Relationship between endocrine disrupting chemicals (phthalate metabolites, triclosan and bisphenols) and vitamin D in female subjects: An exploratory pilot study.

INTRODUCTION: Evidence suggests that endocrine disrupting chemicals (EDCs), commonly used in plastics and personal care products, may be associated with reduced levels of vitamin D. Therefore, this study examined the relationship between phthalate metabolites, 5-chloro-2-(2,4-dichlorophenoxy)phenol (triclosan; TCS) and bisphenols (BPs) with vitamin D3 (25(OH)D3) and active 1,25-dihydroxyvitamin D3 (1,25(OH)2D3), and their relationship to calcium homeostasis. METHODS: 57 female participants (age 31.8 ± 4.6 years; BMI 25.6 ± 3.7 kg/m2) were analyzed for urinary levels of phthalate metabolites, TCS and BPs, and serum levels of 25(OH)D3 and 1,25(OH)2D3, determined by isotope-dilution liquid chromatography tandem mass spectrometry. Serum calcium/calmodulin-dependent (CaM) associated proteins were determined by Slow Off-rate Modified Aptamer (SOMA)-scan. RESULTS: In the study cohort, 25(OH)D3 and 1,25(OH)2D3 levels were 22.9 ± 11.2 ng/mL and 0.05 ± 0.02 ng/mL, respectively: mono-3-carboxypropyl-phthalate (MCPP) correlated negatively with 25(OH)D3 (ρ = -0.53, p = 0.01). 28 of the 57 women recruited were 25(OH)D3 deficient, <20 ng/mL (50 nmol/L): in this group, mono-iso-butylphthalate (MiBP) and mono-butylphthalate (MBP) negatively correlated with 25(OH)D3; (ρ = -0.47, p = 0.049) and (ρ = -0.64, p = 0.005), respectively. EDCs did not correlate with 1,25(OH)2D3, measures of renal function or CaM proteins. CONCLUSION: These putative data indicate that MCPP is related to 25(OH)D3, while MiBP and MBP were related to vitamin D deficiency; however, no correlations were observed with TCS and BPs. No phthalate metabolites correlated with 1,25(OH)2D3, CaM associated proteins or renal function, suggesting that effects occur earlier in the vitamin D pathway and not through modulation of cellular calcium flux. The observed correlations are surprisingly strong compared to other predictors of 25(OH)D3, and larger studies adjusting for potential confounders are warranted.

Uncompensated Care is Highest for Rural Hospitals, Particularly in Non-Expansion States.

High levels of uncompensated care impact hospital profitability and may create challenges for rural hospitals at financial risk of closure. We explore 2019 hospital uncompensated care as a percentage of operating expenses and draw comparisons at a state level by Medicaid expansion status and rural classification. We further compare uncompensated care in 2019 to 2014 in rural hospitals by Medicaid expansion implementation timing. We found that, overall, rural hospitals had more uncompensated care than urban hospitals in 2019 (3.81% vs. 3.12%), but there was a larger difference by expansion status (expansion states: 2.55% vs. non-expansion states: 6.28%). In all but seven states, rural hospitals reported higher uncompensated care than urban, and the 14 states with the highest uncompensated care had not expanded Medicaid. We observed that rural hospital uncompensated care in non-expansion states increased between 2014 and 2019, while the most dramatic decrease occurred in late-expansion states.

Performance evaluation of a diffusive hydrogel-based passive sampler for monitoring of polar organic compounds in wastewater.

An upscaled passive sampler variant (diffusive hydrogel-based passive sampler; HPS) based on diffusive gradients in thin films for polar organic compounds (o-DGT) with seven times higher surface area (22.7 cm2) than a typical o-DGT sampler (3.14 cm2) was tested in several field studies. HPS performance was tested in situ within a calibration study in the treated effluent of a municipal wastewater treatment plant and in a verification study in the raw municipal wastewater influent. HPS sampled integratively for up to 14 days in the effluent, and 8 days in the influent. Sampling rates (Rs) were derived for 44 pharmaceuticals and personal care products, 3 perfluoroalkyl substances, 2 anticorrosives, and 21 pesticides and metabolites, ranging from 6 to 132 mL d-1. Robustness and repeatability of HPS deteriorated after exposures longer than 14 days due to microbial and physical damage of the diffusive agarose layer. In situ Rs values for the HPS can be applied to estimate the aqueous concentration of the calibrated polar organic compounds in wastewater within an uncertainty factor of four. When accepting this level of accuracy, the HPS can be applied for monitoring trends of organic micropollutants in wastewater.

The economic effects of rural hospital closures.

OBJECTIVE: To provide an updated analysis of the economic effects of rural hospital closures. STUDY SETTING: Our study sample was national in scope and consisted of nonmetro counties from 2001 to 2018. STUDY DESIGN: We used a difference-in-differences study design to estimate the effect of a hospital closure on county income, population, unemployment, and size of the labor force. Specifically, we compared economic changes over time in nonmetro counties experiencing a hospital closure to changes in a control group of nonmetro counties over the same time period. We also leveraged insight from recent research to control for estimation bias due to heterogeneity in the closure effect over time or across groups defined by when closure was experienced. DATA EXTRACTION: Data on (adjusted gross) annual income (in real dollars), annual population size, and monthly unemployment rate and labor force size were sourced from the Internal Revenue Service, Census Bureau, and Bureau of Labor Statistics, respectively. We used data from the North Carolina Rural Health Research Program to identify counties that experienced a hospital closure. PRINCIPAL FINDINGS: Of the 1759 nonmetro counties in our study sample, 109 experienced a hospital closure during the study period. Relative to the nonclosure counterfactual, closures significantly decreased labor force size, on average, by 1.4% (95% CI: [-2.1%, -0.8%]). Results also suggest that Prospective Payment System (PPS) hospital closures significantly decreased population size, on average, by 1.1% (95% CI: [-1.7%, -0.5%]), relative to the nonclosure counterfactual. CONCLUSIONS: Our analysis suggests that rural hospital closures often have adverse effects on local economic outcomes. Importantly, the negative economic effects of closure appear to be strongest following Prospective Payment System hospital closures and attenuated when the closed hospital is converted to another type of health care facility, allowing for the continued provision of services other than inpatient care.

Comparing the Leaching Behavior of Per- and Polyfluoroalkyl Substances from Contaminated Soils Using Static and Column Leaching Tests.

Soil contaminated with aqueous film-forming foams (AFFFs) containing per- and polyfluoroalkyl substances (PFASs) at firefighting training sites has become a major concern worldwide. To date, most studies have focused on assessing soil-water partitioning behavior of PFASs and the key factors that can affect their sorption, whereas PFASs leaching from contaminated soils have not yet been widely investigated. This study evaluated the leaching and desorption of a wide range of PFASs from twelve contaminated soils using the Australian Standard Leaching Procedure (ASLP), the U.S. EPA Multiple Extraction Procedure (MEP), and Leaching Environmental Assessment Framework (LEAF). All three leaching tests provided a similar assessment of PFAS leaching behavior. Leaching of PFASs from soils was related to C-chain lengths and their functional head groups. While short-chain (CF2 ≤ 6) PFASs were easily desorbed and leached, long-chain PFASs were more difficult to desorb. PFASs with a carboxylate head group were leached more readily and to a greater extent than those with a sulfonate or sulfonamide head group. Leaching of long-chain PFASs was pH-dependent where leaching increased at high pH, while leaching of short-chain PFASs was less sensitive to pH. Comparing different leaching tests showed that the results using the alkaline ASLP were similar to the cumulative MEP data and the former might be more practical for routine use than the MEP. No single soil property was adequately able to describe PFAS leaching from the soils. Overall, the PFAS chemical structure appeared to have a greater effect on PFAS leaching from soil than soil physicochemical properties.

Infant pacifier sanitization and risk of challenge-proven food allergy: A cohort study.

BACKGROUND: Environmental microbial exposure plays a role in immune system development and susceptibility to food allergy. OBJECTIVE: We sought to investigate whether infant pacifier use during the first postnatal year, with further consideration of sanitization, alters the risk of food allergy by age 1 year. METHODS: The birth cohort recruited pregnant mothers at under 28 weeks' gestation in southeast Australia, with 894 families followed up when infants turned 1 year. Infants were excluded if born under 32 weeks, with a serious illness, major congenital malformation, or genetic disease. Questionnaire data, collected at recruitment and infant ages 1, 6, and 12 months, included pacifier use and pacifier sanitization (defined as the joint exposure of a pacifier and cleaning methods). Challenge-proven food allergy was assessed at 12 months. RESULTS: Any pacifier use at 6 months was associated with food allergy (adjusted odds ratio, 1.94; 95% CI, 1.04-3.61), but not pacifier use at other ages. This overall association was driven by the joint exposure of pacifier-antiseptic use (adjusted odds ratio, 4.83; 95% CI, 1.10-21.18) compared with no pacifier use. Using pacifiers without antiseptic at 6 months was not associated with food allergy. Among pacifier users, antiseptic cleaning was still associated with food allergy (adjusted odds ratio, 3.56; 95% CI, 1.18-10.77) compared with no antiseptic use. Furthermore, persistent and repeated antiseptic use over the first 6 months was associated with higher food allergy risk (P = .029). CONCLUSIONS: This is the first report of a pacifier-antiseptic combination being associated with a higher risk of subsequent food allergy. Future work should investigate underlying biological pathways.

Influences of Chemical Properties, Soil Properties, and Solution pH on Soil-Water Partitioning Coefficients of Per- and Polyfluoroalkyl Substances (PFASs).

The aim of this study was to assess the soil-water partitioning behavior of a wider range of per- and polyfluoroalkyl substances (PFASs) onto soils covering diverse soil properties. The PFASs studied include perfluoroalkyl carboxylates (PFCAs), perfluoroalkane sulfonates (PFSAs), fluorotelomer sulfonates (FTSs), nonionic perfluoroalkane sulfonamides (FASAs), cyclic PFAS (PFEtCHxS), per- and polyfluoroalkyl ether acids (GenX, ADONA, 9Cl-PF3ONS), and three aqueous film-forming foam (AFFF)-related zwitterionic PFASs (AmPr-FHxSA, TAmPr-FHxSA, 6:2 FTSA-PrB). Soil-water partitioning coefficients (log Kd values) of the PFASs ranged from less than zero to approximately three, were chain-length-dependent, and were significantly linearly related to molecular weight (MW) for PFASs with MW > 350 g/mol (R2 = 0.94, p < 0.0001). Across all soils, the Kd values of all short-chain PFASs (≤5 -CF2- moieties) were similar and varied less (<0.5 log units) compared to long-chain PFASs (>0.5 to 1.5  log units) and zwitterions AmPr- and TAmPr-FHxSA (∼1.5 to 2 log units). Multiple soil properties described sorption of PFASs better than any single property. The effects of soil properties on sorption were different for anionic, nonionic, and zwitterionic PFASs. Solution pH could change both PFAS speciation and soil chemistry affecting surface complexation and electrostatic processes. The Kd values of all PFASs increased when solution pH decreased from approximately eight to three. Short-chain PFASs were less sensitive to solution pH than long-chain PFASs. The results indicate the complex interactions of PFASs with soil surfaces and the need to consider both PFAS type and soil properties to describe mobility in the environment.

Urinary Concentrations of Bisphenols in the Australian Population and Their Association with the Per Capita Mass Loads in Wastewater.

Health concerns and related regulation of bisphenol A (BPA) in some countries have led to an increase in the production and use of unregulated and poorly understood BPA analogues, including bisphenol S (BPS), bisphenol F (BPF), bisphenol B (BPB), and bisphenol AF (BPAF). To assess the temporal trends of human exposure to BPA analogues, urine and wastewater samples were collected from South East Queensland, Australia between 2012 and 2017 and analyzed for five bisphenols using validated isotope dilution liquid chromatography tandem mass spectrometry methods. BPA and BPS were the predominant bisphenols detected in both urine and wastewater samples, with median concentrations of 2.5 and 0.64 µg/L in urine and 0.94 and 1.1 µg/L in wastewater, respectively. BPB, BPF, and BPAF had low detection frequencies in both urine and wastewater samples. Concentrations of BPA in both urine and wastewater decreased over the sampling period, whereas concentrations of BPS increased, suggesting that BPS has become a BPA replacement. The contributions of urinary excretion to wastewater were calculated by the ratio of daily per capita urinary excretion to wastewater-based mass loads of bisphenols. Urinary BPA and BPS contributed to less than 1% of the load found in wastewater, indicating that much of the BPA and BPS originates from other sources.

Prenatal phthalate exposure, oxidative stress-related genetic vulnerability and early life neurodevelopment: A birth cohort study.

Prenatal phthalate chemicals may have adverse effects on brain development by various mechanisms including oxidant damage. However, birth cohort findings have been conflicting. This study aimed to (i) investigate the interplay between maternal prenatal phthalate levels, infant genetic vulnerability to oxidative stress, and child neurodevelopment and (ii) examine combined putative oxidant exposures. In a population-based birth cohort of 1064 women with prenatal recruitment in Victoria, Australia, maternal urine was collected at 36 weeks of pregnancy and phthalate metabolite concentrations measured. An unweighted genetic score for oxidative stress was made using a candidate gene approach. Cognition was assessed using the BAYLEY-III at two years (n = 678). Parents completed questionnaires for doctor diagnosed autism spectrum disorder (ASD) (1.4 %), ASD traits (4.9 %) and child inattention/hyperactivity (n = 791). Analyses included multiple linear and logistic regression. Higher prenatal phthalate levels and a higher oxidative stress genetic score were each associated with subsequent ASD. Several oxidative stress-related SNPs modified the association between prenatal phthalates and ASD and other outcomes. Consistent patterns were evident across gene score-phthalate combinations for cognition, ASD, ASD traits and inattention/hyperactivity. Other putative oxidant factors such as prenatal smoking further increased risk. Prenatal phthalate levels and infant oxidative stress-related genetic vulnerability are associated with adverse neurodevelopment. Combined exposures are important. Current recommendations and regulation on maternal phthalate exposure during pregnancy require re-evaluation.

Predictors with regard to ingestion, inhalation and dermal absorption of estimated phthalate daily intakes in pregnant women: The Barwon infant study.

Human exposure to phthalate chemicals, used in consumer product plastics, occurs throughout the day. Phthalate levels in pregnant women are associated with offspring health effects including obesity and neurodevelopmental problems. Knowledge of predictors of exposure is necessary in order to effectively reduce phthalate exposure. The present study aims to identify predictors of phthalate levels in Australian pregnant women from the Barwon Infant study birth cohort. Maternal urine samples from 841 women were analyzed for phthalate metabolites. Maternal diet and food preparation practices, use of volatile household products, household characteristics and personal care product use were assessed with questionnaires. All maternal urine contained phthalate metabolites. Maternal prenatal high-fat milk consumption was associated with higher benzyl butyl phthalate (BBzP) (p < 0.001), and bis(2-ethylhexyl) phthalate (DEHP) (p = 0.0023). Higher phthalate levels were associated with consumption of tinned food (fish and tomatoes). Diethyl phthalate (DEP) levels were significantly higher when women reported using air freshener (35% increase, p = 0.01), aerosols (40% increase, p = 0.005), hair treatment chemicals (28% increase, p = 0.031), and chlorine (34% increase, p = 0.009) compared to no use. Maternal phthalate levels did not vary by reported plastic avoidance during pregnancy. The study showed that phthalate exposure is ubiquitous and increased by multiple factors. Future intervention studies to reduce phthalate levels among pregnant women will need to take into account the variety of sources identified in this study.

Pharmaceuticals, personal care products, food additive and pesticides in surface waters from three Australian east coast estuaries (Sydney, Yarra and Brisbane).

The detection rates of pharmaceuticals (Ps), personal care products (PCPs), current-use pesticides (CUPs) and a food additive (FA) in Brisbane River estuary (Queensland), Sydney estuary (New South Wales) and the Yarra River estuary (Melbourne, Victoria) were: Ps: 16/25, 7/25 and 12/25, respectively, CUPs; 28/53, 5/53 and 23/53, respectively, PCPs: 1/3, 0/3 and, 1/3, respectively and FA; 1/1, 1/1 and 1/1, respectively. Diuron was measured in all estuarine samples, simazine, MCPA and 2,4 D were also commonly measured. Pharmaceuticals: carbamazepine, iopromide paracetamol tramadol and venlafaxine were also commonly measured across the estuaries. Generally, analytes were prominent in Brisbane River estuary, followed by Yarra River/Sydney estuary. Inputs of Ps are likely from leakages or effluents of WWTPs; CUPs are potentially from agricultural and parklands via surface run-off in Brisbane River estuary, while for Sydney and Yarra estuaries, which have separate stormwater and sewer systems, sources are likely to be ingression and leakage.

Concentrations of phthalate metabolites in Australian urine samples and their contribution to the per capita loads in wastewater.

Exposure to phthalates is a public health concern. In this study, we collected both urine and wastewater samples from 2012 to 2017 and analysed for 14 phthalate metabolites to assess human exposure to phthalates in Southeast Queensland (SEQ), and for associations between phthalate metabolites in urine and wastewater samples. Twenty-four pooled urine samples were prepared from 2400 individual specimens every two years (stratified by age, gender and collection year). Wastewater samples were collected from the three major wastewater treatment plants (WWTPs) representing locations in the SEQ region including a regional city, part of the state capital city and a third major urban WWTP in the region. Over the period, decreases for most phthalate metabolites, i.e. mono-butyl phthalate (MBP), mono-isobutyl phthalate (MiBP), monobenzyl phthalate (MBzP), monocyclohexyl phthalate (MCHP), mono(3-carboxypropyl) phthalate (MCPP), mono(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP), mono(2-ethyl-5-oxohexyl) phthalate (MEOHP), and monomethyl phthalate (MMP), but an increase in monoethyl phthalate (MEP, particularly in young children) were observed in urine. In general, temporal changes were smaller in urine pools representing older age groups. We also found substantial variation in per capita mass loads of phthalate metabolites between samples from the three WWTPs with generally higher concentrations of most phthalates in the metropolitan areas. Per capita mass loads of most phthalate metabolites in wastewater were higher than would be expected from the per-capita excretion in urine, suggesting there are additional sources contributing to the majority of the observed phthalate metabolites in wastewater. For MEHHP and MEOHP we estimate that the urinary excretion accounts for a substantial fraction (average about 50%) of the mass load observed in the wastewater hence wastewater data may provide useful for monitoring trends in exposure.

Calibration and validation of a microporous polyethylene passive sampler for quantitative estimation of illicit drug and pharmaceutical and personal care product (PPCP) concentrations in wastewater influent.

Wastewater-based epidemiology (WBE), the per capita normalised measurement of drugs, chemicals or metabolites in wastewater influent, relies on sampling and quantitative analysis to evaluate temporal and spatial trends of chemical consumption. Continuous, high-resolution, flow proportional composite sampling is optimal for accurate representations of chemical mass loads, but is rarely implemented, with conventional autosamplers providing relatively low frequency time or volume proportional samples. However, due to equipment or resource constraints at many wastewater treatment plants (WWTPs), even this may not be feasible. Passive sampling may provide an alternative sampling strategy. To investigate this, samplers comprising hollow, cylindrical Microporous Polyethylene Tubes (MPTs) containing polymeric sorbent phases of Strata-X and Strata-X in agarose were simultaneously deployed in a municipal WWTP influent stream. Samplers were extracted, analysed and evaluated for a range of illicit drugs and pharmaceuticals and personal care products (PPCPs) after 4, 7, 15, 21, and 29 day deployments. The MPT samplers were calibrated against 24-hour time proportional composite grab samples that were collected in parallel. Diffusion through the MPT governed uptake, reducing or eliminating the influence of external flow rates that may fluctuate unpredictably in a WWTP environment. Calibration data for six illicit drugs and fourteen PPCPs, including methamphetamine, benzoylecgonine, MDMA, codeine and carbamazepine, demonstrated linear accumulation in the samplers (R2 ≥ 0.84). Derived sampling rates for these analytes ranged from 0.25 to 17 mL d-1 for ibuprofen and verapamil, respectively. A validation study using this sampling rate data showed the MPT could effectively quantify concentrations (≥0.1 ng mL-1) of a range of amphetamine-type stimulants, opioids and metabolites as well as nicotine, accounting for 95% of the variance in parallel composite grab sample concentrations of these compounds. The MPT sampler shows promise for providing essential monitoring data for WBE, informing future intervention and research strategies.

Greywater irrigation as a source of organic micro-pollutants to shallow groundwater and nearby surface water.

Increased water demands due to population growth and increased urbanisation have driven adoption of various water reuse practices. The irrigation of greywater (water from all household uses, except toilets) has been proposed as one potential sustainable practice. Research has clearly identified environmental harm from the presence of micro-pollutants in soils, groundwater and surface water. Greywater contains a range of micro pollutants yet very little is known about their potential environmental fate when greywater is irrigated to soil. Therefore, this study assessed whether organic micro-pollutants in irrigated greywater were transferred to shallow groundwater and an adjacent surface waterway. A total of 22 organic micro-pollutants were detected in greywater. Six of these (acesulfame, caffeine, DEET, paracetamol, salicylic acid and triclosan) were selected as potential tracers of greywater contamination. Three of these chemicals (acesulfame, caffeine, DEET) were detected in the groundwater, while salicylic acid was also detected in adjacent surface water. Caffeine and DEET in surface water were directly attributable to greywater irrigation. Thus the practice of greywater irrigation can act as a source of organic micro-pollutants to shallow groundwater and nearby surface water. The full list of micro-pollutants that could be introduced via greywater and the risk they pose to aquatic ecosystems is not yet known.

Recruiting for a pragmatic trial using the electronic health record and patient portal: successes and lessons learned.

Objective: Querying electronic health records (EHRs) to find patients meeting study criteria is an efficient method of identifying potential study participants. We aimed to measure the effectiveness of EHR-driven recruitment in the context of ADAPTABLE (Aspirin Dosing: A Patient-centric Trial Assessing Benefits and Long-Term Effectiveness)-a pragmatic trial aiming to recruit 15 000 patients. Materials and Methods: We compared the participant yield of 4 recruitment methods: in-clinic recruitment by a research coordinator, letters, direct email, and patient portal messages. Taken together, the latter 2 methods comprised our EHR-driven electronic recruitment workflow. Results: The electronic recruitment workflow sent electronic messages to 12 254 recipients; 13.5% of these recipients visited the study website, and 4.2% enrolled in the study. Letters were sent to 427 recipients; 5.6% visited the study website, and 3.3% enrolled in the study. Coordinators recruited 339 participants in clinic; 23.6% visited the study website, and 16.8% enrolled in the study. Five-hundred-nine of the 580 UNC enrollees (87.8%) were recruited using an electronic method. Discussion: Electronic recruitment reached a wide net of patients, recruited many participants to the study, and resulted in a workflow that can be reused for future studies. In-clinic recruitment saw the highest yield, suggesting that a combination of recruitment methods may be the best approach. Future work should account for demographic skew that may result by recruiting from a pool of patient portal users. Conclusion: The success of electronic recruitment for ADAPTABLE makes this workflow well worth incorporating into an overall recruitment strategy, particularly for a pragmatic trial.

Rapid screening and identification of chemical hazards in surface and drinking water using high resolution mass spectrometry and a case-control filter.

Access to clean, safe drinking water poses a serious challenge to regulators, and requires analytical strategies capable of rapid screening and identification of potentially hazardous chemicals, specifically in situations when threats to water quality or security require rapid investigations and potential response. This study describes a fast and efficient chemical hazard screening strategy for characterising trace levels of polar organic contaminants in water matrices, based on liquid chromatography high resolution mass spectrometry with post-acquisition 'case-control' data processing. This method allowed for a rapid response time of less than 24 h for the screening of target, suspect and non-target unknown chemicals via direct injection analysis, and a second, more sensitive analysis option requiring sample pre-concentration. The method was validated by fortifying samples with a range of pesticides, pharmaceuticals and personal care products (n = 46); with >90% of target compounds positively screened in samples at 1 ng mL-1, and 46% at 0.1 ng mL-1 when analysed via direct injection. To simulate a contamination event samples were fortified with compounds not present in the commercial library (designated 'non-target compounds'; fipronil and fenitrothion), tentatively identified at 0.2 and 1 ng mL-1, respectively; and a compound not included in any known commercial library or public database (designated 'unknown' compounds; 8Cl- perfluorooctanesulfonic acid), at 0.8 ng mL-1. The method was applied to two 'real-case' scenarios: (1) the assessment of drinking water safety during a high-profile event in Brisbane, Australia; and (2) to screen treated, re-circulated drinking water and pre-treated (raw) water. The validated workflow was effective for rapid prioritisation and screening of suspect and non-target potential hazards at trace levels, and could be applied to a wide range of matrices and investigations where comparison of organic contaminants between an affected and control site and or timeframe is warranted.

Effects of salinity on leaf breakdown: Dryland salinity versus salinity from a coalmine.

Salinization of freshwater ecosystems as a result of human activities represents a global threat for ecosystems' integrity. Whether different sources of salinity with their differing ionic compositions lead to variable effects in ecosystem functioning is unknown. Therefore, the present study assessed the impact of dryland- (50µS/cm to 11,000µS/cm) and coalmine-induced (100µS/cm to 2400µS/cm) salinization on the leaf litter breakdown, with focus on microorganisms as main decomposer, in two catchments in New South Wales, Australia. The breakdown of Eucalyptus camaldulensis leaves decreased with increasing salinity by up to a factor of three. Coalmine salinity, which is characterised by a higher share of bicarbonates, had a slightly but consistently higher breakdown rate at a given salinity relative to dryland salinity, which is characterised by ionic proportions similar to sea water. Complementary laboratory experiments supported the stimulatory impact of sodium bicarbonates on leaf breakdown when compared to sodium chloride or artificial sea salt. Furthermore, microbial inoculum from a high salinity site (11,000µS/cm) yielded lower leaf breakdown at lower salinity relative to inoculum from a low salinity site (50µS/cm). Conversely, inoculum from the high salinity site was less sensitive towards increasing salinity levels relative to inoculum from the low salinity site. The effects of the different inoculum were the same regardless of salt source (sodium bicarbonate, sodium chloride and artificial sea salt). Finally, the microorganism-mediated leaf litter breakdown was most efficient at intermediate salinity levels (≈500µS/cm). The present study thus points to severe implications of increasing salinity intensities on the ecosystem function of leaf litter breakdown, while the underlying processes need further scrutiny.

The Rising Rate of Rural Hospital Closures.

PURPOSE: Since 2010, the rate of rural hospital closures has increased significantly. This study is a preliminary look at recent closures and a formative step in research to understand the causes and the impact on rural communities. METHODS: The 2009 financial performance and market characteristics of rural hospitals that closed from 2010 through 2014 were compared to rural hospitals that remained open during the same period, stratified by critical access hospitals (CAHs) and other rural hospitals (ORHs). Differences were tested using Pearson's chi-square (categorical variables) and Wilcoxon rank test of medians. The relationships between negative operating margin and (1) market factors and (2) utilization/staffing factors were explored using logistic regression. FINDINGS: In 2009, CAHs that subsequently closed from 2010 through 2014 had, in general, lower levels of profitability, liquidity, equity, patient volume, and staffing. In addition, ORHs that closed had smaller market shares and operated in markets with smaller populations compared to ORHs that remained open. Odds of unprofitability were associated with both market and utilization factors. Although half of the closed hospitals ceased providing health services altogether, the remainder have since converted to an alternative health care delivery model. CONCLUSIONS: Financial and market characteristics appear to be associated with closure of rural hospitals from 2010 through 2014, suggesting that it is possible to identify hospitals at risk of closure. As closure rates show no sign of abating, it is important to study the drivers of distress in rural hospitals, as well as the potential for alternative health care delivery models.

Process Improvement for Interinstitutional Research Contracting.

INTRODUCTION: Sponsored research increasingly requires multiinstitutional collaboration. However, research contracting procedures have become more complicated and time consuming. The perinatal research units of two colocated healthcare systems sought to improve their research contracting processes. METHODS: The Lean Process, a management practice that iteratively involves team members in root cause analyses and process improvement, was applied to the research contracting process, initially using Process Mapping and then developing Problem Solving Reports. RESULTS: Root cause analyses revealed that the longest delays were the individual contract legal negotiations. In addition, the "business entity" was the research support personnel of both healthcare systems whose "customers" were investigators attempting to conduct interinstitutional research. Development of mutually acceptable research contract templates and language, chain of custody templates, and process development and refinement formats decreased the Notice of Grant Award to Purchase Order time from a mean of 103.5 days in the year prior to Lean Process implementation to 45.8 days in the year after implementation (p = 0.004). CONCLUSIONS: The Lean Process can be applied to interinstitutional research contracting with significant improvement in contract implementation.