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The fuel routes at each advanced gas-cooled reactor power station are required to operate safely and reliably to keep the reactors operational. On average, about one-sixth of the total fuel inventory must be renewed each year. A variety of refuelling modes are employed at particular stations arising from detailed design, historical and safetycase considerations. At Hartlepool and Heysham 1, which are of the same design, routine refuelling is done in batches with the reactors off-load and depressurized (although pressurized off-load refuelling is also permitted). The batches are as large as practicable in order to minimize output losses due to refuelling. The batch process involves both the exchange of spent fuel assemblies for new ones the transfer of part-burnt fuel assemblies to new positions in the core to improve fuel utilization-known as 'radial shuffling'. Once the batch is complete, a programme of irradiated fuel disposals (separating the fuelassemblies into individual fuel elements and culminating in the dispatch of fuel elements off site in flasks) and new fuel assembly builds is begun. These operations involve the use of several fuel route plant facilities including cooling ponds. The refuelling process from the build of new fuel to the final handling of complete irradiated fuel assemblies is covered by a refuelling safety case. Further safety cases exist for the handling of individual irradiated elements both onand off site. All these cases are updated as necessary via a formal plant modifications procedure and they have recently been subject to a ten-yearly periodic safety review (PSR). Arising from the PSR, workto consolidate the cases is in progress including studies in the seismic and human factors areas. Development work to improve the efficiency of the fuel route is also under way. This involves process improvements to assist operators engineered improvements to improve speed and reliability fuel utilization improvements by increases in discharge ir [ABSTRACT FROM AUTHOR]

Background: We aimed to compare the diagnostic accuracy of the Alere Triage Cardio3 Tropinin I (TnI) assay (Alere, Inc., USA) and the PathFast cTnI-II (Mitsubishi Chemical Medience Corporation, Japan) against the central laboratory assay Singulex Erenna TnI assay (Singulex, USA)., Methods: Using the Markers in the Diagnosis of Acute Coronary Syndromes (MIDAS) study population, we evaluated the ability of three different assays to identify patients with acute myocardial infarction (AMI). The MIDAS dataset, described elsewhere, is a prospective multicenter dataset of emergency department (ED) patients with suspected acute coronary syndrome (ACS) and a planned objective myocardial perfusion evaluation. Myocardial infarction (MI) was diagnosed by central adjudication., Results: The C-statistic with 95% confidence intervals (CI) for diagnosing MI by using a common population (n=241) was 0.95 (0.91-0.99), 0.95 (0.91-0.99), and 0.93 (0.89-0.97) for the Triage, Singulex, and PathFast assays, respectively. Of samples with detectable troponin, the absolute values had high Pearson (R(P)) and Spearman (R(S)) correlations and were R(P)=0.94 and R(S)=0.94 for Triage vs Singulex, R(P)=0.93 and R(S)=0.85 for Triage vs PathFast, and R(P)=0.89 and R(S)=0.73 for PathFast vs Singulex., Conclusions: In a single comparative population of ED patients with suspected ACS, the Triage Cardio3 TnI, PathFast, and Singulex TnI assays provided similar diagnostic performance for MI.

Background: The HEART score and North American Chest Pain Rule (NACPR) are decision rules designed to identify acute chest pain patients for early discharge without stress testing or cardiac imaging. This study compares the clinical utility of these decision rules combined with serial troponin determinations., Methods and Results: A secondary analysis was conducted of 1005 participants in the Myeloperoxidase In the Diagnosis of Acute coronary syndromes Study (MIDAS). MIDAS is a prospective observational cohort of Emergency Department (ED) patients enrolled from 18 US sites with symptoms suggestive of acute coronary syndrome (ACS). The ability to identify participants for early discharge and the sensitivity for ACS at 30 days were compared among an unstructured assessment, NACPR, and HEART score, each combined with troponin measures at 0 and 3h. ACS, defined as cardiac death, acute myocardial infarction, or unstable angina, occurred in 22% of the cohort. The unstructured assessment identified 13.5% (95% CI 11.5-16%) of participants for early discharge with 98% (95% CI 95-99%) sensitivity for ACS. The NACPR identified 4.4% (95% CI 3-6%) for early discharge with 100% (95% CI 98-100%) sensitivity for ACS. The HEART score identified 20% (95% CI 18-23%) for early discharge with 99% (95% CI 97-100%) sensitivity for ACS. The HEART score had a net reclassification improvement of 10% (95% CI 8-12%) versus unstructured assessment and 19% (95% CI 17-21%) versus NACPR., Conclusions: The HEART score with 0 and 3 hour serial troponin measures identifies a substantial number of patients for early discharge while maintaining high sensitivity for ACS., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: Previous research has demonstrated the prognostic value of echocardiography with tissue Doppler imaging (TDI) in the heart failure (HF) population. Heart rate recovery (HRR) has also recently shown promise as a prognostic marker., Hypothesis: We hypothesize echocardiography with TDI and HRR will be significantly correlated and both will provide prognostic information., Methods: A total of 243 subjects underwent echocardiography with TDI and maximal exercise testing to determine: (1) the ratio between mitral early (E) to mitral annular (E') and E to mitral late (A) velocity; (2) left ventricular ejection fraction (LVEF); (3) left ventricular (LV) mass; (4) LV end-systolic volume (LVESV); and (5) HRR at 1 minute postexercise (HRR(1))., Results: HRR(1) was significantly correlated with LVEF (r = 0.14, P = .03), LV mass (r = - 0.30, P <.001), E/A (r = - 0.22, P = .001), and E/E' (r = - 0.49, P <.001). Multivariate Cox regression analysis revealed HRR(1) was the strongest predictor of cardiac mortality (chi(2): 55.5, P <.001); LV mass (residual chi(2): 13.1, P <.001), E/E' (residual chi(2): 11.2, P = .001), and LVESV (residual chi(2): 5.9, P = .015) all added significant prognostic value and were retained in the regression while LVEF was removed (residual chi(2): 0.008, P = .93)., Conclusions: To our knowledge, this is the first investigation demonstrating an association between HRR and variables obtained from echocardiography with TDI in subjects with HF. The combination of both assessment techniques provides improved prognostic discrimination., (Copyright 2010 Wiley Periodicals, Inc.)

Background: Studies have established that physiologic instability and services mismatching precede adverse events in hospitalized patients. In response to these considerations, the concept of a Rapid Response System (RRS) has emerged. The responding team is commonly known as a medical emergency team (MET), rapid response team (RRT), or critical care outreach (CCO). Studies show that an RRS may improve outcome, but questions remain regarding the benefit, design elements, and advisability of implementing a MET system., Methods: In June 2005 an International Conference on Medical Emergency Teams (ICMET) included experts in patient safety, hospital medicine, critical care medicine, and METs. Seven of 25 had no experience with an RRS, and the remainder had experience with one of the three major forms of RRS. After preconference telephone and e-mail conversations by the panelists in which questions to be discussed were characterized, literature reviewed, and preliminary answers created, the panelists convened for 2 days to create a consensus document. Four major content areas were addressed: What is a MET response? Is there a MET syndrome? What are barriers to METS? How should outcome be measured? Panelists considered whether all hospitals should implement an RRS., Results: Patients needing an RRS intervention are suddenly critically ill and have a mismatch of resources to needs. Hospitals should implement an RRS, which consists of four elements: an afferent, "crisis detection" and "response triggering" mechanism; an efferent, predetermined rapid response team; a governance/administrative structure to supply and organize resources; and a mechanism to evaluate crisis antecedents and promote hospital process improvement to prevent future events.

Oxygen consumption (VO(2)) on-kinetics describes the rate change in oxygen uptake at the initiation of exercise. Several mathematical and graphical methods are used to assess VO(2) on-kinetics during constant-load or progressive exercise. VO(2) on-kinetics is prolonged in patients with heart failure (HF) compared with individuals who have normal cardiopulmonary function. Cardiac function has been implicated as one of the controlling mechanism for this observation. The contribution that pulmonary, vascular, and skeletal muscle function makes to delayed VO(2) on-kinetics in HF has yet to be determined. VO(2) on-kinetics also appears to have clinical value in HF, although evidence supporting this claim is limited. Questions about the controlling mechanism(s) and practical application of VO(2) on-kinetics in HF therefore remain unanswered. This report provides an overview of VO(2) on-kinetics assessment techniques, reviews research pertaining to the HF population, and provides direction for future investigations.

The safety and efficacy of exercise training in patients with congestive heart failure (CHF) is well established; however, the impact that exercise has on the subgroup of CHF patients awaiting heart transplant while on intravenous positive inotropic support remains largely unreported. This case study describes the safety and efficacy of exercise training in a patient awaiting heart transplant while on intravenous milrinone. Over a 1.2-year period, 246 exercise sessions were conducted with a total of 180.15 hours of aerobic exercise. During that time, the patient experienced only one hypotensive episode during exercise and had no other adverse events. The patient demonstrated a 38% increase in aerobic exercise time and a 34% increase in sustainable exercise workload. Research is needed to demonstrate the positive impact of exercise training on this subgroup of CHF patients.

Study Objective: Erroneous time documentation of emergency treatment caused by the variation in the accuracy of timepieces has profound medical, medicolegal, and research consequences. The purpose of this study was to confirm the variation of critical timepiece settings in an urban emergency care system noted in previous studies and to implement and monitor the results of a prospective program to improve time synchronization., Methods: Timepieces (n = 393) used by firefighters, paramedics, and emergency physicians and nurses were randomly sampled immediately before and at two time intervals (1 and 4 months) after attempted synchronization to the US atomic clock standard. The setting on each timepiece was compared with the atomic clock. From the data, a mathematical simulation estimated the number of time-related documentation errors that would occur in 2,500 simulated cardiac arrest cases using timepieces with accuracy similar to those found in the EMS system before and after attempted synchronization., Results: Before attempted synchronization, the timepieces had a mean error of 2.0 (95% confidence interval 1.8 to 2.3) minutes. One month after attempted synchronization, the mean error decreased significantly to .9(.8 to 1.1) minute. However, it increased to 1.7 (1.5 to 1.9) minutes within 4 months. Mathematical simulation before attempted synchronization predicted that 93% of cardiac arrest cases would contain a documentation error of 2 minutes or more and that 41% of cases would contain a documentation error of 5 minutes or more. Attempted synchronization cut the 2-minute documentation error rate in half and reduced the 5-minute documentation error rate by three fourths. However, the error rates were predicted to return to baseline 4 months after attempted synchronization., Conclusion: Emergency medical timepieces are often inaccurate, making it difficult to reconstruct events for medical, medicolegal, or research purposes. Community synchronization of timepieces to the atomic clock can reduce the problem significantly, but the effects of a one-time attempted synchronization event are short-lived.

Objectives: The purpose of this study was to determine whether the rate of hospital admission for acute myocardial infarction (AMI) varies seasonally in a large, prospective U.S. registry., Background: Identification of specific patterns in the timing of the onset of AMI is of importance because it implies that there are triggers external to the atherosclerotic plaque. Using death certificate data, most investigators have noted a seasonal pattern to the death rate from AMI. However, it is unclear whether this observation is due to variation in the prevalence of AMI or to other factors that may alter the likelihood of a fatal outcome., Methods: We examined the seasonal mean number of cases of AMI (adjusted for the length of days in each season) that were submitted to the National Registry of Myocardial Infarction (NRMI) by 138 high volume core hospitals over a 3-year period (December 21, 1990 through December 20, 1993) during which the number of hospitals participating in the Registry was stable. Data were analyzed using general linear modeling and analysis of variance., Results: High volume core hospitals reported 83,541 cases of AMI to the Registry during the study period. Approximately 10% more such cases were entered into the Registry in winter or spring than in summer (p < 0.05). The same trends were seen in both northern and southern states, men and women, patients < 70 versus > or = 70 years of age and those with Q wave versus non-Q wave AMI., Conclusions: We conclude that there is a seasonal pattern to the reporting rate of cases of AMI in the NRMI. This observation further supports the hypothesis that acute cardiovascular events may be triggered by events that are external to the atherosclerotic plaque.

Improper placement of recording electrodes on the skin can generate misleading patterns on the electrocardiogram (ECG). The alterations in the normal ECG caused by lead misplacement were reviewed. Although most clinicians can recognize the common right arm/left arm lead switch that imitates a nonsinus atrial rhythm with high anterolateral myocardial infarction, many other errors are possible. Less common lead placement errors are often difficult to detect. Exchanging the right arm and left leg leads creates what seems to be an inferior wall myocardial infarction and a nonsinus atrial rhythm in normal patients. Reversal of the right arm and right leg connections creates a unique pattern of diffuse low voltage in the limb leads. Precordial lead switches are common and can be recognized by the abnormal R wave progression that is created.

Plasma immunoreactive beta-melanocyte stimulating hormone (beta-MSH) has been measured in patients taking a progestogen-only oral contraceptive and in patients taking combined estrogen-progestogen therapy, of whom some had chloasma. Plasma levels did not differ significantly from those in a group of age- and sex-matched controls. It is concluded that the pigmentation of chloasma is not due to increased plasma concentrations of immunoreactive beta-MSH.

HLA class I phenotyping was performed using T-lymphocyte populations isolated by immunomagnetic beads (IMBs) coated with monoclonal antibodies with specificity for CD2, CD4 or CD8. The results were compared to those obtained using density gradient-separated lymphocytes (PBL). The typing trays were read by the automated simultaneous double-fluorescence (SDF) technique previously established in our laboratory using an Astroscan 2100 system. The aims of the present study were to establish whether the advantages of IMB lymphocyte separation and automated plate reading by SDF were complementary and whether the results obtained by IMB-SDF and PBL-SDF were concordant. Similarity coefficients for paired results obtained by IMB-SDF and PBL-SDF varied between 0.825 using anti-CD8-coated IMBs and 0.914 using anti-CD4-coated IMBs with a consistent excess of stronger results observed with the PBL-SDF technique. The variations observed did not result in incorrect phenotype assignment but would significantly influence a cross-matching test. These results illustrate the feasibility of using IMB-separated lymphocytes for HLA phenotyping by SDF.