BackgroundRapid access chest pain clinics have facilitated the early diagnosis and treatment of patients with coronary heart disease and angina. Despite this important service provision, coronary heart disease continues to be under-diagnosed and many patients are left untreated and at risk. Recent advances in imaging technology have now led to the widespread use of noninvasive computed tomography, which can be used to measure coronary artery calcium scores and perform coronary angiography in one examination. However, this technology has not been robustly evaluated in its application to the clinic.Methods/designThe SCOT-HEART study is an open parallel group prospective multicentre randomized controlled trial of 4,138 patients attending the rapid access chest pain clinic for evaluation of suspected cardiac chest pain. Following clinical consultation, participants will be approached and randomized 1:1 to receive standard care or standard care plus ≥64-multidetector computed tomography coronary angiography and coronary calcium score. Randomization will be conducted using a web-based system to ensure allocation concealment and will incorporate minimization. The primary endpoint of the study will be the proportion of patients diagnosed with angina pectoris secondary to coronary heart disease at 6 weeks. Secondary endpoints will include the assessment of subsequent symptoms, diagnosis, investigation and treatment. In addition, long-term health outcomes, safety endpoints, such as radiation dose, and health economic endpoints will be assessed. Assuming a clinic rate of 27.0% for the diagnosis of angina pectoris due to coronary heart disease, we will need to recruit 2,069 patients per group to detect an absolute increase of 4.0% in the rate of diagnosis at 80% power and a two-sided P value of 0.05. The SCOT-HEART study is currently recruiting participants and expects to report in 2014.DiscussionThis is the first study to look at the implementation of computed tomography in the patient care pathway that is outcome focused. This study will have major implications for the management of patients with cardiovascular disease.Trial registrationClinicalTrials.gov Identifier: NCT01149590

A distinct ulcerative dermatitis known as “freshwater skin disease” is an emerging clinical and pathological presentation in coastal cetaceans worldwide. In Australia, two remarkably similar mortality events enabled the creation of a case definition based on pathology and environmental factors. The first affected a community of endemic Tursiops australis in the Gippsland Lakes, Victoria, while the second occurred among T. aduncus resident in the Swan-Canning River system, Western Australia. The common features of both events were (1) an abrupt and marked decrease in salinity (from > 30ppt to < 5ppt) due to rainfall in the catchments, with hypo-salinity persisting weeks to months, and (2) dermatitis characterized grossly by patchy skin pallor that progressed to variable circular or targetoid, often raised, and centrally ulcerated lesions covering up to 70% of the body surface. The affected skin was often colonized by a variety of fungal, bacterial and algal species that imparted variable yellow, green or orange discoloration. Histologic lesions consisted of epidermal hydropic change leading to vesiculation and erosion; alternately, or in addition, the formation of intra-epithelial pustules resulting in ulceration and hypodermal necrosis. Thus, the environmental factors and characteristic pathologic lesions, are necessary components of the case definition for freshwater skin disease.

Cetacean stranding records can provide vital information on species richness and diversity through space and time. Here we collate stranding records from Victoria, Australia and assess them for temporal, spatial and demographic trends. Between 1920 and 2016, 424 stranding events involving 907 individuals were recorded across 31 Cetacea species from seven families, including five new species records for the state. Seven of these events were mass strandings, and six mother and calf strandings were recorded. Importantly, 48% of the species recorded are recognised as data deficient on the IUCN Red List. The most commonly recorded taxa were Tursiops spp. (n = 146) and Delphinus delphis (common dolphins, n = 81), with the greatest taxonomic richness (n = 24) and highest incidence of stranding events documented within the Otways mesoscale bioregion. We found no seasonal stranding patterns anywhere in the state. While our findings improve understanding of the spatial and temporal patterns of cetacean diversity within Victoria, we suggest greater effort to collect demographic data at stranding events in order to better study state-wide patterns through time. We conclude with guidelines for minimum data collection standards for future strandings to maximise information capture from each event.

Vessels cause considerable disturbance to cetaceans world-wide, with potential long-term impacts to population viability. Here we present a comprehensive review of vessel impacts to cetacean behavior in Australian waters (2003–2015), finding inadequate protections to be in place. The majority of these studies found trends of decreased animal travel and resting behavioral states as well as low compliance to regulations, and they recommended further regulatory action such as greater enforcement or monitoring, or passive management strategies. As a case study, we conducted the first field assessment of vessel compliance with the Wildlife (Marine Mammal) Regulations 2009 in Gippsland Lakes, Australia, and provide the first assessment of the endangered Gippsland Lakes Burrunan dolphin (Tursiops australis) population’s behavioral ecology. Dolphin behavior and vessel regulation compliance data were collected during boat-based surveys of Gippsland Lakes from July 2017 to January 2018, with a total of 22 dolphin group sightings resulting in 477 five-minute point samples. 77% of dolphin sightings involved vessel interactions (within 400 m), and 56 regulation breaches were observed. These breaches were most severe in summer (mean = 4.54 breaches/hour). Vessels were found to alter dolphin behavior before, during, and after interactions and regulation breaches, including increased mating (mate guarding) and milling behavioral states, and increased ‘fish catch’, ‘high leap’ and ‘tail slap’ behavioral events. These behavioral changes may indicate masking of the dolphins' acoustic communication, disturbance of prey, increased dolphin transition behaviors, and/or induced stress and changes to group structure (including increased mate guarding). While our results provide evidence of short-term altered behavior, the potential for long-term effects on population dynamics for this threatened species is high. In the context of reported inadequate cetacean protection Australia-wide, our management recommendations include greater monitoring and enforcement, and the utilisation of adaptive management.

Vessel impacts on marine mammals are of growing concern, and marine mammals in urbanized marine environments are at particular risk of exposure. Port Phillip Bay (Victoria, Australia) is one such environment, in which Australian fur seals (AUFS; Arctocephalus pusillus doriferus) haul‐out to rest, yet little is known about the impacts of vessels on resting seals. We used remote camera traps to investigate the influence of vessel traffic on AUFS behavior at a nonbreeding haul‐out site. Environmental, temporal, and vessel‐related variables were all associated with changes in AUFS alertness at this site. All vessel types elicited increased alertness above base‐line levels (25%), with recreational and commercial motorized vessels associated with a 5.7%–10.8% increase in alertness. Unidentified vessels, the government vessel, and kayaks were associated with significantly increased alertness of 21.7%, 46.4%, and 60.7%, respectively, though accounted for only 6.2% of vessel observations. Vessels breaching current approach regulations (<5 m) showed a 32% increase in alertness, significantly higher than nonbreach approaches. Partial and complete flushing of the platform was rare, occurring in 1.0% of images analyzed. These results suggest that vessels do elicit a response from AUFS at this haul‐out site, and that further monitoring of vessel activity and compliance is required.

Water systems can positively influence public well-being by teaming up with health agencies.Two case studies are presented that show how this collaborative work can happen at a local level.In the United States, the Lead and Copper Rule Revisions open the way for stronger communications across the water and public health sectors.