Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data.

PURPOSE: Health service use is most intensive in the final year of a person's life, with 80% of this expenditure occurring in hospital. Close involvement of primary care services has been promoted to enhance quality end-of-life care that is appropriate to the needs of patients. However, the relationship between primary care involvement and patients' use of hospital care is not well described. This study aims to examine primary care use in the last year of life for cancer patients and its relationship to hospital usage. METHODS: Retrospective cohort study in Victoria, Australia, using linked routine care data from primary care, hospital and death certificates. Patients were included who died related to cancer between 2008 and 2017. RESULTS: A total of 758 patients were included, of whom 88% (n = 667) visited primary care during the last 6 months (median 9.1 consultations). In the last month of life, 45% of patients were prescribed opioids, and 3% had imaging requested. Patients who received home visits (13%) or anticipatory medications (15%) had less than half the median bed days in the last 3 months (4 vs 9 days, p < 0.001, 5 vs 10 days, p = 0.001) and 1 month of life (0 vs 2 days, p = 0.002, 0 vs 3 days, p < 0.001), and reduced emergency department presentations (32% vs 46%, p = 0.006, 31% vs 47% p < 0.001) in the final month. CONCLUSION: This study identifies two important primary care processes-home visits and anticipatory medication-associated with reduced hospital usage and intervention at the end of life.

Greywater treatment in a green wall using different filter materials and hydraulic loading rates.

Green walls in urban environments can be both an aesthetic feature and be of practical use in greywater treatment. This study evaluates the effect of different loading rates (4.5 l/d, 9 l/d, and 18 l/d) on the efficiency of treating actual greywater from a city district in a pilot-scale green wall with five different filter materials as substrates (biochar, pumice, hemp fiber, spent coffee grounds (SCG), and composted fiber soil (CFS)). Three cool climate plant species, Carex nigra, Juncus compressus, and Myosotis scorpioides, were chosen for the green wall. The following parameters were evaluated: biological oxygen demand (BOD), fractions of organic carbon, nutrients, indicator bacteria, surfactants, and salt. Three of the five materials investigated - biochar, pumice, and CFS - showed promising treatment efficiencies. The respective overall reduction efficiencies of BOD, total nitrogen (TN) and total phosphorus (TP) were 99%, 75%, and 57% for biochar; 96%, 58%, and 61% for pumice; and 99%, 82% and 85% for CFS. BOD was stable in the biochar filter material with effluent concentrations of 2 mg/l across all investigated loading rates. However, higher loading rates had a significantly negative effect on hemp and pumice for BOD. Interestingly, the highest loading rate (18 l/d) flowing over pumice removed the highest levels of TN (80%) and TP (86%). Biochar was the most effective material in removing indicator bacteria, with a 2.2-4.0 Log10 reduction for E. coli and enterococci. SCG was the least efficient material, giving a higher BOD in the effluent than in the influent. Therefore, this study presents the potential of natural and waste-derived filter materials to treat greywater effectively and the results can contribute to the future development of nature-based greywater treatment and management practices in urban areas.

Calibration and sensitivity analysis of a novel water flow and pollution model for future city planning: Future Urban Stormwater Simulation (FUSS).

Planning for future urban development and water infrastructure is uncertain due to changing human activities and climate. To quantify these changes, we need adaptable and fast models that can reliably explore scenarios without requiring extensive data and inputs. While such models have been recently considered for urban development, they are lacking for stormwater pollution assessment. This work proposes a novel Future Urban Stormwater Simulation (FUSS) model, utilizing a previously developed urban planning algorithm (UrbanBEATS) to dynamically assess pollution changes in urban catchments. By using minimal input data and adding stochastic point-source pollution to the build-up/wash-off approach, this study highlights calibration and sensitivity analysis of flow and pollution modules, across the range of common stormwater pollutants. The results highlight excellent fit to measured values in a continuous rainfall simulation for the flow model, with one significant calibration parameter. The pollution model was more variable, with TSS, TP and Pb showing high model efficiency, while TN was predicted well only across event-based assessment. The work further explores the framework for the model application in future pollution assessment, and points to the future work aiming to developing land-use dependent model parameter sets, to achieve flexibility for model application across varied urban catchments.

Illicit discharge detection in stormwater drains using an Arduino-based low-cost sensor network.

Illicit discharges in urban stormwater drains are a major environmental concern that deteriorate downstream waterway health. Conventional detection methods such as stormwater drain visual inspection and dye testing have fundamental drawbacks and limitations which can prevent easy location and elimination of illegal discharges in a catchment. We deployed 22 novel low-cost level, temperature and conductivity sensors across an urban catchment in Melbourne for a year to monitor the distributed drainage network, thereby detecting likely illicit discharges ranging from a transitory flow with less than 10 minutes to persistent flows lasting longer than 20 hours. We discuss rapid deployment methods, real-time data collection and online processing. The ensemble analysis of all dry weather flow data across all sites indicates that: (i) large uncertainties are associated with discharge frequency, duration, and variation in water quality within industrial and residential land uses; (ii) most dry weather discharges are intermittent and transient flows which are difficult to detect and not simply due to cross-connections with the sewerage network; (iii) detectable diurnal discharge patterns can support mitigation efforts, including policies and regulatory measures (e.g., enforcement or education) to protect receiving waterways; and, (iv) that it is possible to cost effectively isolate sources of dry weather pollution using a distributed sensor network.

High prevalence of vertebral fractures in seizure patients with normal bone density receiving chronic anti-epileptic drugs.

People with epilepsy who take certain medications are at risk for developing osteoporosis and fractures of the vertebrae that commonly go undiagnosed. By using technology available in a bone density scan, we observed at least one fracture in many subjects with bone density in the normal and osteopenic range. PURPOSE/INTRODUCTION: Chronic use of antiepileptic drugs (AEDs), both enzyme-inducing (phenytoin, phenobarbital, carbamazepine, and primidone) and non-enzyme-inducing (i.e., valproate), is recognized as a cause of secondary osteoporosis. Vertebral compression fractures (VF) are the most common type of osteoporotic fractures and may confer an increased risk of future hip, wrist, and vertebral fractures. Vertebral compression fractures in the general population are frequently asymptomatic, and under-diagnosed. The purpose of this study is to describe the prevalence of VF in a cohort of male veterans with epilepsy on chronic AEDs. METHODS: The cohort for this study consisted of 146 male veterans who carried a diagnosis of epilepsy and were chronic users of AEDs known to cause osteoporosis (phenobarbital, phenytoin, carbamazepine, primidone, and valproate). Chronic AED use was defined as receiving an AED for at least 2 years. Subjects were previously seen in the osteoporosis clinic and had been evaluated by a dual-energy X-Ray absormetry (DXA) instrument including morphometric studies following a standard vertebral fracture assessment (VFA) protocol during the same DXA imaging acquisition session. RESULTS: The mean age was 63 years. Low bone mineral density defined as osteoporosis or osteopenia was observed in 29% and 43% respectively. We observed at least one VF in 41 % of the subjects who had normal BMD, 54% in the osteopenic range, and 75% in the osteoporotic range. CONCLUSIONS: By performing a VFA in addition to standard bone densitometric studies, we disclosed a large prevalence of compression fractures in individuals with epilepsy chronically treated with AEDs who had BMDs in the normal and osteopenic ranges. The addition of VFA or other imaging methods to evaluate VF should be included in the evaluation of bone health in individuals with epilepsy receiving AEDs since it may modify treatment recommendations to prevent future osteoporotic fractures.

Avoiding "Rash" Conclusions: Challenge of IgA Vasculitis in Adults.

IgA vasculitis is primarily a pediatric disease that is rarely encountered in adults. With adults, gastrointestinal manifestations are quite common, yet are nonspecific and may overlap with other diseases, particularly Crohn's disease, which can make the diagnosis a challenging task. Treatment is controversial given the disease course is usually self-limited with few serious complications. We present a case of IgA vasculitis in an adult patient with limited extraintestinal findings illustrating the complexity of arriving at the correct diagnosis.

A ground-layer adaptive optics system with multiple laser guide stars.

To determine the influence of the environment on star formation, we need to study the process in the extreme conditions of massive young star clusters ( approximately 10(4) solar masses) near the centre of our own Galaxy. Observations must be carried out in the near infrared because of very high extinction in visible light within the Galactic plane. We need high resolution to identify cluster members from their peculiar motions, and because most such clusters span more than 1', efficient observation demands a wide field of view. There is at present no space-based facility that meets all these criteria. Ground-based telescopes can in principle make such observations when fitted with ground-layer adaptive optics (GLAO), which removes the optical aberration caused by atmospheric turbulence up to an altitude of approximately 500 m (refs 7-10). A GLAO system that uses multiple laser guide stars has been developed at the 6.5-m MMT telescope, in Arizona. In previous tests, the system improved the resolution of the telescope by 30-50%, limited by wavefront error in the optics, but that was insufficient to allow rapid determination of cluster membership. Here we report observations of the core of the globular cluster M3 made after commissioning a sensor to monitor and remove slowly varying aberration in the optics. In natural seeing of 0.7'', the point spread function at 2.2-mum wavelength was sharpened uniformly to 0.3'' over a field of at least 2'. The wide-field resolution was enhanced by a factor of two to three over previous work, with better uniformity, and extends to a wavelength of 1.2 mum. Entire stellar clusters may be examined in a single pointing, and cluster membership can be determined from two such observations separated by just one year.

Tempering allorecognition to induce transplant tolerance with chemically modified apoptotic donor cells.

The development of organ transplantation as a therapy for end-stage organ failure is among the most significant achievements of 20th century medicine, but chronic rejection remains a barrier to achieving long-term success. Current therapeutic regimens consist of immunosuppressive drugs that are efficient at delaying rejection but are associated with significant risks such as opportunistic infections, toxicity, and malignancy. Thus, the induction of specific immune tolerance to transplant antigens is the coveted aim of researchers. The use of 1-ethyl-3-(3-dimethylaminopropyl)carbodiimide (ECDI)-treated, autoantigen-coupled syngeneic leukocytes has been developed as a specific immunotherapy in preclinical models of autoimmunity and is currently in a phase II clinical trial for the treatment of multiple sclerosis. In this review, we discuss the use of allogeneic ECDI-treated apoptotic donor leukocytes (allo-ECDI-SP) as a strategy for inducing antigen-specific tolerance in allogeneic transplantation. Allo-ECDI-SP therapy induces long-term systemic immune tolerance to transplant antigens by subverting alloimmune recognition and exploiting apoptotic cell uptake pathways to recapitulate innate mechanisms of peripheral tolerance. Lastly, we discuss potential indications and challenges for transitioning allo-ECDI-SP therapy into clinical practice.

Lanicemine: a low-trapping NMDA channel blocker produces sustained antidepressant efficacy with minimal psychotomimetic adverse effects.

Ketamine, an N-methyl-D-aspartate receptor (NMDAR) channel blocker, has been found to induce rapid and robust antidepressant-like effects in rodent models and in treatment-refractory depressed patients. However, the marked acute psychological side effects of ketamine complicate the interpretation of both preclinical and clinical data. Moreover, the lack of controlled data demonstrating the ability of ketamine to sustain the antidepressant response with repeated administration leaves the potential clinical utility of this class of drugs in question. Using quantitative electroencephalography (qEEG) to objectively align doses of a low-trapping NMDA channel blocker, AZD6765 (lanicemine), to that of ketamine, we demonstrate the potential for NMDA channel blockers to produce antidepressant efficacy without psychotomimetic and dissociative side effects. Furthermore, using placebo-controlled data, we show that the antidepressant response to NMDA channel blockers can be maintained with repeated and intermittent drug administration. Together, these data provide a path for the development of novel glutamatergic-based therapeutics for treatment-refractory mood disorders.

Residual indicator bacteria in autosampler tubing: a field and laboratory assessment.

Microbial contamination in surface waters has become a worldwide cause for concern. As efforts are made to reduce this contamination, monitoring is integral to documenting and evaluating water quality improvements. Autosamplers are beneficial in such monitoring efforts, as large data sets can be generated with minimized effort. The extent to which autosamplers can be utilized for microbial monitoring is largely unknown due to concerns over contamination. Strict sterilization regimes for components contacting the water being sampled are difficult, and sometimes logistically implausible, when utilizing autosamplers. Field experimentation showed contamination of fecal coliform in autosamplers to be more of a concern than that of Escherichia coli. Further study in a controlled laboratory environment suggested that tubing configuration has a significant effect on residual E. coli concentrations in sampler tubing. The amount of time that passed since the last sample was collected from a given sampler (antecedent dry weather period - DWP) tubing was also a significant factor. At a DWP of 7 days, little to no contamination was found. Thus, simple protocols such as providing positive drainage of tubing between sample events and programming samplers to include rinses will reduce concerns of contamination in autosamplers.

Uncertainty analysis in urban drainage modelling: should we break our back for normally distributed residuals?

This study presents results on the assessment of the application of a Bayesian approach to evaluate the sensitivity and uncertainty associated with urban rainfall-runoff models. The software MICA was adopted, in which the prior information about the parameters is updated to generate the parameter posterior distribution. The likelihood function adopted in MICA assumes that the residuals between the measured and modelled values have a normal distribution. This is a trait of many uncertainty/sensitivity procedures. This study compares the results from three different scenarios: (i) when normality of the residuals was checked but if they were not normal then nothing was done (unverified); (ii) normality assumption was checked, verified (using data transformations) and a weighting strategy was used that gives more importance to high flows; and (iii) normality assumption was checked and verified, but no weights were applied. The modelling implications of such scenarios were analysed in terms of model efficiency, sensitivity and uncertainty assessment. The overall results indicated that verifying the normality assumption required the models to fit a wider portion of the hydrograph, allowing a more detailed inspection of parameters and processes simulated in both models. Such an outcome provided important information about the advantages and limitations of the models' structure.

Evaluating Escherichia coli removal performance in stormwater biofilters: a preliminary modelling approach.

Stormwater biofilters are not currently optimised for pathogen removal since the behaviour of these pollutants within the stormwater biofilters is poorly understood. Modelling is a common way of optimising these systems, which also provides a better understanding of the major processes that govern the pathogen removal. This paper provides an overview of a laboratory-scale study that investigated how different design and operational conditions impact pathogen removal in the stormwater biofilters. These data were then used to develop a modelling tool that can be used to optimise the design and operation of the stormwater biofilters. The model uses continuous simulations where adsorption and desorption were dominant during wet weather periods and first order die-off kinetics were significant in dry periods between the wet weather events. Relatively high Nash Sutcliffe Efficiencies (>0.5) indicate that the calibrated model is in good agreement with observed data and the optimised model parameters were comparable with values reported in the literature. The model's sensitivity is highest towards the adsorption process parameter followed by the die-off and desorption rate parameters, which implies that adsorption is the governing process of the model. Vegetation is found to have an impact on the wet weather processes since the adsorption and desorption parameters vary significantly with the different plant configurations. The model is yet to be tested against field data and needs to be improved to represent the effect of some other biofilter design configurations, such as the inclusion of the submerged zone.

Performance of enviss™ stormwater filters: results of a laboratory trial.

An experimental study was undertaken by Monash University to develop and test enviss™ stormwater treatment and harvesting technologies - non-vegetated filtration systems with an extremely low footprint. This paper focuses on the water quality and hydraulic performance of two systems tested over a 'year' of operation in a Melbourne climate: (1) REUSE enviss™ filters, designed for stormwater harvesting systems for non-potable supply substitution, and (2) WSUD enviss™ filters, developed to treat urban stormwater prior to discharge to downstream systems. The presence of chlorine as a disinfection agent proved to be very efficient for the removal of microorganisms in REUSE enviss™ filters. WSUD enviss™ filters had the benefit of providing an elevated nutrient treatment performance, due to an extended depth of filter media. However, nutrient outflow concentrations (total nitrogen (TN) in particular) were found to increase during the testing period. Also, extended dry weather periods were found to have a detrimental effect on the treatment performance of almost all pollutants for both filters (nutrients, Escherichia coli and heavy metals). Although hydraulic conductivity results indicated two or three sediment trap replacements per year are required to maintain filtration rates, it is expected that the compressed loading rate schedule overestimated this maintenance frequency.

Zinc-sulphate-heptahydrate coated activated carbon for microbe removal from stormwater.

There is a need to develop effective stormwater filters for passive (without any addition of chemicals or energy) and effective removal of pathogens in order to mainstream stormwater harvesting. This study focuses on the development of coated granular activated carbon (GAC) filtration material in order to develop filters for effective removal of pathogens from urban stormwater. Several laboratory trials were performed to gauge the effectiveness of the filters, which use a mixture of the zinc-sulphate-heptahydrate coated GAC and sand, on the removal of Escherichia coli (E. coli) from semi-natural stormwater. On average, a 98% removal of the inflow concentration of E. coli was achieved. Furthermore, there was also an improvement of approximately 25% in the removal of phosphorous. However, it was found that the treated material was leaching zinc. It was important to determine whether the observed removal of E. coli was indirectly caused by the sampling methodology. The results showed that the inactivation of the E. coli in the collected sample was small compared with the inactivation which actually occurred within the filter. This provides much promise to the filter, but the presence of zinc in the outflow demonstrates the need for further investigation into the stabilisation of the coating process.

Evaluating Escherichia coli removal performance in stormwater biofilters: a laboratory-scale study.

Biofilters are common, low energy technologies used for the treatment of urban stormwater. While they have shown promising results for the removal of stormwater microorganisms, certain factors affect their performance. Hence, this study investigated the effects of particle-microbial interaction, inflow concentration, antecedent microbial levels and plant species on microbial removal capacity. A biofilter column study was set up to evaluate removal performance and a sequential filtration procedure was used to estimate microbial partitioning. The columns were dosed with different concentrations of free phase Escherichia coli only and E. coli mixed with stormwater sediment. Results indicate that the microbial removal is significantly affected by inflow concentration and antecedent microbial levels. Leaching was only observed when a relatively low inflow concentration event occurred within a short period after a very high inflow concentration event. Finally, Lomandra longifolia showed better removal compared with Carex appressa.

Plants against pathogens: Effect of significant antimicrobial-producing plants on faecal microbe inactivation throughout the soil profile of stormwater biofilters.

Stormwater biofilters have demonstrated promising yet variable removal of faecal microorganisms. Significant antimicrobial-producing plants have been proposed as an inexpensive, safe and easily adaptable component of biofilter design to enhance faecal pathogen treatment. The aim of the present study was to investigate whether significant antimicrobial-producing plants improved faecal bacterial inactivation throughout the biofilter soil profile, focusing on four key treatment zones. These were specifically the top sediment/surface layer; the rhizosphere (soil directly attached to and influenced by plant roots); bulk soil (soil not directly associated with roots); and the submerged/saturated zone. Biofilters were configured with either: (1) no plant; (2) Carex appressa, the most highly recommended plant species in Australian biofilter adoption guidelines; or (3) one of two significant antimicrobial-producing Australian plant species, Melaleuca linariifolia or Melaleuca fulgens (n = 3 each). Following 16 months' maturation, systems were dosed with semi-synthetic stormwater containing faecal bacteria Escherichia coli and Enterococcus faecalis to monitor their ensuing die-off within all major biofilter treatment zones. Bacterial inactivation was generally more rapid in M. fulgens and M. linariifolia than C. appressa biofilters, with E. faecalis demonstrating an overall enhanced resistance to inactivation. Top sediment tended to exhibit the highest inactivation rates, significantly correlated with sunlight exposure. Conversely, the rhizosphere supported comparatively prolonged faecal bacterial survival. The authors recommend further investigation of melaleucas and similar highly antimicrobial-producing plants for enhanced faecal pathogen treatment within biofilters and related treatment contexts.