Cost of dialysis therapies in rural and remote Australia - a micro-costing analysis.

BACKGROUND: Maintenance dialysis is a costly and resource intense activity. In Australia, inadequate health infrastructure and poor access to technically skilled staff can limit service provision in remote areas where many Aboriginal dialysis patients live. With most studies based on urban service provision, there is little evidence to guide service development. However permanent relocation to an urban area for treatment can have significant social and financial impacts that are poorly quantified. This study is part of a broader project to quantify the costs and benefits of dialysis service models in urban and remote locations in Australia's Northern Territory (NT). METHODS: We undertook a micro-costing analysis of dialysis service delivery costs in urban, rural and remote areas in the NT from the payer perspective. Recurrent maintenance costs (salaries, consumables, facility management and transportation) as well as capital costs were included. Missing and centralised costs were standardised; results were inflated to 2017 values and reported in Australian dollars. RESULTS: There was little difference between the average annual cost for urban and rural services with respective median costs of $85,919 versus $84,629. However remote service costs were higher ($120,172 - $124,492), driven by higher staff costs. The inclusion of capital costs did not add substantially to annual costs. Annual home haemodialysis costs ($42,927) were similar to other jurisdictions despite the significant differences in program delivery and payment of expenses not traditionally borne by governments. Annual peritoneal dialysis costs ($58,489) were both higher than home and in-centre haemodialysis by recent national dialysis cost studies. CONCLUSION: The cost drivers for staffed services were staffing models and patient attendance rates. Staff salaries and transport costs were significantly higher in remote models of care. Opportunities to reduce expenditure exist by encouraging community supported services and employing local staff. Despite the delivery challenges of home haemodialysis including high patient attrition, the program still provides a cost benefit compared to urban staffed services. The next component of this study will examine patient health service utilisation and costs by model of care to provide a more comprehensive analysis of the overall cost of providing services in each location.

Incorporating indigenous knowledge in health services: a consumer partnership framework.

OBJECTIVES: Healthcare policy and planning should be informed by a partnership between healthcare services and healthcare users. This is critical for people who access care frequently such as indigenous Australians who have a high burden of chronic kidney disease. This study aimed to explore the most appropriate ways of enhancing services by incorporating renal patients' expectations and satisfaction of care in Australia's Northern Territory. STUDY DESIGN: This is a participatory action research. METHODS: Six aboriginal health users with end-stage kidney disease were recruited to form an Indigenous Reference Group. This group met bimonthly between April and November 2017 and meetings took the same structure as a focus group. Findings from these meetings were presented to health policy and planners in a feedback loop implemented by the study. RESULTS: This framework enabled indigenous knowledge to guide the project, indigenous priorities to be identified in this context and timely feedback of information to inform the strengths and priorities of the health service. Changes were recognised and addressed immediately. CONCLUSIONS: This qualitative research framework is a useful mechanism for providing local data to inform patient-centred health system change as expressed by health users. We recommend this consumer partnership framework be embedded into existing operational structures to support the ongoing sustainability of this group.

Short communication: Teat-end shape and udder-level milking characteristics and their associations with machine milking-induced changes in teat tissue condition.

Machine milking-induced changes in teat tissue condition, such as congestion and edema, have been associated with teat canal openness, penetrability, and thus susceptibility to new intramammary infections and diminished animal well-being. The primary objective of this study was to investigate the association of teat-end shape and machine milking-induced short-term changes in teat tissue condition. Our secondary objective was to study the association of udder-level milking characteristics and short-term changes. Data from 125 Holstein cows were analyzed in a longitudinal prospective cohort study. Cows were housed in freestall pens with sand bedding, fed a total mixed ration, and milked 3 times per day. Teat-end shape was classified into 3 categories: pointed, flat, and round. Udder-level milking characteristics were obtained from electronic on-farm milk meters. Short-term changes in teat tissue condition after machine milking were assessed visually. Multivariable generalized mixed model analysis showed an association between teat-end shape and short-term changes. Compared with teats with round teat-end shape, the odds ratio (95% confidence interval) for short-term changes was 1.68 (0.53-5.31) and 0.03 (0.004-0.19) in teats with pointed and flat teat-end shape, respectively. There was an association between milking characteristics and short-term changes such that higher milk flow rate during the first 15 s of milking decreased the likelihood of short-term changes. The adjusted probability of short-term changes for a milking observation of a mid-lactation cow and an average first 15-s milk flow rate of 0.5 and 1.5 kg/min was 53.0% (42.8-63.8) and 32.9% (15.2-57.3), respectively. Our results suggest that teat-end shape may be one of the risk factors that contribute to machine milking-induced short-term changes. Milking characteristics (e.g., first 15-s milk flow rate) may have the potential as a measure to indirectly monitor teat tissue changes associated with machine milking on a daily basis, though further research is needed to validate this hypothesis and to establish thresholds that could serve as on-farm guidelines.

Legionella longbeachae detected in an industrial cooling tower linked to a legionellosis outbreak, New Zealand, 2015; possible waterborne transmission?

A legionellosis outbreak at an industrial site was investigated to identify and control the source. Cases were identified from disease notifications, workplace illness records, and from clinicians. Cases were interviewed for symptoms and risk factors and tested for legionellosis. Implicated environmental sources were sampled and tested for legionella. We identified six cases with Legionnaires' disease and seven with Pontiac fever; all had been exposed to aerosols from the cooling towers on the site. Nine cases had evidence of infection with either Legionella pneumophila serogroup (sg) 1 or Legionella longbeachae sg1; these organisms were also isolated from the cooling towers. There was 100% DNA sequence homology between cooling tower and clinical isolates of L. pneumophila sg1 using sequence-based typing analysis; no clinical L. longbeachae isolates were available to compare with environmental isolates. Routine monitoring of the towers prior to the outbreak failed to detect any legionella. Data from this outbreak indicate that L. pneumophila sg1 transmission occurred from the cooling towers; in addition, L. longbeachae transmission was suggested but remains unproven. L. longbeachae detection in cooling towers has not been previously reported in association with legionellosis outbreaks. Waterborne transmission should not be discounted in investigations for the source of L. longbeachae infection.

Macroinvertebrate Taxonomic and Functional Trait Compositions within Lotic Habitats Affected By River Restoration Practices.

The widespread degradation of lotic ecosystems has prompted extensive river restoration efforts globally, but many studies have reported modest ecological responses to rehabilitation practices. The functional properties of biotic communities are rarely examined within post-project appraisals, which would provide more ecological information underpinning ecosystem responses to restoration practices and potentially pinpoint project limitations. This study examines macroinvertebrate community responses to three projects which aimed to physically restore channel morphologies. Taxonomic and functional trait compositions supported by widely occurring lotic habitats (biotopes) were examined across paired restored and non-restored (control) reaches. The multivariate location (average community composition) of taxonomic and functional trait compositions differed marginally between control and restored reaches. However, changes in the amount of multivariate dispersion were more robust and indicated greater ecological heterogeneity within restored reaches, particularly when considering functional trait compositions. Organic biotopes (macrophyte stands and macroalgae) occurred widely across all study sites and supported a high alpha (within-habitat) taxonomic diversity compared to mineralogical biotopes (sand and gravel patches), which were characteristic of restored reaches. However, mineralogical biotopes possessed a higher beta (between-habitat) functional diversity, although this was less pronounced for taxonomic compositions. This study demonstrates that examining the functional and structural properties of taxa across distinct biotopes can provide a greater understanding of biotic responses to river restoration works. Such information could be used to better understand the ecological implications of rehabilitation practices and guide more effective management strategies.

When is the best time to sample aquatic macroinvertebrates in ponds for biodiversity assessment?

Ponds are sites of high biodiversity and conservation value, yet there is little or no statutory monitoring of them across most of Europe. There are clear and standardised protocols for sampling aquatic macroinvertebrate communities in ponds, but the most suitable time(s) to undertake the survey(s) remains poorly specified. This paper examined the aquatic macroinvertebrate communities from 95 ponds within different land use types over three seasons (spring, summer and autumn) to determine the most appropriate time to undertake sampling to characterise biodiversity. The combined samples from all three seasons provided the most comprehensive record of the aquatic macroinvertebrate taxa recorded within ponds (alpha and gamma diversity). Samples collected during the autumn survey yielded significantly greater macroinvertebrate richness (76% of the total diversity) than either spring or summer surveys. Macroinvertebrate diversity was greatest during autumn in meadow and agricultural ponds, but taxon richness among forest and urban ponds did not differ significantly temporally. The autumn survey provided the highest measures of richness for Coleoptera, Hemiptera and Odonata. However, richness of the aquatic insect order Trichoptera was highest in spring and lowest in autumn. The results illustrate that multiple surveys, covering more than one season, provide the most comprehensive representation of macroinvertebrate biodiversity. When sampling can only be undertaken on one occasion, the most appropriate time to undertake surveys to characterise the macroinvertebrate community biodiversity is during autumn, although this may need to be modified if other floral and faunal groups need to be incorporated into the sampling programme.

Died of wounds: a mortality review.

OBJECTIVES: Combat casualty care is a complex system involving multiple clinicians, medical interventions and casualty transfers. Improving the performance of this system requires examination of potential weaknesses. This study reviewed the cause and timing of death of casualties deemed to have died from their injuries after arriving at a medical treatment facility during the recent conflicts in Iraq and Afghanistan, in order to identify potential areas for improving outcomes. METHODS: This was a retrospective review of all casualties who reached medical treatment facilities alive, but subsequently died from injuries sustained during combat operations in Afghanistan and Iraq. It included all deaths from start to completion of combat operations. The UK military joint theatre trauma registry was used to identify cases, and further data were collected from clinical notes, postmortem records and coroner's reports. RESULTS: There were 71 combat-related fatalities who survived to a medical treatment facility; 17 (24%) in Iraq and 54 (76%) in Afghanistan. Thirty eight (54%) died within the first 24 h. Thirty-three (47%) casualties died from isolated head injuries, a further 13 (18%) had unsurvivable head injuries but not in isolation. Haemorrhage following severe lower limb trauma, often in conjunction with abdominal and pelvic injuries, was the cause of a further 15 (21%) deaths. CONCLUSIONS: Severe head injury was the most common cause of death. Irrespective of available medical treatment, none of this group had salvageable injuries. Future emphasis should be placed in preventative strategies to protect the head against battlefield trauma.

Lighter and heavier initial loads yield similar gains in strength when employing a progressive wave loading scheme.

Progressive wave loading strategies are common within strength and conditioning practice. The purpose of this study was to contribute to the understanding of this strategy by evaluating the effectiveness of 2 wave loading bench press training programmes that differed only in the initial load that was used to start the first wave. Thirty-four resistance-trained men were divided into 2 groups and performed 2 training sessions each week for 20 weeks. One session consisted of 6 sets of 2 repetitions, while the other consisted of 5 sets of 5 repetitions. The load used was incremented by 2.5% of one repetition maximum (1RM) each week until the subject could no longer complete the programmed repetitions. At this point, the load was decreased, and then started to ascend again. The initial loads for the 2 sessions were 87.5% and 80% 1RM respectively for the heavier group, and for the lighter group were 82.5% and 75% 1RM. The subjects experienced a significant improvement in their bench press performance (higher load group: pre test = 106.5 kg ± 14.6, post test = 112.2 kg ± 12.4, p ≤ 0.05; lower load group: pre test = 105.7 kg ± 14.1, post test = 114.3 kg ± 11.0, p ≤ 0.05), but there was no difference in the magnitude of the improvment between the two groups. These results tend to support the common practical recommendation to start with a lighter load when employing a progressive wave loading strategy, as such a strategy yields similar improvements in performance with a lower level of exertion in training.

The United Kingdom Primary Immune Deficiency (UKPID) Registry: report of the first 4 years' activity 2008-2012.

This report summarizes the establishment of the first national online registry of primary immune deficency in the United Kingdom, the United Kingdom Primary Immunodeficiency (UKPID Registry). This UKPID Registry is based on the European Society for Immune Deficiency (ESID) registry platform, hosted on servers at the Royal Free site of University College, London. It is accessible to users through the website of the United Kingdom Primary Immunodeficiency Network (www.ukpin.org.uk). Twenty-seven centres in the United Kingdom are actively contributing data, with an additional nine centres completing their ethical and governance approvals to participate. This indicates that 36 of 38 (95%) of recognized centres in the United Kingdom have engaged with this project. To date, 2229 patients have been enrolled, with a notable increasing rate of recruitment in the past 12 months. Data are presented on the range of diagnoses recorded, estimated minimum disease prevalence, geographical distribution of patients across the United Kingdom, age at presentation, diagnostic delay, treatment modalities used and evidence of their monitoring and effectiveness.

Towards the characterization and validation of alcohol use disorder subtypes: integrating consumption and symptom data.

BACKGROUND: There is evidence that measures of alcohol consumption, dependence and abuse are valid indicators of qualitatively different subtypes of alcohol involvement yet also fall along a continuum. The present study attempts to resolve the extent to which variations in alcohol involvement reflect a difference in kind versus a difference in degree. METHOD: Data were taken from the 2001-2002 National Epidemiologic Survey of Alcohol and Related Conditions. The sample (51% male; 72% white/non-Hispanic) included respondents reporting past 12-month drinking at both waves (wave 1: n = 33644; wave 2: n = 25186). We compared factor mixture models (FMMs), a hybrid of common factor analysis (FA) and latent class analysis (LCA), against FA and LCA models using past 12-month alcohol use disorder (AUD) criteria and five indicators of alcohol consumption reflecting frequency and heaviness of drinking. RESULTS: Model comparison revealed that the best-fitting model at wave 1 was a one-factor four-class FMM, with classes primarily varying across dependence and consumption indices. The model was replicated using wave 2 data, and validated against AUD and dependence diagnoses. Class stability from waves 1 to 2 was moderate, with greatest agreement for the infrequent drinking class. Within-class associations in the underlying latent factor also revealed modest agreement over time. CONCLUSIONS: There is evidence that alcohol involvement can be considered both categorical and continuous, with responses reduced to four patterns that quantitatively vary along a single dimension. Nosologists may consider hybrid approaches involving groups that vary in pattern of consumption and dependence symptomatology as well as variation of severity within group.

New oral anticoagulants: a practical guide on prescription, laboratory testing and peri-procedural/bleeding management. Australasian Society of Thrombosis and Haemostasis.

New oral anticoagulants (NOAC) are becoming available as alternatives to warfarin to prevent systemic embolism in patients with non-valvular atrial fibrillation and for the treatment and prevention of venous thromboembolism. An in-depth understanding of their pharmacology is invaluable for appropriate prescription and optimal management of patients receiving these drugs should unexpected complications (such as bleeding) occur, or the patient requires urgent surgery. The Australasian Society of Thrombosis and Haemostasis has set out to inform physicians on the use of the different NOAC based on current available evidence focusing on: (i) selection of the most suitable patient groups to receive NOAC, (ii) laboratory measurements of NOAC in appropriate circumstances and (iii) management of patients taking NOAC in the perioperative period, and strategies to manage bleeding complications or 'reverse' the anticoagulant effects for urgent invasive procedures.

A new species of Hemiphyllodactylus Bleeker, 1860 (Squamata: Gekkonidae) from Ba Na-Nui Chua Nature Reserve, Central Vietnam.

A new species of the gekkonid Hemiphyllodactylus banaensis sp. nov. is described from Ba Na-Nui Chua Nature Reserve in central Vietnam. Previously included within H. yunnanensis, the new species is distinguished from all other congeners by having the unique combination of a maximum SVL of 48.2 mm in males and 51.0 mm in females; seven chin scales extending transversely from the union of the first and second infralabials and posterior margin of mental; enlarged postmental scales; 9-12 supralabials; 9-11 infralabials; 18-20 longitudinally arranged dorsal scales at midbody contained within one eye diameter; 20-21 precloacal and femoral pore-bearing scales contiguous in males and 0-20 contiguous pore-bearing precloacal scales in females; dorsal pattern on body composed of transverse blotches and two whitish stripes across shoulder extending to sacrum; postsacral mark whitish brown and bearing anteriorly projecting arms; and caecum and oviducts unpigmented.

Haemorrhage and coagulopathy in the Defence Medical Services.

Over the past 12 years, the United Kingdom Defence Medical Services have evolved an integrated 'damage control resuscitation - damage control surgery' sequence for the management of patients sustaining complex injuries. During 2009, over 3200 units of blood products were administered as massive transfusions to severely injured UK personnel. An important part of the approach to traumatic bleeding is the early, empirical use of predefined ratios of blood and clotting products. As soon as control of bleeding is achieved, current practice is to switch towards a tailored transfusion, based on clinical and laboratory assessments, including point-of-care coagulation testing. A key goal is to provide resuscitation seamlessly throughout surgery, so that patients leave the operating room with their normal physiology restored. This article outlines the current management of haemorrhage and coagulation employed in Afghanistan from the point of wounding to transfer back to the National Health Service.

X-linked anhidrotic ectodermal dysplasia with immunodeficiency is caused by impaired NF-kappaB signaling.

The molecular basis of X-linked recessive anhidrotic ectodermal dysplasia with immunodeficiency (EDA-ID) has remained elusive. Here we report hypomorphic mutations in the gene IKBKG in 12 males with EDA-ID from 8 kindreds, and 2 patients with a related and hitherto unrecognized syndrome of EDA-ID with osteopetrosis and lymphoedema (OL-EDA-ID). Mutations in the coding region of IKBKG are associated with EDA-ID, and stop codon mutations, with OL-EDA-ID. IKBKG encodes NEMO, the regulatory subunit of the IKK (IkappaB kinase) complex, which is essential for NF-kappaB signaling. Germline loss-of-function mutations in IKBKG are lethal in male fetuses. We show that IKBKG mutations causing OL-EDA-ID and EDA-ID impair but do not abolish NF-kappaB signaling. We also show that the ectodysplasin receptor, DL, triggers NF-kappaB through the NEMO protein, indicating that EDA results from impaired NF-kappaB signaling. Finally, we show that abnormal immunity in OL-EDA-ID patients results from impaired cell responses to lipopolysaccharide, interleukin (IL)-1beta, IL-18, TNFalpha and CD154. We thus report for the first time that impaired but not abolished NF-kappaB signaling in humans results in two related syndromes that associate specific developmental and immunological defects.

Is it time to actively look for vasa praevia?

Vasa praevia can cause acute severe fetal haemorrhage prior to or during rupture of the membranes, contributing to perinatal morbidity and mortality. There are no large prospective studies relating to vasa praevia and there is no place for a randomised controlled trial as it would be ethically unjustifiable given the poor prognosis. There are no national guidelines for the management of vasa praevia. Identification of vasa praevia by the 3rd trimester of pregnancy warrants the offer of delivery by planned caesarean section to avoid the complications. This is essentially intuitive and logical rather than based on any randomised trials. A universal screening programme for vasa praevia is not currently supported by a robust evidence base; however, the role of prenatal diagnosis requires an informed debate, as high quality data may not be forthcoming, given the low evidence of the condition. Increasing awareness and understanding of the clinical situations can accumulate information, which identify and treat this tragic complication of childbirth.

Domain-wall spin dynamics in kagome antiferromagnets.

We report magnetization and neutron scattering measurements down to 60 mK on a new family of Fe based kagome antiferromagnets, in which a strong local spin anisotropy combined with a low exchange path network connectivity lead to domain walls intersecting the kagome planes through strings of free spins. These produce unfamiliar slow spin dynamics in the ordered phase, evolving from exchange-released spin flips towards a cooperative behavior on decreasing the temperature, probably due to the onset of long-range dipolar interaction. A domain structure of independent magnetic grains is obtained that could be generic to other frustrated magnets.

A novel in vivo ovine model of transfusion-related acute lung injury (TRALI).

BACKGROUND AND OBJECTIVES: Even with the introduction of specific risk-reduction strategies, transfusion-related acute lung injury (TRALI) continues to be a leading cause of transfusion-related morbidity and mortality. Existing small animal models have not yet investigated TRALI resulting from the infusion of heat-treated supernatant from whole blood platelet concentrates. In this study, our objective was the development of a novel in vivo two-event model of TRALI in sheep. MATERIALS AND METHODS: Lipopolysaccharide (LPS; 15 µg/kg) as a first event, modelled clinical infection. Transfusion (estimated at 10% of total blood volume) of heat-treated pooled supernatant from date-of-expire human whole blood platelet concentrates (d5-PLT-S/N) was used as a second event. TRALI was defined by both hypoxaemia that developed either during the transfusion or within two hours of its completion and post-mortem histological evidence of pulmonary oedema. RESULTS: LPS infusion did not cause lung injury itself, but did result in decreased circulating levels of lymphocytes and neutrophils with evidence of the latter becoming sequestered in the lungs. Sheep that received LPS (first event) followed by d5-PLT-S/N (second event) displayed decreased pulmonary compliance, decreased end tidal CO(2) and increased arterial partial pressure of CO(2) relative to control sheep, and 80% of these sheep developed TRALI. CONCLUSIONS: This novel ovine two-event TRALI model presents a new tool for the investigation of TRALI pathogenesis. It represents the first description of an in vivo large animal model of TRALI and the first description of TRALI caused by transfusion with heat-treated pooled supernatant from human whole blood platelet concentrates.

Use of thromboelastometry in the assessment of coagulation before epidural insertion after massive transfusion.

A British soldier presented to the UK Field Hospital, Afghanistan with bilateral traumatic lower limb amputations. Resuscitation and surgery followed accepted damage control principles. Blood component therapy was in keeping with UK military guidelines and included platelets and cryoprecipitate. The patient's trachea was extubated following insertion of an effective epidural. Ten days later, in the UK, he developed neurological symptoms and the presence of a subdural haematoma was confirmed on magnetic resonance imaging. Conventional laboratory coagulation results in this patient were above accepted limits for epidural insertion; however, thromboelastometry before insertion was suggestive of reduced platelet function. This case highlights the risk of relying solely on platelet count as a marker of platelet function following massive transfusion. Thromboelastometry provides additional information for the assessment of coagulation and should form part of the assessment of coagulation following massive transfusion before epidural insertion.