A nurse-led approach to urgent results management at Sydney Sexual Health Centre demonstrates benefits to client outcomes and cost savings: a time efficiency and health system cost analysis.

BACKGROUND: The timely provision of test results to facilitate early access to treatment is an essential component of sexually transmissible infection (STI) control and contributes to a significant proportion of the workload at sexual health services. We aimed to estimate the time to deliver client results and treatment as well as the health system costs of the nurse-led urgent results management model at the Sydney Sexual Health Centre (SSHC) compared to an alternative 'ordering clinician' model. METHODS: We conducted a retrospective analysis of urgent results managed by the results nurse over 2weeks in 2019 and an observational study over 2weeks in 2021, where 10 clinicians managed five of their own urgent results. Additional activity data were gathered to determine the annual health system costs for both models. RESULTS: In the nurse-led model 211 of 280 clients required notification; 156 (73.9%) were notified on the day their results became available, and the median time to treatment (n =137) was 1day. The annual health system cost for the nurse-led model was A$3922143. In the ordering clinician model, 17 (42.5%) clients were notified on the same day, and of the 27 clients treated at SSHC, the median time to treatment increased to 4days. The annual health system cost for the ordering clinician model was A$4043667.28 compared with the nurse-led model, and an additional 33.3h per week of clinician time was required for the same level of service provision. CONCLUSIONS: This study highlights the strengths of the nurse-led results model at SSHC, demonstrating improved client outcomes for STI notification and treatment times and health systems savings.

Response to Comment on "Tropical forests are a net carbon source based on aboveground measurements of gain and loss".

The Hansen et al critique centers on the lack of spatial agreement between two very different datasets. Nonetheless, properly constructed comparisons designed to reconcile the two datasets yield up to 90% agreement (e.g., in South America).

Early initiation of antiretroviral therapy (ART): from point-of-care test to ART at a peer-led community-based testing site in Sydney.

The effect of performing baseline HIV investigations (BLHIVI) at the time of a reactive HIV point-of-care test in the pathway to antiretroviral therapy (ART) in a community setting has not been described. In this study, 67 men newly diagnosed with HIV across three service models were analysed. The median time to ART was 30, 29.5 and 38 days (P=0.29) at a peer-led community testing site intervention group, in a historical control group and in an urban publicly funded sexual health service respectively. In a community setting, the inclusion of BLHIVI has the potential to reduce the time to early ART initiation.

Tropical forests are a net carbon source based on aboveground measurements of gain and loss.

The carbon balance of tropical ecosystems remains uncertain, with top-down atmospheric studies suggesting an overall sink and bottom-up ecological approaches indicating a modest net source. Here we use 12 years (2003 to 2014) of MODIS pantropical satellite data to quantify net annual changes in the aboveground carbon density of tropical woody live vegetation, providing direct, measurement-based evidence that the world's tropical forests are a net carbon source of 425.2 ± 92.0 teragrams of carbon per year (Tg C year-1). This net release of carbon consists of losses of 861.7 ± 80.2 Tg C year-1 and gains of 436.5 ± 31.0 Tg C year-1 Gains result from forest growth; losses result from deforestation and from reductions in carbon density within standing forests (degradation or disturbance), with the latter accounting for 68.9% of overall losses.

Determination of 8-iso-prostaglandin F(2α) (8-iso-PGF(2α)) in human urine by ultra-performance liquid chromatography-tandem mass spectrometry.

A rapid, simple and sensitive method was developed for the determination of 8-iso-PGF2α in urine using ultra performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS); 8-iso-PGF2α-d4 was used as the internal standard (IS). Chromatographic separation was performed using an Acquity BEH C18 column with a mobile phase composition of A: 0.1% acetic acid in methanol:acetonitrile (1:1, v:v) and B: 0.1% acetic acid in water (A:B, 32.5:67.5, v:v). Detection was performed on a triple-quadrupole tandem mass spectrometer using atmospheric pressure chemical ionization (APCI) in negative mode and using multiple reaction monitoring (MRM). The MS/MS ion transitions monitored were m/z 353→193 and 357→197 for 8-iso-PGF2α and IS, respectively. The calibration curve was prepared in PBS buffer because of the presence of endogenous concentrations of analyte in the control matrix; the internal standard successfully correcting for matrix effects. Good linearity was observed over the concentration range of 0.025-20 ng/mL; the method proving to be accurate and reliable was successfully used in support of a pharmacodynamic study in humans.

Current literature and imaging techniques of aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL).

Aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL) are a recognized complication of metal-on-metal bearing hip prostheses. There is an impending concern regarding the future investigation and management of patients who have received such implants. The current literature is discussed, and the current guidelines for management of these patients in the UK are reviewed. The various imaging techniques available, such as computed tomography, metal artefact reduction magnetic resonance imaging, and ultrasound are discussed and evaluated with respect to the assessment of patients with suspected ALVAL. The histopathological findings are discussed with images of the tissue changes provided. Images of the radiological findings are also provided for all general radiological methods. ALVAL and its radiological presentation is an important issue that unfortunately may become a significant clinical problem.

Using social network analysis and agent-based modelling to explore information flow using common operational pictures for maritime search and rescue operations.

The concept of common operational pictures (COPs) is explored through the application of social network analysis (SNA) and agent-based modelling to a generic search and rescue (SAR) scenario. Comparing the command structure that might arise from standard operating procedures with the sort of structure that might arise from examining information-in-common, using SNA, shows how one structure could be more amenable to 'command' with the other being more amenable to 'control' - which is potentially more suited to complex multi-agency operations. An agent-based model is developed to examine the impact of information sharing with different forms of COPs. It is shown that networks using common relevant operational pictures (which provide subsets of relevant information to groups of agents based on shared function) could result in better sharing of information and a more resilient structure than networks that use a COP. PRACTITIONER SUMMARY: SNA and agent-based modelling are used to compare different forms of COPs for maritime SAR operations. Different forms of COP change the communications structures in the socio-technical systems in which they operate, which has implications for future design and development of a COP.

Multimodal control of sensors on multiple simulated unmanned vehicles.

The use of multimodal (speech plus manual) control of the sensors on combinations of one, two, three or five simulated unmanned vehicles (UVs) is explored. Novice controllers of simulated UVs complete a series of target checking tasks. Two experiments compare speech and gamepad control for one, two, three or five UVs in a simulated environment. Increasing the number of UVs has an impact on subjective rating of workload (measured by NASA-Task Load Index), particularly when moving from one to three UVs. Objective measures of performance showed that the participants tended to issue fewer commands as the number of vehicles increased (when using the gamepad control), but, while performance with a single UV was superior to that of multiple UVs, there was little difference across two, three or five UVs. Participants with low spatial ability (measured by the Object Perspectives Test) showed an increase in time to respond to warnings when controlling five UVs. Combining speech with gamepad control of sensors on UVs leads to superior performance on a secondary (respond-to-warnings) task (implying a reduction in demand) and use of fewer commands on primary (move-sensors and classify-target) tasks (implying more efficient operation). STATEMENT OF RELEVANCE: Benefits of multimodal control for unmanned vehicles are demonstrated. When controlling sensors on multiple UVs, participants with low spatial orientation scores have problems. It is proposed that the findings of these studies have implications for selection of UV operators and suggests that future UV workstations could benefit from multimodal control.

Use of U.S. croplands for biofuels increases greenhouse gases through emissions from land-use change.

Most prior studies have found that substituting biofuels for gasoline will reduce greenhouse gases because biofuels sequester carbon through the growth of the feedstock. These analyses have failed to count the carbon emissions that occur as farmers worldwide respond to higher prices and convert forest and grassland to new cropland to replace the grain (or cropland) diverted to biofuels. By using a worldwide agricultural model to estimate emissions from land-use change, we found that corn-based ethanol, instead of producing a 20% savings, nearly doubles greenhouse emissions over 30 years and increases greenhouse gases for 167 years. Biofuels from switchgrass, if grown on U.S. corn lands, increase emissions by 50%. This result raises concerns about large biofuel mandates and highlights the value of using waste products.

Contributions to accelerating atmospheric CO2 growth from economic activity, carbon intensity, and efficiency of natural sinks.

The growth rate of atmospheric carbon dioxide (CO(2)), the largest human contributor to human-induced climate change, is increasing rapidly. Three processes contribute to this rapid increase. Two of these processes concern emissions. Recent growth of the world economy combined with an increase in its carbon intensity have led to rapid growth in fossil fuel CO(2) emissions since 2000: comparing the 1990s with 2000-2006, the emissions growth rate increased from 1.3% to 3.3% y(-1). The third process is indicated by increasing evidence (P = 0.89) for a long-term (50-year) increase in the airborne fraction (AF) of CO(2) emissions, implying a decline in the efficiency of CO(2) sinks on land and oceans in absorbing anthropogenic emissions. Since 2000, the contributions of these three factors to the increase in the atmospheric CO(2) growth rate have been approximately 65 +/- 16% from increasing global economic activity, 17 +/- 6% from the increasing carbon intensity of the global economy, and 18 +/- 15% from the increase in AF. An increasing AF is consistent with results of climate-carbon cycle models, but the magnitude of the observed signal appears larger than that estimated by models. All of these changes characterize a carbon cycle that is generating stronger-than-expected and sooner-than-expected climate forcing.

A prospective comparative study to examine the effects of oral diazepam on blood pressure and anxiety levels in patients with acute epistaxis.

OBJECTIVE: To examine the effects of oral diazepam on blood pressure and anxiety in patients with acute epistaxis. STUDY DESIGN AND SETTING: A prospective comparative study in an otorhinolaryngology tertiary referral centre. PARTICIPANTS: Patients with acute epistaxis requiring hospital admission. INTERVENTION: Oral diazepam. MAIN OUTCOME MEASURES: Anxiety and blood pressure levels. RESULTS: 32 patients received diazepam and 45 did not (control). On average, patients were hypertensive on admission (mean [standard deviation (SD)] systolic blood pressure diazepam group=157 mmHg [26], control=152 mmHg [23]; diastolic blood pressure diazepam group=87 mmHg [16], control=87 mmHg [18]). Both groups showed significant blood pressure reduction on discharge (p<0.0001) but the difference in mean blood pressure reduction between the two groups was insignificant (systolic blood pressure p=0.16, 95% confidence interval [CI]=-5 to +19 mmHg; diastolic blood pressure p=0.43, 95% CI=-8 to +10 mmHg). Anxiety was significantly lower on discharge (p<0.0001) but the difference in mean fall in anxiety scores between the two groups was insignificant (p=0.08, 95% CI=0 to +2). There was no significant correlation between total diazepam and changes in blood pressure (systolic blood pressure p=0.32; diastolic blood pressure p=0.65) or anxiety (p=0.73), nor between blood pressure and anxiety on admission (systolic blood pressure p=0.45; diastolic blood pressure p=0.72). CONCLUSIONS: Elevated blood pressure and anxiety in acute epistaxis patients reduced on epistaxis resolution irrespective of oral diazepam use. The elevated blood pressure does not appear to be directly related to anxiety.

Distributed situation awareness in dynamic systems: theoretical development and application of an ergonomics methodology.

The purpose of this paper is to propose foundations for a theory of situation awareness based on the analysis of interactions between agents (i.e. both human and non-human) in subsystems. This approach may help to promote a better understanding of technology-mediated interaction in systems, as well as helping in the formulation of hypotheses and predictions concerning distributed situation awareness. It is proposed that agents within a system each hold their own situation awareness, which may be very different from (although compatible with) that of other agents. It is argued that we should not always hope for, or indeed want, sharing of this awareness, as different system agents have different purposes. This view marks situation awareness as a dynamic and collaborative process binding agents together on tasks on a moment-by-moment basis. Implications of this viewpoint for the development of a new theory of, and accompanying methodology for, distributed situation awareness are offered.

Satellite-observed photosynthetic trends across boreal North America associated with climate and fire disturbance.

We analyzed trends in a time series of photosynthetic activity across boreal North America over 22 years (1981 through 2003). Nearly 15% of the region displayed significant trends, of which just over half involved temperature-related increases in growing season length and photosynthetic intensity, mostly in tundra. In contrast, forest areas unaffected by fire during the study period declined in photosynthetic activity and showed no systematic change in growing season length. Stochastic changes across the time series were predominantly associated with a frequent and increasing fire disturbance regime. These trends have implications for the direction of feedbacks to the climate system and emphasize the importance of longer term synoptic observations of arctic and boreal biomes.

Lessons from the syphilis outbreak in homosexual men in east London.

OBJECTIVES: To describe the epidemiology, presentation, and diagnosis of early syphilis in 103 homosexual men in east London. METHODS: A retrospective study using data from KC60 returns, the Health Protection Agency (HPA) enhanced surveillance forms and case notes. RESULTS: 40 cases of primary (PS), 40 of secondary (SS) and 23 of early latent syphilis were identified, 33% co-infected with HIV. 41% had concurrent sexually transmitted infections (STIs). Pain featured in 35% of PS and itch in 13% of rashes. Dark ground microscopy (DGM), performed in 44 of the symptomatic cases, was positive in 37 (84%) allowing early management. Initial syphilis serology was negative in 15/40 (37%) cases of PS. 51% and 49% opted for parenteral and oral treatment, respectively. In 53/103 (51%) cases oral sex was the only risk factor. 86% of infections were UK acquired. Only 4% of contacts were seen. CONCLUSION: This outbreak, reflecting the resurgence of syphilis across the United Kingdom, highlights several important points. Painful chancres and itchy rash are common presentations. DGM is a highly sensitive diagnostic tool. Initial negative serological screening tests are common in PS and sero-surveillance for 3 months is recommended. The high prevalence of concomitant STIs indicates ongoing unprotected sexual intercourse. Oral sex is a significant risk factor and is a distinctly "unsafe" practice. Conventional partner notification is ineffective. Other methods of screening of the at-risk homosexual population are warranted. Continued education is required to reduce STI acquisition in homosexual men.

Detection of mammaglobin in the sera of patients with breast cancer.

Current procedures for the diagnosis of breast cancer are cumbersome and invasive, making detection of this disease difficult. A rapid screening test for early detection of breast cancer would allow for better management of this deadly disease. In this report, we show that, with the exception of the skin, mammaglobin mRNA is specifically expressed in mammary tissue and commonly overexpressed in breast cancer. Mammaglobin is not expressed in other types of cancer including colon, lung, ovarian, and prostate cancer. Breast-specific expression of mammaglobin protein was shown using immunohistochemical methods. Mammaglobin is secreted from both established breast cancer cell lines and primary breast carcinoma cells cultured in vitro. Using a monoclonal antibody-based assay for monitoring the presence of mammaglobin in serum, elevated levels of mammaglobin were detected in sera of patients with breast cancer, but not in healthy women. Thus, mammaglobin, which is overexpressed and secreted from breast carcinoma cells, is detectable in sera of patients with breast cancer and may provide a rapid screening test for the diagnosis and management of breast cancer.

High grade abnormalities following an 'inconclusive' smear.

OBJECTIVE: The National Health and Medical Research Council (NHMRC) recommends a report of 'inconclusive possible high grade epithelial abnormality', but many laboratories only report 'inconclusive' with reference to any possible high grade disease elsewhere in the report. This study was performed to determine possible reasons for cytological difficulties resulting in this category of report and to determine the rate of significant disease within this category. DESIGN: Retrospective record review. Clinical details were extracted without patient-identifying data. SETTING: Gynaecological Oncology Department, King George V/Royal Prince Alfred Hospital. POPULATION: Two hundred patients referred with the cytological abnormality. MATERIALS AND METHODS: An adequate colposcopic diagram documenting size, distribution and grade of lesion was required. All patients had colposcopy with management according to colposcopic and histological results as appropriate to their disease. OUTCOME MEASURES: Colposcopic features, topography and size of any lesion, histological results, treatments performed and subsequent review of untreated patients. RESULTS: Colposcopy found high-grade lesions in 43% and carcinoma in 1%. Histopathology found 49% and 4% respectively. Treatment was performed in 124 patients. Inflammation was found in 27%, a small lesion in 43% and endocervical disease in 21%. CONCLUSIONS: The high rate of endocervical disease, inflammation and small lesions may explain the cytological difficulties leading to an 'inconclusive' result. The authors believe that the term 'inconclusive' alone does not adequately convey the high level of risk faced by these patients.

Projecting the future of the U.S. carbon sink.

Atmospheric and ground-based methods agree on the presence of a carbon sink in the coterminous United States (the United States minus Alaska and Hawaii), and the primary causes for the sink recently have been identified. Projecting the future behavior of the sink is necessary for projecting future net emissions. Here we use two models, the Ecosystem Demography model and a second simpler empirically based model (Miami Land Use History), to estimate the spatio-temporal patterns of ecosystem carbon stocks and fluxes resulting from land-use changes and fire suppression from 1700 to 2100. Our results are compared with other historical reconstructions of ecosystem carbon fluxes and to a detailed carbon budget for the 1980s. Our projections indicate that the ecosystem recovery processes that are primarily responsible for the contemporary U.S. carbon sink will slow over the next century, resulting in a significant reduction of the sink. The projected rate of decrease depends strongly on scenarios of future land use and the long-term effectiveness of fire suppression.