Patterns of Mental Health Service Use in Australian Workers with Low Back Pain: A Retrospective Cohort Study.

PURPOSE: To describe the volume, timing and provider of mental health services provided to workers with accepted low back pain (LBP) claims, and to identify determinants of service volume and time to first mental health service. METHODS: Using claim and service-level workers' compensation data from four Australian states (Queensland, South Australia, Western Australia, Victoria) for LBP claims with at least one mental health service lodged between 1 July 2011 and 30 June 2015. Mental health services occurring 30 days prior to 730 days following claim acceptance were examined. Outcomes were number of mental health services and time (weeks) from claim acceptance to first service, calculated overall, by provider and interaction type, and by independent variables (age group, sex, time loss duration, financial year of lodgement, jurisdiction, socioeconomic status, remoteness). Negative binomial and Cox regression models examined differences between service volume and time to first service by independent variables, respectively. RESULTS: Of workers with LBP claims who accessed mental health services, psychologist services were most common (used by 91.2% of workers) and 16% of workers saw multiple provider types. Number of services increased with time loss duration, as did time to first service. Victorian workers had the most services, yet accessed them latest. CONCLUSIONS: Psychologist services were most common, longer duration claims used more mental health services but accessed them later, and there were a number of jurisdictional differences. Results suggest opportunities for workers' compensation authorities to provide, to those who may benefit, greater and earlier access to mental health care.

Biocompatibility of Antifogging SiO-doped Diamond-Like Carbon Laparoscope Coatings.

Laparoscopes can suffer from fogging and contamination difficulties, resulting in a reduced field of view during surgery. A series of diamond-like carbon films, doped with SiO, were produced by pulsed laser deposition for evaluation as biocompatible, antifogging coatings. DLC films doped with SiO demonstrated hydrophilic properties with water contact angles under 40°. Samples subjected to plasma cleaning had improved contact angle results, with values under 5°. Doping the DLC films with SiO led to an average 40% decrease in modulus and 60% decrease in hardness. Hardness of the doped films, 12.0 - 13.2 GPa, was greater than that of the uncoated fused silica substrate, 9.2 GPa. The biocompatibility was assessed through CellTiter-Glo assays, with the films demonstrating statistically similar levels of cell viability when compared to the control media. The absence of ATP released by blood platelets in contact with the DLC coatings suggests in vivo hemocompatibility. The SiO doped films displayed improved transparency levels in comparison to undoped films, achieving up to an average of 80% transmission over the visible spectrum and an attenuation coefficient of 1.1 × 104 cm-1 at the 450 nm wavelength. The SiO doped DLC films show promise as a method of fog prevention for laparoscopes.

Opportunities to engage health system leaders in whole systems approaches to physical activity in England.

BACKGROUND: Physical activity plays an important role in maintaining good health and wellbeing, non-communicable disease prevention and can improve healthcare outcomes. Some progress is being made on incorporating physical activity into routine care, but less on engaging health system leaders in the 'whole systems' approaches which are increasingly recognised as important for addressing complex public health challenges such as physical inactivity. This commentary builds upon the findings of a recent study and aims to identify opportunities for engaging National Health Service (NHS) systems leaders in whole systems approaches to physical activity. OPPORTUNITIES FOR ACTION IN ENGLAND: Pockets of good practice exist from which lessons can be learned, but there are systemic issues that discourage and create barriers, and a need for meaningful engagement, leadership and action at national, regional and local levels. National and regional actors like Sport England, NHS England, health professional bodies, Active Partnerships, the Local Government Association and the Office for Health Improvement and Disparities can encourage and support government and the NHS to change policy drivers, culture and practices. Emerging opportunities include the 2021 White Paper Integration and Innovation, development of local integrated care systems, leadership from health charities and investment in non-clinical interventions ('social prescribing'). At local level, public health and physical activity specialists and other organisations have a key role as champions and facilitators of local whole systems approaches and engagement of local NHS leaderships. Finally, although whole systems action is about collaborative leadership, individual champions of physical activity can make a difference in influencing NHS leaders at every level towards whole systems working.

Transforming Growth Factor-induced Protein Promotes NF-κB-mediated Angiogenesis during Postnatal Lung Development.

Pulmonary angiogenesis is a key driver of alveolarization. Our prior studies showed that NF-κB promotes pulmonary angiogenesis during early alveolarization. However, the mechanisms regulating temporal-specific NF-κB activation in the pulmonary vasculature are unknown. To identify mechanisms that activate proangiogenic NF-κB signaling in the developing pulmonary vasculature, proteomic analysis of the lung secretome was performed using two-dimensional difference gel electrophoresis. NF-κB activation and angiogenic function was assessed in primary pulmonary endothelial cells (PECs) and TGFBI (transforming growth factor-ß-induced protein)-regulated genes identified using RNA sequencing. Alveolarization and pulmonary angiogenesis was assessed in wild-type and Tgfbi null mice exposed to normoxia or hyperoxia. Lung TGFBI expression was determined in premature lambs supported by invasive and noninvasive respiratory support. Secreted factors from the early alveolar, but not the late alveolar or adult lung, promoted proliferation and migration in quiescent, adult PECs. Proteomic analysis identified TGFBI as one protein highly expressed by the early alveolar lung that promoted PEC migration by activating NF-κB via αvß3 integrins. RNA sequencing identified Csf3 as a TGFBI-regulated gene that enhances nitric oxide production in PECs. Loss of TGFBI in mice exaggerated the impaired pulmonary angiogenesis induced by chronic hyperoxia, and TGFBI expression was disrupted in premature lambs with impaired alveolarization. Our studies identify TGFBI as a developmentally regulated protein that promotes NF-κB-mediated angiogenesis during early alveolarization by enhancing nitric oxide production. We speculate that dysregulation of TGFBI expression may contribute to diseases marked by impaired alveolar and vascular growth.

DNA Rchitect: an R based visualizer for network analysis of chromatin interaction data.

MOTIVATION: Visualization of multiple genomic data generally requires the use of public or commercially hosted browsers. Flexible visualization of chromatin interaction data as genomic features and network components offer informative insights to gene expression. An open source application for visualizing HiC and chromatin conformation-based data as 2D-arcs accompanied by interactive network analyses is valuable. RESULTS: DNA Rchitect is a new tool created to visualize HiC and chromatin conformation-based contacts at high (Kb) and low (Mb) genomic resolutions. The user can upload their pre-filtered HiC experiment in bedpe format to the DNA Rchitect web app that we have hosted or to a version they themselves have deployed. Using DNA Rchitect, the uploaded data allows the user to visualize different interactions of their sample, perform simple network analyses, while also offering visualization of other genomic data types. The user can then download their results for additional network functionality offered in network based programs such as Cytoscape. AVAILABILITY AND IMPLEMENTATION: DNA Rchitect is freely available both as a web application written primarily in R available at http://shiny.immgen.org/DNARchitect/ and as an open source released under an MIT license at: https://github.com/alosdiallo/DNA_Rchitect.

Measuring the effectiveness of catch-up MMR delivered by school nurses compared to signposting to general practice on improving MMR coverage.

BACKGROUND: This study assesses whether increased coverage of the measles, mumps and rubella (MMR) vaccination differs between areas where school nurses deliver catch-up MMR doses to adolescents in school settings, compared to signposting to general practice. METHODS: A retrospective cohort study was conducted using Child Health Information Services records within the NHS England South (South Central) commissioning boundary. The sample population included children born 1 September 2000-31 August 2001, in school year 9 during the 2014-15 academic year. RESULTS: The primary outcome findings show an increase in coverage of at least one dose of MMR by 1.6% (n = 334) in the cohort receiving catch-up MMR, compared to 0.2% (n = 12) in the cohort signposted to general practice. Over time, the difference in increase between the two cohorts was 1.4%, analysed using the chi-squared comparison of proportions test, providing strong evidence (P < 0.0001) that school nurse delivery of catch-up MMR is effective at increasing coverage. The findings also suggest that school nurse delivery of catch-up MMR may benefit Black, Asian and minority ethnic children and those from more deprived backgrounds. CONCLUSIONS: It is recommended that commissioners of school-aged immunization services incorporate the delivery of catch-up MMR doses in their contracts with school nurses.

Validity of systemic antibiotics and systemic corticosteroid usage for chronic rhinosinusitis as metrics of disease burden.

BACKGROUND: The frequencies of systemic antibiotics and oral corticosteroids taken for chronic rhinosinusitis (CRS) indicate poor CRS disease control. We sought to determine the validity and responsiveness of these metrics as reflections of CRS disease burden. METHODOLOGY: One hundred and eighty-seven patients undergoing medical management for CRS were recruited. Participants were assessed at two time points: enrollment and a follow-up appointment three to nine months later. At each time point, CRS related antibiotic and oral corticosteroid usage in the previous three months was measured, while general and disease-specific quality of life (QOL) was measured using the visual analog scale of the 5-dimension EuroQol questionnaire (EQ-5D VAS) and the 22-item Sinonasal Outcome Test (SNOT-22), respectively. RESULTS: The frequency of CRS-related antibiotics and oral corticosteroids use was cross-sectionally correlated with EQ-5D VAS and SNOT-22 at the corresponding time points. For participants reporting usage of these medications at enrollment, there was a decrease of 1 course per 3 months for both CRS-related antibiotics and oral corticosteroids. Change in CRS-related antibiotics from enrollment to follow-up was correlated with change in both EQ-5D and SNOT-22 over the same timeframe. The change in CRSrelated oral corticosteroids was correlated with change in both EQ-5D VAS and SNOT-22). These correlations were stronger in the subset of patients who had a change in these metrics over the study period. CONCLUSIONS: The frequencies of CRS-related antibiotic use and oral corticosteroid use are valid and responsive measures of CRS disease burden.

Reduction in mortality risk with opioid agonist therapy: a systematic review and meta-analysis.

INTRODUCTION: Opioid agonist therapies are effective medications that can greatly improve the quality of life of individuals with opioid use disorder. However, there is significant uncertainty about the risks of cause-specific mortality in and out of treatment. OBJECTIVE: This systematic review and meta-analysis explored the association between methadone and buprenorphine with cause-specific mortality among opioid-dependent persons. METHODS: We searched six online databases to identify relevant cohort studies, calculating all-cause and overdose-specific mortality rates during periods in and out of treatment. We pooled mortality estimates using multivariate random effects meta-analysis of the crude mortality rate per 1000 person-years of follow-up as well as relative risks comparing mortality in vs. out of treatment. RESULTS: A total of 32 cohort studies (representing 150 235 participants, 805 423.6 person-years, and 9112 deaths) met eligibility criteria. Crude mortality rates were substantially higher among methadone cohorts than buprenorphine cohorts. Relative risk reduction was substantially higher with methadone relative to buprenorphine when time in-treatment was compared to time out-of-treatment. Furthermore, the greatest mortality reduction was conferred during the first 4 weeks of treatment. Mortality estimates were substantially heterogeneous and varied significantly by country, region, and by the nature of the treatment provider. CONCLUSION: Precautions are necessary for the safer implementation of opioid agonist therapy, including baseline assessments of opioid tolerance, ongoing monitoring during the induction period, education of patients about the risk of overdose, and coordination within healthcare services.

The association between driving time and unhealthy lifestyles: a cross-sectional, general population study of 386 493 UK Biobank participants.

BACKGROUND: Driving is a common type of sedentary behaviour; an independent risk factor for poor health. The study explores whether driving is also associated with other unhealthy lifestyle factors. METHODS: In a cross-sectional study of UK Biobank participants, driving time was treated as an ordinal variable and other lifestyle factors dichotomized into low/high risk based on guidelines. The associations were explored using chi-square tests for trend and binary logistic regression. RESULTS: Of the 386 493 participants who drove, 153 717 (39.8%) drove <1 h/day; 140 140 (36.3%) 1 h/day; 60 973 (15.8%) 2 h/day; and 31 663 (8.2%) ≥3 h/day. Following adjustment for potential confounders, driving ≥3 h/day was associated with being overweight/obese (OR = 1.74, 95% CI: 1.64-1.85), smoking (OR = 1.48, 95% CI: 1.37-1.63), insufficient sleep (1.70, 95% CI: 1.61-1.80), low fruit/vegetable intake (OR = 1.26, 95% CI: 1.18-1.35) and low physical activity (OR = 1.05, 95% CI: 1.00-1.11), with dose relationships for the first three, but was not associated with higher alcohol consumption (OR = 0.94, 95% CI: 0.87-1.02). CONCLUSIONS: Sedentary behaviour, such as driving, is known to have an independent association with adverse health outcomes. It may have additional impact mediated through its effect on other aspects of lifestyle. People with long driving times are at higher risk and might benefit from targeted interventions.

Comparing the effects of low and high load resistance exercise to failure on adaptive responses to resistance exercise in young women.

The aim of this study was to compare the effect of 6 weeks of resistance training to volitional failure at low (30% 1 repetition maximum (RM)) or high (80%1RM) loads on gains in muscle size and strength in young women. Thirteen women (age: 29.7 ± 4.7years; height 166.7 ± 6.4cm; weight 64.2 ± 12.2kg) completed 2 training sessions per week for 6 weeks and muscle strength (1RM), muscle thickness (ultrasound) were measured before and after training. Training comprised 1 set to volitional failure of unilateral leg extensions and bicep curls with each limb randomly assigned to train at either 80% 1RM or 30% 1RM. Increases in muscle thickness [arms: 6.81 ± 3.15% (30% 1RM), 5.90 ± 3.13% (80% 1RM) and legs: 9.37 ± 5.61% (30% 1RM), 9.13 ± 7.9% (80% 1RM)] and strength [arms: 15.4 ± 12.2% (30% 1RM), 18.26 ± 12.2% (80% 1RM) and legs: 25.30 ± 18.4 (30% 1RM), 27.20 ± 14.5 (80% 1RM)] were not different between loads. When resistance exercise is performed to volitional failure gains in muscle size and strength are independent of load in young women.

Quality of life impairment due to chronic rhinosinusitis in asthmatics is mediated by asthma control.

BACKGROUND: Chronic rhinosinusitis (CRS) and asthma, when comorbid, may influence each other’s disease course and decrease quality of life (QOL). Our objective was to determine if poorer asthma control due to CRS symptoms could be a mechanism for decreased QOL in asthmatic CRS patients. METHODS: A total of 120 asthmatic CRS patients were recruited. CRS symptom burden was measured using the 22-item Sinonasal Outcome Test (SNOT-22) and patient-reported CRS symptom control, general health-related QOL was measured using the visual analog scale of the 5-dimensional EuroQol quality of life survey (EQ-5D VAS), and asthma control was measured using the Asthma Control Test (ACT). Association was sought between these outcome measures. A mediation model was created and validated to show that asthma control mediated the association between CRS symptom burden and decreased general health-related QOL. RESULTS: ACT score was associated with SNOT-22, EQ-5D VAS was associated with SNOT-22 score, and EQ-5D VAS was associated with ACT score. A statistically significant mediation effect for ACT score in the association between SNOT-22 and EQ-5D VAS), which represented 22.1% of the total effect of SNOT-22 on EQ-5D VAS, was identified. Similar findings were made for patientreported CRS symptom control instead of SNOT-22 score. CONCLUSIONS: In asthmatic CRS patients, a sizeable portion of CRS impact on QOL is indirectly mediated through the effect of CRS on poorer asthma control which may then drive decreased QOL.

Responsiveness and minimal clinically important difference for the EQ-5D in chronic rhinosinusitis.

BACKGROUND: The 5-dimensional EuroQol questionnaire (EQ-5D) is validated to measure general health-related quality of life (QOL). Our objective was to determine the responsiveness and minimal clinically important difference (MCID) of the EQ-5D health utility value (EQ-5D HUV) and visual analog scale (EQ-5D VAS) in chronic rhinosinusitis (CRS). METHODS: 203 adults undergoing medical management for CRS were prospectively recruited. General health-related QOL (using EQ-5D HUV and EQ-5D VAS) and CRS-specific QOL (using the 22-item Sinonasal Outcome Test [SNOT-22]) were measured at enrollment and a subsequent follow-up time point 2-12 months later. At follow-up, participants also rated change in general health as Much worse, A little worse, About the same, A little better or Much better compared to enrollment. The EQ-5D HUV and EQ-5D VAS MCIDs were calculated using distribution-based, anchor-based, and receiver operator characteristic (ROC) curve-based methods. RESULTS: Change in SNOT-22 score was correlated with EQ-5D HUV and EQ-5D VAS change. Using the different methods of calculating MCID, we find the EQ-5D HUV MCID to be 0.04 and EQ-5D VAS MCID to be 8.0. The calculated EQ-5D MCIDs had approximately a sensitivity of 40-50% and specificity of 80% in detecting patients experiencing noticeable improvement in general health. CONCLUSIONS: The EQ-5D responds well to changing CRS symptomatology. We propose MCIDs for EQ-5D HUV of 0.04 and EQ-5D VAS of 8 in CRS patients, which although specific, are not sensitive for detecting patients experiencing improvement in general health.

Depressed mood is associated with loss of productivity in allergic rhinitis.

Allergic rhinitis (AR) is associated with significant decreases in quality of life and productivity losses. We hypothesized that symptoms of AR may differentially associate with lost productivity due to AR. We performed a cross-sectional cohort study of 105 prospectively recruited patients with persistent AR. AR control, severity of depressed mood, and sinonasal symptoms were assessed with the Rhinitis Control Assessment Test (RCAT), Patient Health Questionnaire (PHQ-2), and the 22-item Sinonasal Outcome Test (SNOT-22), respectively. Lost productivity was assessed by asking the number of days of work/school missed due to AR in the last 3 months. Patients missed a mean of 1.5 days (SD:2.9) of work or school. Lost productivity was associated with PHQ-2 (adjusted linear regression coefficient [ß] = .68, 95% CI: 0.20-1.15, P = .007) analysis but not SNOT-22 or RCAT scores. Productivity losses due to AR are associated with severity of depressed mood rather than classic nasal or extra-nasal symptoms of AR.

A longitudinal, observational study examining the relationships of patient satisfaction with services and mental well-being to their clinical course in young people with Type 1 diabetes mellitus during transition from child to adult health services.

AIM: We hypothesized that participant well-being and satisfaction with services would be positively associated with a satisfactory clinical course during transition from child to adult health care. METHODS: Some 150 young people with Type 1 diabetes mellitus from five diabetes units in England were recruited to a longitudinal study of transition. Each young person was visited at home four times by a research assistant; each visit was 1 year apart. Satisfaction with services (Mind the Gap; MTG) and mental well-being (Warwick-Edinburgh Mental Well-being Scale; WEMWBS) were captured. Change in HbA1c , episodes of ketoacidosis, clinic and retinal screening attendance were used to assess clinical course. In total, 108 of 150 (72%) young people had sufficient data for analysis at visit 4. RESULTS: Mean age at entry was 16 years. By visit 4, 81.5% had left paediatric healthcare services. Median HbA1c increased significantly (P = 0.01) from 69 mmol/mol (8.5%) at baseline to 75 mmol/mol (9.0%) at visit 4. WEMWBS scores were comparable with those in the general population at baseline and were stable over the study period. MTG scores were also stable. By visit 4, some 32 individuals had a 'satisfactory' and 76 a 'suboptimal' clinical course. There were no significant differences in average WEMWBS and MTG scores between the clinical course groups (P = 0.96, 0.52 respectively); nor was there a significant difference in transfer status between the clinical course groups. CONCLUSIONS: The well-being of young people with diabetes and their satisfaction with transition services are not closely related to their clinical course. Investigating whether innovative psycho-educational interventions can improve the clinical course is a research priority.

Management of adults with diabetes on the haemodialysis unit: summary of guidance from the Joint British Diabetes Societies and the Renal Association.

Diabetic nephropathy remains the principal cause of end-stage renal failure in the UK and its prevalence is set to increase. People with diabetes and end-stage renal failure on maintenance haemodialysis are highly vulnerable, with complex comorbidities, and are at high risk of adverse cardiovascular outcomes, the leading cause of mortality in this population. The management of people with diabetes receiving maintenance haemodialysis is shared between diabetes and renal specialist teams and the primary care team, with input from additional healthcare professionals providing foot care, dietary support and other aspects of multidisciplinary care. In this setting, one specialty may assume that key aspects of care are being provided elsewhere, which can lead to important components of care being overlooked. People with diabetes and end-stage renal failure require improved delivery of care to overcome organizational difficulties and barriers to communication between healthcare teams. No comprehensive guidance on the management of this population has previously been produced. These national guidelines, the first in this area, bring together in one document the disparate needs of people with diabetes on maintenance haemodialysis. The guidelines are based on the best available evidence, or on expert opinion where there is no clear evidence to inform practice. We aim to provide clear advice to clinicians caring for this vulnerable population and to encourage and improve education for clinicians and people with diabetes to promote empowerment and self-management.

Orthopaedic Surgeon Density in South Africa.

BACKGROUND: In the era of global surgery, there are limited data regarding the available surgical workforce in South Africa. METHODS: This aim of this study was to determine the orthopaedic surgeon density in South Africa. This involved a quantitative descriptive analysis of all registered specialist orthopaedic surgeons in South Africa, using data collected from various professional societal national databases. RESULTS: The results showed 1.63 orthopaedic surgeons per 100,000 population. The vast majority were male (95%) with under two-thirds (65%) being under the age of 55 years. The majority of the orthopaedic surgeons were found in Gauteng, followed by the Western Cape and Kwa-Zulu Natal. The majority of specialists reportedly worked either full time or part time in the private sector (95%), and the orthopaedic surgeon density per uninsured population (0.36) was far below that of the private sector (8.3). CONCLUSION: Interprovincial differences as well as intersectoral differences were marked indicating geographic and socio-economic maldistribution of orthopaedic surgeons. This parallels previous studies which looked at other surgical sub-disciplines in South Africa. Addressing this maldistribution requires concerted efforts to expand public sector specialist posts as well as quantifying the burden of orthopaedic disease in both private and public sectors before recommendations can be made regarding workforce allocation in the future. LEVEL OF EVIDENCE: IV.

Integrating Spectroscopy with Potato Disease Management.

Spectral phenotyping is an efficient method for the nondestructive characterization of plant biochemical and physiological status. We examined the ability of a full range (350 to 2,500 nm) of foliar spectral data to (i) detect Potato virus Y (PVY) and physiological effects of the disease in visually asymptomatic leaves, (ii) classify different strains of PVY, and (iii) identify specific potato cultivars. Across cultivars, foliar spectral profiles of PVY-infected leaves were statistically different (F = 96.1, P ≤ 0.001) from noninfected leaves. Partial least-squares discriminate analysis (PLS-DA) accurately classified leaves as PVY infected (validation κ = 0.73) and the shortwave infrared spectral regions displayed the strongest correlations with infection status. Although spectral profiles of different PVY strains were statistically different (F = 6.4, P ≤ 0.001), PLS-DA did not classify different strains well (validation κ = 0.12). Spectroscopic retrievals revealed that PVY infection decreased photosynthetic capacity and increased leaf lignin content. Spectral profiles of potato cultivars also differed (F = 9.2, P ≤ 0.001); whereas average spectral classification was high (validation κ = 0.76), the accuracy of classification varied among cultivars. Our study expands the current knowledge base by (i) identifying disease presence before the onset of visual symptoms, (ii) providing specific biochemical and physiological responses to disease infection, and (iii) discriminating between multiple cultivars within a single plant species.

Chronic rhinosinusitis exacerbations are differentially associated with lost productivity based on asthma status.

BACKGROUND: The frequency of chronic rhinosinusitis (CRS) exacerbations is an independent predictor of quality of life. The objective of this study was to evaluate if increased CRS exacerbations predict decreased productivity. METHODS: Cross-sectional study of adult CRS patients. Number of patient-reported CRS-related antibiotic and oral corticosteroids courses and sinus infections in the past three months were used as metrics for acute exacerbations of CRS (AECRS). Productivity loss was measured by asking participants the number of lost days of work or school due to CRS in the past three months. Associations were sought between lost productivity and AECRS, controlling for clinical and demographic characteristics. RESULTS: 371 participants were recruited. 28.8% of study participants had comorbid asthma. The mean number of lost days of productivity due to CRS in the last three months was 1.5 for asthmatic participants and 2.4 for non-asthmatic participants. In asthmatics, CRS-related lost productivity was significantly associated with number of CRS-related antibiotics used (and oral corticosteroids used, with a trend for sinus infections. No AECRS metric was significantly associated with lost productivity in non-asthmatics. However, when focusing on non-asthmatics reporting missed days of work or school due to CRS, we found statistically significant associations between AECRS metrics and lost productivity. CONCLUSIONS: The frequency of AECRS is associated with CRS-related lost productivity in asthmatics and in the subset of non-asthmatics with moderate CRS-related productivity losses.

Wastewater recycling in Antarctica: Performance assessment of an advanced water treatment plant in removing trace organic chemicals.

The Australian Antarctic Division (AAD) operates Australia's Davis Station in the Antarctic. In 2005, Davis Station's wastewater treatment plant failed and since then untreated, macerated effluent has been discharged to the ocean. The objectives of this study were to determine whether an advanced water treatment plant (AWTP) commissioned by the AAD and featuring a multi-barrier process involving ozonation, ceramic microfiltration, biologically activated carbon filtration, reverse osmosis, ultraviolet disinfection and chlorination was capable of producing potable water and a non-toxic brine concentrate that can be discharged with minimal environmental impact. The AWTP was tested using water from a municipal wastewater treatment plant in Tasmania, Australia. We used spot water and passive sampling combined with two multi-residue chromatographic-mass spectrometric methods and a range of recombinant receptor-reporter gene bioassays to screen trace organic chemicals (TrOCs), toxicity and receptor activity in the Feed water, in the environmental discharge (reject water), and product water from the AWTP for six months during 2014-15, and then again for three months in 2016. Across the two surveys we unambiguously detected 109 different TrOCs in the feed water, 39 chemicals in the reject water, and 34 chemicals in the product water. Sample toxicity and receptor activity in the feed water samples was almost totally removed in both testing periods, confirming that the vast majority of the receptor active TrOCs were removed by the treatment process. All the NDMA entering the AWTP in the feed and/or produced in the plant (typically < 50 ng/L), was retained into the reject water with no NDMA observed in the product water. In conclusion, the AWTP was working to design, and releases of TrOCs at the concentrations observed in this study would be unlikely cause adverse effects on populations of aquatic organisms in the receiving environment or users of the potable product water.

Caesarean section surgical techniques: 3 year follow-up of the CORONIS fractional, factorial, unmasked, randomised controlled trial.

BACKGROUND: The CORONIS trial reported differences in short-term maternal morbidity when comparing five pairs of alternative surgical techniques for caesarean section. Here we report outcomes at 3 years follow-up. METHODS: The CORONIS trial was a pragmatic international 2 × 2 × 2 × 2× 2 non-regular fractional, factorial, unmasked, randomised controlled trial done at 19 sites in Argentina, Chile, Ghana, India, Kenya, Pakistan, and Sudan. Pregnant women were eligible if they were to undergo their first or second caesarean section through a planned transverse abdominal incision. Women were randomly assigned by a secure web-based allocation system to one intervention from each of the three assigned pairs. All investigators, surgeons, and participants were unmasked to treatment allocation. In this follow-up study, we compared outcomes at 3 years following blunt versus sharp abdominal entry, exteriorisation of the uterus for repair versus intra-abdominal repair, single versus double layer closure of the uterus, closure versus non-closure of the peritoneum, and chromic catgut versus polyglactin-910 for uterine repair. Outcomes included pelvic pain; deep dyspareunia; hysterectomy and outcomes of subsequent pregnancies. Outcomes were assessed masked to the original trial allocation. This trial is registered with the Current Controlled Trials registry, number ISRCTN31089967. FINDINGS: Between Sept 1, 2011, and Sept 30, 2014, 13,153 (84%) women were followed-up for a mean duration of 3·8 years (SD 0·86). For blunt versus sharp abdominal entry there was no evidence of a difference in risk of abdominal hernias (adjusted RR 0·66; 95% CI 0·39-1·11). We also recorded no evidence of a difference in risk of death or serious morbidity of the children born at the time of trial entry (0·99, 0·83-1·17). For exteriorisation of the uterus versus intra-abdominal repair there was no evidence of a difference in risk of infertility (0·91, 0·71-1·18) or of ectopic pregnancy (0·50, 0·15-1·66). For single versus double layer closure of the uterus there was no evidence of a difference in maternal death (0·78, 0·46-1·32) or a composite of pregnancy complications (1·20, 0·75-1·90). For closure versus non-closure of the peritoneum there was no evidence of a difference in any outcomes relating to symptoms associated with pelvic adhesions such as infertility (0·80, 0·61-1·06). For chromic catgut versus polyglactin-910 sutures there was no evidence of a difference in the main comparisons for adverse pregnancy outcomes in a subsequent pregnancy, such as uterine rupture (3·05, 0·32-29·29). Overall, severe adverse outcomes were uncommon in these settings. INTERPRETATION: Although our study was not powered to detect modest differences in rare but serious events, there was no evidence to favour one technique over another. Other considerations will probably affect clinical practice, such as the time and cost saving of different approaches. FUNDING: UK Medical Research Council and the Department for International Development.