A Method for Catchment Scale Mapping of Groundwater-Dependent Ecosystems to Support Natural Resource Management (Queensland, Australia)

Immediate and foreseeable threats to groundwater-dependent ecosystems (GDEs) are widely acknowledged, many linked to altered groundwater regimes including changes in groundwater flow, flux, pressure, level and/or quality (Eamus et al. in Aust J Bot 54:97-114, 2006a). Natural resource managers and other decision-makers often lack sufficient information at an appropriate scale to understand the groundwater dependency of ecosystems and ensure that GDEs are adequately considered in decision-making processes. This paper describes a new catchment scale mapping method for GDEs based on the integration of local expert knowledge with detailed spatial datasets to delineate GDEs at a scale compatible with management and planning activities. This overcomes one of the key criticisms often levelled at broader scale mapping methods-that information from local and regional experts, with significant understanding of landscape processes and ecosystems, is not incorporated into the datasets used by decision-makers. Expert knowledge is conveyed in the form of pictorial conceptual models representing the components, processes and interrelationships of groundwater within a catchment and the ecosystems dependent on it. Each mapped GDE is linked to a pictorial conceptual model and a mapping rule-set to provide decision-makers with valuable information about where, how and why GDEs exist in a landscape.

Circulating CD56dim natural killer cells and CD56+ T cells that produce interferon-γ or interleukin-10 are expanded in asymptomatic, E antigen-negative patients with persistent hepatitis B virus infection

Infection with hepatitis B virus (HBV) can result in spontaneous resolution or chronic infection, which can remain asymptomatic or can progress to cirrhosis and/or hepatocellular carcinoma. The host immune response is thought to be a major determinant of the outcome of HBV infection and virus-specific cytotoxic T lymphocytes (CTL) can mediate immunity against the virus and cause liver pathology. Antigen-nonspecific innate lymphocytes may also contribute to HBV infection and liver disease, therefore, we examined the frequencies, phenotypes, cytolytic activities and cytokine profiles of circulating natural killer (NK) cells, CD1d-restricted invariant natural killer T (iNKT) cells and CD56(+) T cells in 102 asymptomatic HBV-infected patients and compared them with those in 66 uninfected control subjects. NK cells expressing low levels of CD56 (CD56(dim)) and CD56(+) T cells were significantly expanded in the circulation of HBV-infected patients compared with control subjects. CD1d expression and iNKT cell frequencies were similar in both groups. Despite these expansions, we did not detect augmented natural or cytokine-induced cytotoxicity in the HBV-infected subjects. All lymphocyte populations studied produced interferon-γ (IFN-γ) significantly more frequently when taken from HBV-infected patients compared with when taken from healthy controls. Additionally, NK cells from the patients more frequently produced interleukin-10. As our HBV-infected cohort consisted of asymptomatic patients with low viral loads, we propose that CD56(dim) NK cells and CD56(+) T cells control HBV infection by noncytolytic mechanisms.

Transitions to palliative care for older people in acute hospitals: a mixed-methods study

Background

Improving the provision of palliative and end-of-life care is a priority for the NHS. Ensuring an appropriately managed ‘transition’ to a palliative approach for care when patients are likely to be entering the last year of life is central to current policy. Acute hospitals represent a significant site of palliative care delivery and specific guidance has been published regarding the management of palliative care transitions within this setting.

Aims

(1) to explore how transitions to a palliative care approach are managed and experienced in acute hospitals and to identify best practice from the perspective of clinicians and service users; (2) to examine the extent of potentially avoidable hospital admissions amongst hospital inpatients with palliative care needs.

Design

A mixed-methods design was adopted in two hospitals in England, serving diverse patient populations. Methods included (1) two systematic reviews; (2) focus groups and interviews with 58 health-care professionals to explore barriers to, and facilitators of, palliative care transitions in hospital; (3) a hospital inpatient survey examining palliative care needs and aspects of management including a self-/proxy-completed questionnaire, a survey of medical and nursing staff and a case note review; (4) in-depth interviews with 15 patients with palliative care needs; (5) a retrospective case note review of all inpatients present in the hospital at the time of the survey who had died within the subsequent 12 months; and (6) focus groups with 83 key decision-makers to explore the implications of the findings for service delivery and policy.

Results

Of the 514 patients in the inpatient survey sample, just over one-third (n = 185, 36.0%) met one or more of the Gold Standards Framework (GSF) prognostic indicator criteria for palliative care needs. The most common GSF prognostic indicator was frailty, with almost one-third of patients (27%) meeting this criteria. Agreement between medical and nursing staff and the GSF with respect to identifying patients with palliative care needs was poor. In focus groups, health professionals reported difficulties in recognising that a patient had entered the last 12 months of life. In-depth interviews with patients found that many of those interviewed were unaware of their prognosis and showed little insight into what they could expect from the trajectory of their disease. The retrospective case note review found that 35 (7.2%) admissions were potentially avoidable. The potential annual cost saving across both hospitals of preventing these admissions was approximately £5.3M. However, a 2- or 3-day reduction in length of stay for these admissions would result in an annual cost saving of £21.6M or £32.4M respectively.

Conclusions

Patients with palliative care needs represent a significant proportion of the hospital inpatient population. There is a significant gap between NHS policy regarding palliative and end-of-life care management in acute hospitals in England and current practice.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Age of transfused blood is not associated with increased postoperative adverse outcome after cardiac surgery

BACKGROUND

This study investigated the hypothesis that storage age of transfused red blood cells (RBCs) is associated with adverse outcome after cardiac surgery, and examined association between volume of RBC transfusions and outcome after cardiac surgery.

METHODS

Adult patients undergoing first time elective/urgent cardiac surgery who had received RBC transfusion perioperatively were included. Three prospective institutional databases were linked. Patients were grouped according to the oldest storage age of any RBCs transfused: those who received only RBCs stored for ≤14 days, only RBCs stored for >14 days, and a mixture of both ages of blood. The effect of RBC age on early mortality, postoperative ventilation ≥72 h, renal failure, pulmonary and infectious complications, length of intensive care stay, and postoperative ventilation time was examined using regression analyses with adjustment for confounding factors, including number of units transfused.

RESULTS

Data were analysed on 1153 patients who received a total of 5962 RBC units. There was no difference in adjusted odds of any outcome between the ≤14 days group and the group who received RBCs aged >14 days. Multivariate logistic regression analyses disclosed number of RBC units transfused as the most consistent factor associated with major postoperative complications, P<0.0001 in all cases. A trend of increasing complication rate was observed with more units transfused.

CONCLUSIONS

Storage age of RBC transfusion up to 35 days was not associated with increased postoperative adverse outcome after cardiac surgery. The number of RBC units transfused is consistently associated with adverse outcome.

Phase II study of sorafenib with gemcitabine and erlotinib (GES) in first-line advanced pancreatic cancer

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Background: Addition of erlotinib (E) to gemcitabine (G) results in improved OS for patients (pts) with advanced pancreatic cancer. Many pancreatic tumors have constitutively activated ras/raf pathways and overexpress VEGF. Sorafenib (S), a multitargeted tyrosine kinase inhibitor, including VEGR 1-3, PDGFR-α and β and the RAF/MEK/ERK pathway, when combined with G and E may synergize, resulting in a more complete blockade of the signal transduction cascade in pancreatic cancer growth and progression, and improved outcome.

Methods: Pts with previously untreated, histologically confirmed, unresectable pancreatic adenocarcinoma, PS 0-1, and adequate organ function were eligible and received G 1,000 mg/m2 over 30 min qw x 3 every 4w. E 150 mg PO daily and S 400 mg PO bid were given continuously. CT scans were performed every 2 cycles (8w). Primary endpoint included PFS at 4 mos and secondary endpoints included safety and tolerability of the novel combination, RR, and OS.

Results: 45 pts enrolled, 44 evaluable for toxicity(1 not treated), and 30 evaluable for response. Median age was 64 (45-84), 32 males (71%), 43 (96%) had metastatic disease, PS was 0 in 26 (58%). Median number of cycles was 2 (0-10). Grade (gr) 3 toxicity included: thrombocytopenia 5; diarrhea 4; vomiting 4; HFS, hyperbilirubinemia, hyperglycemia and SOB each 3 pts; 1 bowel perforation and 1 epistaxis. Gr 4 toxicity included 1 each: bowel perforation, GI bleed, transaminitis, hyperglycemia and sepsis with hypotension. 2 patients only required dose reduction of S for HFS. There were 2 PR (7%), 13 SD (43%), overall RR of 7% and DCR of 50%. Median TTP 111 days (95% CI = 53-175) and median OS 195 days (144-290). PFS at 16 weeks was 49%, just reaching statistical significance.

Conclusions: The combination of G and E plus S in the treatment of advanced pancreatic cancer is a well tolerated regimen without significant increased toxicity as compared to G alone, except for very manageable cutaneous reactions. While the primary endpoint met our pre-determined criteria (compared with NCIC PA.3), this study does not suggest a major benefit for addition of S to G-E when compared to published data. Supported in part by grants from Bayer Healthcare Pharmaceuticals/Onyx and OSI.

No significant financial relationships to disclose.

Shoulder injury related to vaccine administration (SIRVA)

Shoulder pain is a common transient side-effect of vaccination. Infrequently, patients can develop prolonged shoulder pain and dysfunction following vaccination. A series of 13 cases are described in which persistent shoulder dysfunction and pain developed following immunization. Common clinical characteristics include absence of a history of prior shoulder dysfunction, previous exposure to vaccine administered, rapid onset of pain, and limited range of motion. The proposed mechanism of injury is the unintentional injection of antigenic material into synovial tissues resulting in an immune-mediated inflammatory reaction. Careful consideration should be given to appropriate injection technique when administering intramuscular vaccinations to reduce the risk of shoulder injury.

Bacterioplankton in antarctic ocean waters during late austral winter: abundance, frequency of dividing cells, and estimates of production

Bacterioplankton productivity in Antarctic waters of the eastern South Pacific Ocean and Drake Passage was estimated by direct counts and frequency of dividing cells (FDC). Total bacterioplankton assemblages were enumerated by epifluorescent microscopy. The experimentally determined relationship between in situ FDC and the potential instantaneous growth rate constant (mu) is best described by the regression equation ln mu = 0.081 FDC - 3.73. In the eastern South Pacific Ocean, bacterioplankton abundance (2 x 10 to 3.5 x 10 cells per ml) and FDC (11%) were highest at the Polar Front (Antarctic Convergence). North of the Subantarctic Front, abundance and FDC were between 1 x 10 to 2 x 10 cells per ml and 3 to 5%, respectively, and were vertically homogeneous to a depth of 600 m. In Drake Passage, abundance (10 x 10 cells per ml) and FDC (16%) were highest in waters south of the Polar Front and near the sea ice. Subantarctic waters in Drake Passage contained 4 x 10 cells per ml with 4 to 5% FDC. Instantaneous growth rate constants ranged between 0.029 and 0.088 h. Using estimates of potential mu and measured standing stocks, we estimated productivity to range from 0.62 mug of C per liter . day in the eastern South Pacific Ocean to 17.1 mug of C per liter . day in the Drake Passage near the sea ice.