Emergency medicine physician supervision and mortality among patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda: a retrospective analysis of a single-centre training programme.

OBJECTIVES: To assess the association between emergency medicine physician supervision and 3-day mortality for patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda. DESIGN: Retrospective cohort analysis with multivariable logistic regression. SETTING: Single rural Ugandan emergency unit. PARTICIPANTS: All patients presenting for care from 2009 to 2019. INTERVENTIONS: Three cohorts of patients receiving care from non-physician clinicians had three different levels of physician supervision: 'Direct Supervision' (2009-2010) emergency medicine physicians directly supervised all care; 'Indirect Supervision' (2010-2015) emergency medicine physicians were consulted as needed; 'Independent Care' (2015-2019) no emergency medicine physician supervision. PRIMARY OUTCOME MEASURE: Three-day mortality. RESULTS: 38 033 ED visits met inclusion criteria. Overall mortality decreased significantly across supervision cohorts ('Direct' 3.8%, 'Indirect' 3.3%, 'Independent' 2.6%, p<0.001), but so too did the rates of patients who presented with ≥3 abnormal vitals ('Direct' 32%, 'Indirect' 19%, 'Independent' 13%, p<0.001). After controlling for vital sign abnormalities, 'Direct' and 'Indirect' supervision were both significantly associated with reduced OR for mortality ('Direct': 0.57 (0.37 to 0.90), 'Indirect': 0.71 (0.55 to 0.92)) when compared with 'Independent Care'. Sensitivity analysis showed that this mortality benefit was significant for the minority of patients (17.2%) with ≥3 abnormal vitals ('Direct': 0.44 (0.22 to 0.85), 'Indirect': 0.60 (0.41 to 0.88)), but not for the majority (82.8%) with two or fewer abnormal vitals ('Direct': 0.81 (0.44 to 1.49), 'Indirect': 0.82 (0.58 to 1.16)). CONCLUSIONS: Emergency medicine physician supervision of emergency care non-physician clinicians is independently associated with reduced overall mortality. This benefit appears restricted to the highest risk patients based on abnormal vitals. With over 80% of patients having equivalent mortality outcomes with independent non-physician clinician emergency care, a synergistic model providing variable levels of emergency medicine physician supervision or care based on patient acuity could safely address staffing shortages.

Conceptual Modelling of Two Large-Scale Mine Water Geothermal Energy Schemes: Felling, Gateshead, UK.

A conceptual model is presented of two MW-scale low enthalpy mine water geothermal heat pump schemes that are being developed in Tyneside, UK. The Abbotsford Road scheme (54.955° N 1.556° W) is operating (as of May 2021) at 20-30 L/s, abstracting groundwater (and heat) from an unmined Coal Measures Upper Aquifer System (UAS) and reinjecting to the deeper High Main Aquifer System (HMAS), associated with the High Main (E) coal workings and the overlying High Main Post sandstone. A similar scheme, 700 m away at Nest Road (54.959° N 1.564° W), abstracts at 40 L/s from the HMAS, recovers heat from the mine water and reinjects the thermally spent water to deeper workings associated with the Hutton (L), Harvey-Beaumont (N) (and possibly other) coal seams, termed the Deep Mined Aquifer System (DMAS). The three aquifer systems are vertically discontinuous and possess different hydraulic (storage, transmissivity and continuity) properties that would have been near-impossible to predict in advance of drilling. At the sites, 10 boreholes were drilled to obtain five usable production/reinjection boreholes. Development of mine water geothermal energy schemes thus carries a significant project risk, and also a potential ongoing maintenance burden related to iron hydroxide scaling. These do not preclude mine water geothermal as a useful low carbon heating and cooling technology, but the involvement of skilled hydrogeologists, hydrochemists, mining and groundwater engineers is a pre-requisite.

Lymphatic vessels are essential for the removal of cholesterol from peripheral tissues by SR-BI-mediated transport of HDL.

Removal of cholesterol from peripheral tissues to the bloodstream via reverse cholesterol transport (RCT) is a process of major biological importance. Here we demonstrate that lymphatic drainage is required for RCT. We have previously shown that hypercholesterolemia in mice is associated with impaired lymphatic drainage and increased lipid accumulation in peripheral tissues. We now show that restoration of lymphatic drainage in these mice significantly improves cholesterol clearance. Conversely, obstruction of lymphatic vessels in wild-type mice significantly impairs RCT. Finally, we demonstrate using silencing RNA interference, neutralizing antibody, and transgenic mice that removal of cholesterol by lymphatic vessels is dependent on the uptake and transcytosis of HDL by scavenger receptor class B type I expressed on lymphatic endothelium. Collectively, this study challenges the current view that lymphatic endothelium is a passive exchange barrier for cholesterol transport and provides further evidence for its interplay with lipid biology in health and disease.