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Background Delirium is a complication that presents a frequent challenge on our inpatient wards. Early recognition, detection and diagnosis of delirium can improve patient outcomes. The 4 ‘A’s Test (4AT) is a validated, rapid initial assessment tool that is a sensitive and specific method of screening for delirium in hospitalised patients. Aims To determine the prevalence of use of the 4AT and to reveal if increasing staff awareness yielded improvement in use of the 4AT and detection of delirium. Methods Initial data collection analysed inpatient notes on our rehabilitation (rehab) ward and medical assessment unit (MAU), for any terminology suggestive of an underlying delirium. Rehab ward nursing staff had already received training on delirium detection. Following this, formal teaching was delivered to junior doctors, and 4AT lanyard cards were distributed. One month later, another round of data collection was undertaken. Throughout the year, nurses in MAU were educated on delirium. Further data was collected 1 year later. Results Baseline data analysis showed use of the 4AT on the rehab ward (75%) was significantly greater than MAU (20%). This was associated with increased detection/diagnosis of delirium on the rehab ward (75% diagnosed, 100% concordance with 4AT use) compared to MAU (20%). After 1 month, use of the 4AT improved dramatically on MAU (50%) and remained high on the rehab ward, improving to 87.5%. Results at 1 year show use of the 4AT continues to remain high on the rehab ward (75%) in at-risk patients. In addition, there remains a sustained improvement in 4AT use on MAU (40%) compared to baseline data (20%). Diagnosis and recording of delirium continues to improve on MAU (100% of suspected patients diagnosed), and remains high (75%) on our rehab ward. Conclusion Our findings support the continued use of the 4AT screening tool and ongoing staff education and training in order to improve knowledge and confidence in detecting signs of delirium.

Background Delirium is a complication that presents a frequent challenge on our inpatient wards. Early recognition, detection and diagnosis of delirium can improve patient outcomes. The 4 ‘A’s Test (4AT) is a validated, rapid initial assessment tool that is a sensitive and specific method of screening for delirium in hospitalised patients. Aims To determine the prevalence of use of the 4AT and to reveal if increasing staff awareness yielded improvement in use of the 4AT and detection of delirium. Methods Initial data collection analysed inpatient notes on our rehabilitation (rehab) ward and medical assessment unit (MAU), for any terminology suggestive of an underlying delirium. Rehab ward nursing staff had already received training on delirium detection. Following this, formal teaching was delivered to junior doctors, and 4AT lanyard cards were distributed. One month later, another round of data collection was undertaken. Throughout the year, nurses in MAU were educated on delirium. Further data was collected 1 year later. Results Baseline data analysis showed use of the 4AT on the rehab ward (75%) was significantly greater than MAU (20%). This was associated with increased detection/diagnosis of delirium on the rehab ward (75% diagnosed, 100% concordance with 4AT use) compared to MAU (20%). After 1 month, use of the 4AT improved dramatically on MAU (50%) and remained high on the rehab ward, improving to 87.5%. Results at 1 year show use of the 4AT continues to remain high on the rehab ward (75%) in at-risk patients. In addition, there remains a sustained improvement in 4AT use on MAU (40%) compared to baseline data (20%). Diagnosis and recording of delirium continues to improve on MAU (100% of suspected patients diagnosed), and remains high (75%) on our rehab ward. Conclusion Our findings support the continued use of the 4AT screening tool and ongoing staff education and training in order to improve knowledge and confidence in detecting signs of delirium.

Hyperkalemia is common among elderly patients and is associated with an increase in morbidity and mortality. Patients at highest risk for developing hyperkalemia are those with chronic kidney disease (CKD) and heart failure (HF), particularly those on guideline-recommended inhibitors of the renin-angiotensin-aldosterone system (RAAS). Hyperkalemia remains a challenge for clinicians practicing in the long-term care setting as they are often faced with the difficult decision of down-titrating or discontinuing RAAS inhibitors in response to hyperkalemia in the very patients who derive the greatest benefit from these agents. In the past, options to chronically manage hyperkalemia were limited. Patiromer was approved for the treatment of hyperkalemia in 2015 and has been shown to maintain normokalemia for up to 52 weeks in patients with CKD and/or HF on RAAS inhibitors. With the emergence of a new hyperkalemia treatment, there could be a paradigm shift away from the discontinuation of guideline recommended therapies, allowing the continuation of RAAS inhibitor therapy to effectively manage HF symptoms and reduce the risk of rehospitalization in patients with HF, and slow the progression to end-stage renal disease in patients with CKD.

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

Epicardial electrical events were reconstructed using an inverse model for left ventricular (LV) pacing and during ventricular tachycardia (VT) induced during implantation of a biventricular pacemaker and/or internal defibrillator. The electrocardiographic position of the pacing lead, determined from the region of most negative potential 30 ms after the pacing spike, was compared with the radiographic position. Activation characterized by isochronal maps was correlated with the echocardiographic/myocardial scintigraphic data. Reconstructed epicardial isopotential/isochronal maps during VT were used to determine the presence of reentry. In 7 patients during LV pacing, epicardial isopotential maps located the maximum negative potentials anterolaterally (n = 3), posterolaterally (n = 2), and posteriorly (n = 2). Isochronal maps demonstrated activation patterns including regions of delayed activation that, in 5 patients, correlated with areas of akinesia/hypokinesia or fixed defects on echocardiography/myocardial scintigraphy. The mean difference between the radiographically measured right ventricular to LV pacing lead distance and calculated electrocardiographic right ventricular to LV pacing site distance was 1.7 cm. During VT, induced in 5 patients, single-loop reentry was observed in 3 and figure-of-8 reentry in 2. Exit site and regions of fast/slow conduction and conduction block that correlated with anatomic areas of infarction defined by echocardiography/myocardial scintigraphy were demonstrated. In conclusion, epicardial maps reconstructed from the body surface map can identify LV pacing sites and demonstrate reentry during VT. The body surface map could thus identify optimal pacing sites for LV pacing and targets for VT ablation.

After several decades of theoretical developments, desk studies, experimental wind turbines and prototype wind farms, the first large-scale commercial developments of offshore wind farms are now being built. To support and accelerate this development, the European Commission funded a project, ‘Concerted Action on Offshore Wind Energy in Europe’ (CA-OWEE), which aimed to gather, evaluate, synthesize and distribute knowledge on all aspects of offshore wind energy, including offshore technology, electrical integration, economics, environmental impacts and political aspects. The partners are from a wide range of fields and include developers, utilities, consultants, research institutes and universities. This article reports on the final conclusions of this project, with the complete report being available online at http://www.offshorewindenergy.org. Copyright © 2003 John Wiley & Sons, Ltd.

Aims To evaluate the role of novel biomarkers in early detection of acute myocardial infarction (MI) in patients admitted with acute chest pain. Methods and results A prospective study of 664 patients presenting to two coronary care units with chest pain was conducted over 3 years from 2003. Patients were assessed on admission: clinical characteristics, ECG (electrocardiogram), renal function, cardiac troponin T (cTnT), heart fatty acid binding protein (H-FABP), glycogen phosphorylase-BB, NT-pro-brain natriuretic peptide, D-dimer, hsCRP (high sensitivity C-reactive protein), myeloperoxidase, matrix metalloproteinase-9, pregnancy associated plasma protein-A, soluble CD40 ligand. A ≥12 h cTnT sample was also obtained. MI was defined as cTnT ≥ 0.03 µg/L. In patients presenting

To evaluate the prognostic role of novel biomarkers for the risk stratification of patients admitted with ischemic-type chest pain, a prospective study of 664 patients presenting to 2 coronary care units with ischemic-type chest pain was conducted over 3 years beginning in 2003. Patients were assessed on admission for clinical characteristics, electrocardiographic findings, renal function, cardiac troponin T (cTnT), markers of myocyte injury (heart fatty acid-binding protein [H-FABP] and glycogen phosphorylase BB), neurohormonal activation (N-terminal-pro-brain natriuretic peptide [NT-pro-BNP]), hemostatic activity (fibrinogen and D-dimer), and vascular inflammation (high-sensitivity C-reactive protein, myeloperoxidase, matrix metalloproteinase-9, pregnancy-associated plasma protein-A, and soluble CD40 ligand). Aor=12-hour cTnT sample was also obtained. Myocardial infarction (MI) was defined as peak cTnTor=0.03 microg/L. Patients were followed for 1 year from the time of admission. The primary end point was death or MI. Elevated fibrinogen, D-dimer, H-FABP, NT-pro-BNP, and peak cTnT were predictive of death or MI within 1 year (unadjusted odds ratios 2.5, 3.1, 5.4, 5.4, and 6.9, respectively). On multivariate analysis, H-FABP and NT-pro-BNP were selected, in addition to age, peak cTnT, and left ventricular hypertrophy on initial electrocardiography, as significant independent predictors of death or MI within 1 year. Patients without elevations of H-FABP, NT-pro-BNP, or peak cTnT formed a very low risk group in terms of death or MI within 1 year. A very high risk group had elevations of all 3 biomarkers. In conclusion, the measurement of H-FABP and NT-pro-BNP at the time of hospital admission for patients with ischemic-type chest pain adds useful prognostic information to that provided by the measurement of baseline and 12-hour cTnT.

We aimed to develop 12-lead electrocardiographic (ECG) models testing ST-elevation criteria with QRST variables and compare their performance with the 80-lead body surface map (BSM) in detection of acute myocardial infarction (AMI). Because the prevalence of non-ST-elevation AMI is increasing worldwide, advances in early ECG detection of AMI are urgently needed. The study population was 755 consecutive patients presenting with ischemic chest pain from January 2002 to June 2004. All patients had electrocardiography and body surface mapping performed at initial presentation. AMI occurred in 519 patients (69%, cardiac troponin T or I levelor =0.1 ng/ml). Of these 519 patients, 303 (58%) had no ST-elevation on the initial 12-lead electrocardiogram. Ten patients were classified as having an "aborted AMI" and were included in the AMI analysis. The American College of Cardiology/European Society of Cardiology criteria for ST-elevation on 12-lead electrocardiogram identified 236 patients with AMI (sensitivity 45%, specificity 92%). Additional QRST features improved sensitivity (51% to 68%) but with decreased specificity (71% to 89%), with the optimal multivariate ECG model having a c-statistic of 0.75. The optimal BSM model identified 402 patients as having AMI (sensitivity 76%, specificity 92%, c-statistic 0.84). This improvement in sensitivity over the 12-lead electrocardiogram was due mainly to detection of ST-elevation in the high right anterior, posterior, and right ventricular territories and AMI in the presence of left bundle branch block. In conclusion, QRST variables added to criteria for ST-elevation result in improvement in sensitivity of the 12-lead electrocardiogram, although with decreased specificity. The BSM is superior in detecting AMI and demonstrates the importance of electroanatomic evaluation of patients with acute coronary syndromes.

Background Noncontact endocardial mapping allows accurate beat-to-beat reconstruction of the reentrant pathway of ventricular tachycardia and improves outcomes after ablation. Several studies support electrocardiographic imaging (ECGI) as a means of noninvasively outlining epicardial activation despite constraints of internal geometry. However, few have explored its clinical application. This study aims to evaluate ECGI during selective left ventricular (LV) pacing, relative to an invasive approach. Methods Multisite pacing was performed within the left ventricles of 3 patients undergoing invasive procedures. Simultaneous recording of endocardial potentials using a noncontact multielectrode array and body surface potentials (BSP) using an 80-electrode torso vest was performed. A total of 16 recordings were made. The inverse solution was applied to BSP to reconstruct epicardial activation. Single-paced beats from real and virtual electrograms were used to construct 3-dimensional isochronal and isopotential maps. Endocardial and epicardial data were then superimposed onto a single geometry to allow quantitative comparison of activation foci. Results Good correlation was observed between endocardial activation patterns and those reconstructed from BSP using ECGI. This was repeatedly demonstrated in all LV regions except for the septum (3 recordings). Epicardial isochronal maps were able to locate early and late activation to mean distances of 13.8 ± 4.7 and 12.5 ± 3.7 mm from endocardial data. Isopotential maps localized pacing sites with comparable accuracy (14 ± 5.3 mm). Conclusions Body surface potentials and reconstructed epicardial activation patterns during LV pacing correlate well with endocardial data acquired invasively. The exception was during pacing of the septum. Although early results are encouraging, further quantitative data are required to fully validate and apply this noninvasive tool in the clinical arena.

After several decades of theoretical developments, desk studies, experimental wind turbines and prototype wind farms, the first large-scale commercial developments of offshore wind farms are now being built. To support and accelerate this development, the European Commission funded a project, "Concerted Action on Offshore Wind Energy in Europe" (CA-OWEE), which aimed to gather, evaluate, synthesise and distribute knowledge on all aspects of offshore wind energy, including offshore technology, electrical integration, economics, environmental impacts and political aspects. The partners are from a wide range of fields and include developers, utilities, consultants, research institutes and universities. This paper reports on the final conclusions of this project, with the complete report being available online at http//www.offshorewindenergy.org.