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Chest pain is one of the most common presentations to emergency departments. However, only 5.1% will be diagnosed with an acute coronary syndrome, representing considerable time and expense in the diagnosis and investigation of the patients eventually found not to be suffering from an acute coronary syndrome. PubMed and Medline databases were searched with variations of the terms "chest pain", "emergency department", "computed tomography coronary angiography". After review, 52 articles were included. Computed tomography coronary angiography (CTCA) is a class I endorsement for investigating chest pain in major international societal guidelines. CTCA offers excellent sensitivity and negative predictive value in identifying patients with coronary disease, with prognostic data impacting patient management. If CTCA is to be applied to all comers, it is pertinent to discuss the advantages and potential pitfalls if use in the Australian system is to be increased.

The authors sought to prospectively determine the safety and efficacy of next-day discharge using the Vancouver 3M (Multidisciplinary, Multimodality, but Minimalist) Clinical Pathway.Transfemoral transcatheter aortic valve replacement (TAVR) is an alternative to surgery in high- and intermediate-risk patients; however, hospital stays average at least 6 days in most trials. The Vancouver 3M Clinical Pathway is focused on next-day discharge, made possible by the use of objective screening criteria as well as streamlined peri- and post-procedural management guidelines.Patients were enrolled from 6 low-volume (100 TAVR/year), 4 medium-volume, and 3 high-volume (200 TAVR/year) centers in Canada and the United States. The primary outcomes were a composite of all-cause death or stroke by 30 days and the proportion of patients successfully discharged home the day following TAVR.Of 1,400 screened patients, 411 were enrolled at 13 centers and received a SAPIEN XT (58.2%) or SAPIEN 3 (41.8%) valve (Edwards Lifesciences, Irvine, California). In centers enrolling exclusively in the study, 55% of screened patients were enrolled. The median age was 84 years (interquartile range: 78 to 87 years) with a median STS score of 4.9% (interquartile range: 3.3% to 6.8%). Next-day discharge home was achieved in 80.1% of patients, and within 48 h in 89.5%. The composite of all-cause mortality or stroke by 30 days occurred in 2.9% (95% confidence interval: 1.7% to 5.1%), with neither component of the primary outcome affected by hospital TAVR volume (p = 0.51). Secondary outcomes at 30 days included major vascular complication 2.4% (n = 10), readmission 9.2% (n = 36), cardiac readmission 5.7% (n = 22), new permanent pacemaker 5.7% (n = 23), andmild paravalvular regurgitation 3.8% (n = 15).Adherence to the Vancouver 3M Clinical Pathway at low-, medium-, and high-volume TAVR centers allows next-day discharge home with excellent safety and efficacy outcomes.

To evaluate the association between markers of precapillary pulmonary hypertension (PH) and survival in transcatheter aortic valve replacement (TAVR).The importance of precapillary PH has been sparsely investigated in patients undergoing TAVR. It may prove an important risk factor for poor outcomes.We identified patients at our institution undergoing TAVR with a baseline right heart catheterization (RHC) demonstrating PH. We evaluated the association between markers of precapillary PH and survival including the diastolic pulmonary gradient (DPG), transpulmonary gradient (TPG), and pulmonary vascular resistance (PVR). A multivariable analysis was performed using Cox Proportional Hazards Models, adjusting for age, gender, body mass index, and pulmonary artery systolic pressure (PASP) on echocardiography.We identified 133 patients with PH on RHC. Of these 111 had low DPG and 22 had high DPG. All 3 markers of precapillary PH were associated with worse survival post TAVR, with OR of 2.1 (95% CI 1.1-3.9, P = 0.02), 3.4 (95% CI 1.8-6.4, P 0.001) and 2.5 (95% CI 1.4-4.5, P = 0.003) for high DPG, TPG, and PVR, respectively. On multivariable analysis, both TPG and PVR remained predictors of worse survival, with OR of 3.4 (95% CI 1.7-6.9, P = 0.001) and 2.5 (95% CI 1.4-4.5, P = 0.003). Echocardiographic PASP and DPG were not predictive of survival.In patients undergoing TAVR, parameters of precapillary PH are associated with lower survival, and provide incremental prognostication over echocardiographic PASP. RHC should continue to play an important role in risk stratification prior to TAVR. © 2017 Wiley Periodicals, Inc.

Energy and carbon are at the nexus of climate change, environment, health, and socio-economic development. The imperative to move towards cleaner and renewable energy to reduce greenhouse gas is gaining significant public and private sector support. Reducing carbon in the atmosphere has fast emerged as a major means to achieve this, since carbon content can be measured and hence the pathways can be well-defined. The December 2009 Copenhagen Accord recognized “the scientific view that the increase in global temperature should be below 2 degrees Celsius on the basis of equity and in the context of sustainable development.” To achieve this goal, the emerging scenario (e.g., the International Energy Agency (IEA) Report: World Energy Outlook 2009) is that the atmospheric concentration of CO 2 be stabilized at around 450 ppm. If global emissions peak in 2015, we estimate that annual reductions in CO 2 concentration of up to 5% would be necessary, equivalent to the Kyoto Protocol targets. Delaying reductions beyond the 2015 peak, however, would necessitate more drastic reduction rates that would be very difficult to achieve. To reach the necessary annual reduction in either case, investment in nonfossil energy must be significantly increased.

(1990). EIA AND SUSTAINABLE DEVELOPMENT. Impact Assessment: Vol. 8, Integrating Impact Assessment into the Planning Process, pp. 15-23.

Environmental awareness and concern is increasing, moving to the top of the political agenda. It is a major factor that will have significant implications for all operations of the oil industry. This paper discusses the impact on the oil industry of global warming, as a result of the increase in greenhouse gases, and the potential policies/strategies to limit CO 2 , through energy efficiency measures, fuel switching, risk reduction and environmental legislation.

The United Nations Environment Programme, UNEP, with the assistance of W.S. Atkins Research and Development, started work on developing guidelines for Assessing Industrial Environmental Impact and Environmental Criteria for the Siting of Industry in March 1978. At three ad hoc expert meetings it was agreed that the guidelines to be developed should not be of a cook book type of manual which would recommend a rigid step by step approach for undertaking environmental impact assessment. A rigid approach was considered not suitable since the guidelines would need to have global applications. Furthermore, as each industrial project would be somewhat different from another, and sited in different types of locations, a flexible approach would be needed to carry out impact assessments. The guidelines should therefore aim to provide a framework from which an appropriate environmental impact assessment process could be structured, taking into account the local conditions.

Experiments were conducted during a 5 mo period (September 1975 to January 1976) to determine the Pb concentrations in Bangkok streets and blood Pb levels of Bangkok's population. A total of 185 air samples and 222 blood samples was collected and analyzed. Street Pb levels are in the range of 6.16 to 22.48 μg m−3 and blood Pb levels are in the range of 1 to 34 μg (100 g)−1 of whole blood, with an average value of 12.3 μg (100 g)P−1. The effects of various parameters on air and blood Pb levels are discussed in this paper. Air Pb levels are found to be closely related to traffic volume and proximity to the roads. Blood Pb levels are found to increase progressively with age, reaching a saturation value at about 40 yr of age. The average time spent daily on roads by the people and the distance of their residence/workplace from the main road are found to be major parameters, affecting the blood Pb levels. There is no evidence to show that blood and air Pb levels are directly related, at the present ambient exposure levels.

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