAT) score and presence of distal internal carotid artery occlusion (DICAO). We used simulation studies to validate performance of the randomization program before making any adaptations during the trial. For the first 90 patients enrolled in ARTSS-2, we evaluated performance of our randomization program using chi-square tests of homogeneity or extended Fisher's exact test. We also designed a four-step partly Bayesian safety stopping rule for low and high dose Argatroban arms. Results Homogeneity of the study arms was confirmed with respect to distribution of study site (UK sites vs. US sites, P = 0.98), HAT score (0–2 vs. 3–5, P = 1.0), and DICAO (N/A vs. No vs. Yes, P = 0.97). Our stopping thresholds for safety of low and high dose Argatroban were not crossed. Despite challenges, data quality was assured. Conclusions We recommend adaptive designs for randomization and Bayesian safety stopping rules for multisite Phase I/II RCTs for maintaining additional flexibility. Efficient data coordination could lead to improved data quality.

iEditing splits the mind.1 1 This article is dedicated to Kevin Mount. It operates – with critical resistance, as Johanna Drucker reminds us – across that great divide between reading and looking w...

The New York-based writer and editor Bonnie Marranca has a unique voice in modern American arts and letters. As a writer she has championed the experimental tradition in theatre and performance for more than 35 years. As an essayist she has consistently explored form, in relation to artistic experiment. In the late fall of 2011 I recorded a talk with her, during the course of a long afternoon at her downtown apartment close to the Hudson River. The occasion was prompted by the imminent publication of the 100th issue of PAJ: A Journal of Performance and Art, as well as by the Excellence in Editing Award for Sustained Achievement which had been recently given to her by ATHE [Association for Theatre in Higher Education]. The interview explores connections within her work and considers the way in which it has developed in conversation with artists in and around New York, bringing to light her continuing interest in spirituality, ecology and modernism, the cross connections between the avant-garde and popular ...

Imagine this: There was a time – oh, say thirty or even forty years ago now – when as young feminists we were obsessed by false words, when we wanted to discard that old ‘male-functioning’ language...

The aim of this project was to evaluate the effectiveness and outcomes of a redesigned newly licensed nurse orientation program. A unique aspect of this program was an end-of-orientation simulated four-patient assignment that was designed to assess five categories of critical thinking: prioritization and delegation, problem recognition, clinical decision making, clinical implementation, and reflection. Newly licensed nurses' critical thinking was measured by the Advisory Board's Critical Thinking Diagnostic tool at 10 weeks, 6 months, and 12 months. Findings showed that in all five categories of critical thinking, a significant increase was found between the 10-week and 6-month evaluation. Two of the categories—prioritization and delegation, and problem recognition—were found to have a significant increase from the 6-month evaluation to the 12-month evaluation. In addition, newly licensed nurses reported improvement in their confidence and in their preparation to work independently. J Contin Educ Nurs. 2017;48(1):22–28.

Martha Wilson Sourcebook: 40 Years of Reconsidering Performance, Feminism, Alternative Spaces Edited by Martha Wilson. Independent Curators International 2011. New York's alternative art spaces: th...

John Cage has had a long and remarkably wide influence in the United Kingdom. Not only was the run-up to his centenary year filled with music and art events, including a major touring exhibition of his visual art curated by British artist Jeremy Millar, but his work has also been adopted by popular culture. In 2010, for instance, a collective of pop musicians recorded his 4’ 33” as a Christmas single and strove to have it head the music charts. In the same year, on the BBC’s radio program Desert Island Discs, poet Ian McMillan chose 4’ 33” as the one record he would want to take to a desert island.1 Within British culture Cage remains a radical touchstone—an intriguing, even mysterious, figure: he was, after all, an American. Talking about what Cage has meant to him, again on BBC radio in the series Great Lives, in 2007, the British-born and American-raised artist Michael Craig Martin said of him, “when someone influences you, it is because they say something that in your heart is familiar to you. They are hitting on something you already feel.” The history of that something, and of Cage’s presence in Britain, is the subject of this. In it I pick up traces of some long standing, and in some cases, long forgotten, transatlantic conversations about art, education, and culture that reveal something about the times and circles through which Cage moved, and which connect British and American counter-cultural histories.

This article identifies a new dramaturgy, which foregrounds the process of mediation between the starting proposition of a work and its eventual realization in performance. Such a dramaturgy does not proceed from text as a known set of procedures, but instead questions what those procedures might be. Thus, the article moves towards an idea of dramaturgy as a material process. Taking the example of In Bed (2002) a work created with students from George Mason University, and in collaboration with Claire Hind, Simon Zimmerman, Ange Taggart and Huda Totonji, the author discusses the way in which the dramaturgical structure of the work was created from the inside, through the activity of performers carrying out tasks in real time, documenting and reflecting on those tasks and imagining new ones. She moves on to compare dramaturgically open works, such as her own five-minute text, also entitled In Bed (2008), with the Fluxus event score that both records a performance moment and is permanently open for ...

Potassium is a shortfall nutrient according to the 2010 Dietary Guidelines for Americans. Only 3% of Americans meet the recommended Adequate Intake of 4700 mg/d for potassium. Bioavailability of potassium has not been considered in setting requirements as no food has been tested. Among adult potato consumers potatoes provide 19-20% of potassium in the diet. The aim of this study was to compare bioavailability and dose response of potassium from non-fried white potatoes with skin with potassium gluconate. Thirty five healthy, normotensive men and women with a mean age of 29.7 (+/- 11.2) years and BMI of 24.3 (+/- 4.4) kg/m2 (mean +/- (SD)) were enrolled in this single-blind, cross-over, randomized controlled trial. Participants were randomized to 1 of 8 interventions of potassium: 0 (control repeated twice), 720 (~18.5), 1440 (~37), 2160 (~55.5) mg/day (mEq/day) consumed as a potassium gluconate supplement or white potato with skin added to the basal diet containing ~2300 mg/day (~60 mEq/day) potassium. Bi...

Background: Enrollment into acute ischemic stroke (AIS) trials is usually limited to weekday working hours. At our center, the majority of patients (64%) that receive tPA arrive after-hours. As a result, a large portion of eligible patients do not receive the opportunity to participate in these trials, hence enrollment rate suffers. Objectives: Demonstrate ongoing experience regarding feasibility and implementation of a 24/7 enrollment plan for an international AIS trial. Compare differences in patients’ characteristics enrolled during working hours ( WH - Mon-Fri 07:00-17:00) vs. after hours+weekend ( AH ). Methods: Data obtained from an on-going, multi-center, randomized, time-sensitive, tPA-adjunctive clinical trial (ARTSS-2; NCT01464788) Centers capable of doing so, implemented an on-call system for coordinators to respond AH. AH enrollment includes a coordinated effort to reduce time and meet the time challenges of screening, consent, randomization and starting study drug before the end of tPA infusion. The coordinator arrives at the ED to assist in-house physician with study procedures. We conducted descriptive analyses that explore differences between WH vs. AH . Results: As of 08/14, a total of 240 patients were eligible of which 75 were enrolled. Of these, 32 (43%) were enrolled AH at a total of 6 sites. 15 of 32 AH patients were enrolled at non-coordinating centers. AH patients were younger and more likely to be male (Table 1). Compared to WH, AH enrollment did not delay tPA initiation, time to website randomization, or initiation of study drug. No signal of increased harm or trial protocol deviations was evident between the two groups. Conclusion: 24/7 clinical trial enrollment is safe and feasible in a multicenter, international thrombolysis trial. We increased recruitment by 75% with no delays in randomization or initiation of study treatment. Efforts to provide 24/7 coverage should be implemented to improve trial recruitment rates.

93-100 This essay was part of my ongoing research interest in the relationship between language, voice, writing and sound composition in art, and in the work of American artists who began their careers in the late 1950s. It considered as its core Bruce Nauman’s 2005 installation in the Turbine Hall at Tate Modern from a theoretical and historical perspective focussing on Nauman’s interest in language, sound and musical composition. My title played on his (‘Raw Materials’) and on the Miltonic reference in Philip Pullman’s theatrical Trilogy ‘His Dark Materials’ playing at the time at the National Theatre. I connected this with the oblique reference to John Cage in roar/raw, and the references in Nauman’s work to Cage’s ‘Roaratorio’, suggesting a dynamic interplay around authorship, primal matter, voice, text and sound as material elements, and alchemy. The fact that Nauman may not have had any idea of Pullman’s juxtaposed (half a mile away) trilogy, only added to the Naumanesque magnetism between the titles. In experiencing the work I moved through the Cage connection to realizing Nauman’s deep interest in and conscious references to the work of Alvin Lucier and Steve Reich, and through research, learned that he had worked with Reich in the late 1950s and had been the subject of Reich’s research for his piece Pendulum Music. The article is one of several that re-see and re-member visual art in terms of other art forms – language poetry, music and literature. Rather than seeing this art as interdisciplinary I see instances of artistic expression within the terms and conditions suggested by other forms. The conceptual power and conscious literary (to Beckett particularly) and musical references within the construction of Nauman’s work made this especially fruitful as a research project that has led to other writings in progress.

These are books about the pleasure of the text in the widest sense. They are each sumptuously produced, visually pleasurable books that engage in intriguing ways with the pleasure of making art and the pleasure of challenging ideas. This doesn’t mean that they celebrate naive and essentialist notions of what feminism is, or what it means to be a woman artist, in fact quite the contrary. It means that they foreground pleasure, wit, and subversion at that strange moment in our culture when the dynamism of popular feminism has faded. In one sense they act as correctives. In another sense they each acknowledge these new historical circumstances, and seem, in different ways, to speak back to them.

Background Around 30% to 62% of older individuals fall each year, with adverse consequences of falls being by no means limited to physical injury and escalating levels of dependence. Many older individuals suffer from a variety of adverse psychosocial difficulties related to falling including fear, anxiety, loss of confidence and subsequent increasing activity avoidance, social isolation and frailty. Such ‘fear of falling’ is common and disabling, but definitive studies examining the effective management of the syndrome are lacking. Cognitive behavioural therapy has been trialed with some success in a group setting, but there is no adequately powered randomised controlled study of an individually based cognitive behavioural therapy intervention, and none using non-mental health professionals to deliver the intervention. Methods/Design We are conducting a two-phase study examining the role of individual cognitive behavioural therapy delivered by healthcare assistants in improving fear of falling in older adults. In Phase I, the intervention was developed and taught to healthcare assistants, while Phase II is the pragmatic randomised controlled study examining the efficacy of the intervention in improving fear of falling in community-dwelling elders attending falls services. A qualitative process evaluation study informed by Normalization Process Theory is being conducted throughout to examine the potential promoters and inhibitors of introducing such an intervention into routine clinical practice, while a health economic sub-study running alongside the trial is examining the costs and benefits of such an approach to the wider health economy. Trial registration Current Controlled Trials ISRCTN78396615