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The Canterbury Region of New Zealand has undergone rapid and significant land use intensification over the last three decades resulting in a substantial increase of nitrate-nitrogen leached to the environment. In this article, we determined the nitrate grey water footprint of milk, which is the amount of water needed to dilute nitrogen leached past the root zone to meet different receiving water nitrate standards per milk production unit. Our analysis revealed the nitrate grey water footprint for Canterbury ranged from 433 to 11,110 litres of water per litre of milk, depending on the water standards applied. This footprint is higher than many estimates for global milk production, and reveals that footprints are very dependent on inputs included in the analyses and on the water quality standards applied to the receiving water. The extensive dairy farming in Canterbury is leading to significant pollution of the region’s groundwater, much of which is used for drinking water. Dairy farming at this intensity is unsustainable and if not reduced could pose a significant risk to human health and the market perception of the sustainability of the New Zealand dairy industry and its products.

Background The Electrocardiogram (ECG) remains as the crucial tool to diagnose acute ST-elevation myocardial infarction (STEMI). Activation of the cardiac catheterization team to perform Primary Percutaneous Coronary Intervention (PPCI) largely depends on the interpretation of the ECG at the time of first medical contact with the patient. In Northern Ireland, if the referrer decides that the ECG shows a STEMI they would then transmit the ECG to a designated Coronary Care Nurse who then decides whether to activate the PPCI pathway or to transfer the patient to the nearest Emergency Department (ED). Objective We sought to ascertain the impact, ECG based decisions have on the PPCI pathway and specifically on clinical outcomes. Methods ECG and clinical data were retrospectively reviewed for consecutive patients referred to the PPCI pathway over an 8-month period as part of a continuous audit. Patients were either accepted or turned down for PPCI by the Nurse. All ECGs were retrospectively adjudicated upon with a final diagnosis made by a senior Coronary Care nurse and Interventional Cardiologist. ECG interpretation was evaluated in the referrer group, the ECG machine, and the nurse activator. Results A total of 344 patients were referred to the PPCI pathway over the 8-month period. 114 (33%) were accepted for PPCI. All accepted patients met diagnostic ECG criteria with 97/114 (85%) having a final diagnosis of STEMI. 230 referrals (67%) were turned down for PPCI, predominantly on the basis of lack of diagnostic criteria. All turndowns were considered appropriate. Paramedics were the main referrers 205/344 (60%) with the remainder from ED. The ECG machine suggested an ischaemic diagnosis in 95/97 (Sensitivity=98%) of patients with STEMI and 103/198 (1-Specificity=52%, Specificity=48%) of the turndown cases (patients with a final diagnosis of ACS/angina were excluded from the turndown group when calculating machine specificity). Of those referred for PPCI, 66% of the ED referrals were turned down. Of those referred by Paramedics for PPCI 67% were turned down. The STEMI group were significantly younger that the turndown group (63 ± 12 vs. 68 ± 17, p Conclusions ECG interpretation by referrers in this nurse-led primary PCI pathway is sub-optimal. The high rate of false positives in ECG machine diagnoses in the turndown group could be an influencing factor in the human-decision making. There is a need to find ways to improve ECG interpretation, particularly in a time critical PPCI pathway.

Introduction From the 15th September 2014 every citizen in Northern Ireland has 24/7 access to Cardiac Catheterisation for patients experiencing an acute STEMI or emergent PCI. In one of the 2 designated Primary Percutaneous Coronary Intervention (PPCI) enabled centres, registrar cover is not available, therefore the responsibility to activate the 24/7 PPCI Pathway was given to a senior cardiac nurse known as PPCI activator. AIM To provide a safe and effective nurse led 24/7 PPCI service. Method Consecutive calls received by the Activator from January 2015 to December 2015 were evaluated. An interventional cardiologist and senior PPCI activator retrospectively evaluated all case report files and ECGs. Each clinical decision made at the time of call was assessed and the diagnoses /outcomes were recorded. The total calls for the period Jan 2015 – Dec 2015 were recorded and continuous audit performed. Results A total of 618 calls were received. Of this 416/618 (67%) were turned down. The nurse activators turned down 369/416 (89%)of the calls. The remaining 47/416 (11%) were turned down following discussion with the interventional cardiologist on call. On review all turn downs were deemed appropriate with a wide range of clinical diagnoses. Approximately 15% (58/416) of the referrals sent to the PPCI activator were actually discharged from the ER. Sepsis was diagnosed in 63/416 (15%) of cases. An acute coronary syndrome was ultimately diagnosed in 108/416 (25%) of cases. There were no inappropriate turn-downs by the PPCI activators. Conclusion Nurse led decision-making in a PPCI pathway is a safe and effective way to manage referrals made for presumed STEMI. Work is required to improve ECG interpretation among those that refer to this pathway.