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ObjectiveTo examine the prognostic values of systemic immune-inflammation indices of hemodialysis (HD) vascular access failure and develop a prediction model for vascular access failure based on the most pertinent systemic immune-inflammation index.Study designA prospective cohort study.Setting & participantsPatients undergoing autogenous HD vascular access surgeries or arteriovenous graft as a permanent hemodialysis access in a tertiary center in southwest China from January 2020 to June 2022.PredictorsSystemic immune-inflammation indices, including NLR, dNLR, AAPR, SIRI, SII, PNI, PLR, and LIPI, and clinical variables.OutcomesThe outcome was defined as survival of the hemodialysis access, with both occluded and stenotic access being considered as instances of access failure.Analytical approachCox proportional hazard regression model.Results2690 patients were included in the study population, of whom 658 experienced access failure during the follow-up period. The median duration of survival for HD vascular access was 18 months. The increased systemic immune-inflammation indices, including dNLR, NLR, SII, PNI, SIRI, PLR, and LIPI, are predictive of HD access failure, with SII demonstrating the strongest prognostic value. A simple SII-based prediction model for HD access failure was developed, achieving C-indexes of 0.6314 (95% CI: 0.6249 – 0.6589) and 0.6441 (95% CI: 0.6212 – 0.6670) for predicting 6- and 12-month access survival, respectively.ConclusionsSystemic immune-inflammation indices are significantly and negatively associated with HD vascular access survival. A simple SII-based prediction model was developed and anticipates further improvement through larger study cohort and validation from diverse centers.

Abstract Background Little is known about the relationship between patients' cultural and linguistic backgrounds and patient activation, especially in people with diabetes and chronic kidney disease (CKD). We examined the association between culturally and linguistically diverse (CALD) background and patient activation and evaluated the impact of a codesigned integrated kidney and diabetes model of care on patient activation by CALD status in people with diabetes and CKD. Methods This longitudinal study recruited adults with diabetes and CKD (Stage 3a or worse) who attended a new diabetes and kidney disease service at a tertiary hospital. All completed the patient activation measure at baseline and after 12 months and had demographic and clinical data collected. Patients from CALD backgrounds included individuals who spoke a language other than English at home, while those from non‐CALD backgrounds spoke English only as their primary language. Paired t‐tests compared baseline and 12‐month patient activation scores by CALD status. Results Patients from CALD backgrounds had lower activation scores (52.1 ± 17.6) compared to those from non‐CALD backgrounds (58.5 ± 14.6) at baseline. Within‐group comparisons showed that patient activation scores for patients from CALD backgrounds significantly improved by 7 points from baseline to 12 months follow‐up (52.1 ± 17.6–59.4 ± 14.7), and no significant change was observed for those from non‐CALD backgrounds (58.5 ± 14.6–58.8 ± 13.6). Conclusions Among patients with diabetes and CKD, those from CALD backgrounds report worse activation scores. Interventions that support people from CALD backgrounds with comorbid diabetes and CKD, such as the integrated kidney and diabetes model of care, may address racial and ethnic disparities that exist in patient activation and thus improve clinical outcomes. Patient or Public Contribution Patients, caregivers and national consumer advocacy organisations (Diabetes Australia and Kidney Health Australia) codesigned a new model of care in partnership with healthcare professionals and researchers. The development of the model of care was informed by focus groups of patients and healthcare professionals and semi‐structured interviews of caregivers and healthcare professionals. Patients and caregivers also provided a rigorous evaluation of the new model of care, highlighting its strengths and weaknesses.

OBJECTIVES:. Among patients with severe acute kidney injury (AKI) admitted to the ICU in high-income countries, regional practice variations for fluid balance (FB) management, timing, and choice of renal replacement therapy (RRT) modality may be significant. DESIGN:. Secondary post hoc analysis of the STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial (ClinicalTrials.gov number NCT02568722). SETTING:. One hundred-fifty-three ICUs in 13 countries. PATIENTS:. Altogether 2693 critically ill patients with AKI, of whom 994 were North American, 1143 European, and 556 from Australia and New Zealand (ANZ). INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Total mean FB to a maximum of 14 days was +7199 mL in North America, +5641 mL in Europe, and +2211 mL in ANZ (p < 0.001). The median time to RRT initiation among patients allocated to the standard strategy was longest in Europe compared with North America and ANZ (p < 0.001; p < 0.001). Continuous RRT was the initial RRT modality in 60.8% of patients in North America and 56.8% of patients in Europe, compared with 96.4% of patients in ANZ (p < 0.001). After adjustment for predefined baseline characteristics, compared with North American and European patients, those in ANZ were more likely to survive to ICU (p < 0.001) and hospital discharge (p < 0.001) and to 90 days (for ANZ vs. Europe: risk difference [RD], –11.3%; 95% CI, –17.7% to –4.8%; p < 0.001 and for ANZ vs. North America: RD, –10.3%; 95% CI, –17.5% to –3.1%; p = 0.007). CONCLUSIONS:. Among STARRT-AKI trial centers, significant regional practice variation exists regarding FB, timing of initiation of RRT, and initial use of continuous RRT. After adjustment, such practice variation was associated with lower ICU and hospital stay and 90-day mortality among ANZ patients compared with other regions.

Summary: Background: Sodium glucose co-transporter 2 (SGLT2) inhibitors reduce the risk of kidney failure and death in patients with chronic kidney disease (CKD) but are underused. We evaluated the number of patients with CKD in Australia that would be eligible for treatment and estimated the number of cardiorenal and kidney failure events that could be averted with improved uptake of SGLT2 inhibitors. Methods: This cross-sectional observational study leveraged nationally representative primary care data from 392 Australian general practices (MedicineInsight) between 1 January 2020 and 31 December 2021. We identified patients that would have met inclusion criteria of key SGLT2 inhibitor trials and applied these data to age and sex-stratified estimates of CKD prevalence for the Australian population (using national census data), estimating the number of preventable events using trial event rates. Key outcomes included cardiorenal events (CKD progression, kidney failure, or death due to cardiovascular or kidney disease) and kidney failure. Findings: In MedicineInsight, 44.2% of adults with CKD would have met CKD eligibility criteria for an SGLT2 inhibitor; baseline use was 4.1%. Applying these data to the Australian population, 230,246 patients with CKD would have been eligible for treatment with an SGLT2 inhibitor. Optimal implementation of SGLT2 inhibitors (75% uptake) could reduce cardiorenal and kidney failure events annually in Australia by 3644 (95% CI 3526–3764) and 1312 (95% CI 1242–1385), respectively. Interpretation: Improved uptake of SGLT2 inhibitors for patients with CKD in Australia has the potential to prevent large numbers of patients experiencing CKD progression or dying due to cardiovascular or kidney disease. Identifying strategies to increase the uptake of SGLT2 inhibitors is critical to realising the population-level benefits of this drug class. Funding: University of New South Wales Scientia Program and Boehringer Ingelheim Eli Lilly Alliance.

AbstractAcute kidney injury (AKI) occurred in 12.8% of patients undergoing surgery and is associated with increased mortality. Chronic kidney disease (CKD) is a well-known risk for death and cardiovascular disease (CVD). Effects of AKI and CKD on patients undergoing coronary angiography (CAG) remain incompletely defined. The aim of our study was to investigate the relationship between acute and CKD and mortality in patients undergoing CAG. The cohort study included 49,194 patients in the multicenter cohort from January 2007 to December 2018. Cox regression analyses and Fine-Gray proportional subdistribution risk regression analysis are used to examine the association between kidney disease and all-cause and cardiovascular mortality. In the present study, 13,989 (28.4%) patients had kidney disease. During follow-up, 6144 patients died, of which 4508 (73.4%) were due to CVD. AKI without CKD (HR: 1.54, 95% CI: 1.36–1.74), CKD without AKI (HR: 2.02, 95% CI: 1.88–2.17), AKI with CKD (HR: 3.26, 95% CI: 2.90–3.66), and end-stage kidney disease (ESKD; HR: 5.63, 95% CI: 4.40–7.20) were significantly associated with all-cause mortality. Adjusted HR (95% CIs) for cardiovascular mortality was significantly elevated among patients with AKI without CKD (1.78 [1.54–2.06]), CKD without AKI (2.28 [2.09–2.49]), AKI with CKD (3.99 [3.47–4.59]), and ESKD (6.46 [4.93–8.46]). In conclusion, this study shows that acute or CKD is present in up to one-third of patients undergoing CAG and is associated with a substantially increased mortality. These findings highlight the importance of perioperative management of kidney function, especially in patients with CKD.Impact StatementWhat is already known on this subject? Acute kidney injury (AKI) occurred in 12.8% of patients undergoing surgery and is linked to a 22.2% increase in mortality. Chronic kidney disease (CKD) is a well-known risk for death and cardiovascular events. Effects of AKI and CKD on patients undergoing coronary angiography (CAG) remain incompletely defined.What do the results of this study add? This study shows that kidney disease is present in up to one-third of patients undergoing CAG and is associated with a substantially increased mortality. AKI and CKD are independent predicators for mortality in patients undergoing CAG.What are the implications of these findings for clinical practice and/or further research? These findings highlight the importance of perioperative management of kidney function, especially in patients with CKD.

Rationale & Objective: The benefit–risk profile of rivaroxaban versus warfarin for atrial fibrillation (AF) in patients with chronic kidney disease is uncertain. We compared rivaroxaban with warfarin across the range of kidney function in adults with AF. Study Design: Multicenter retrospective cohort. Setting & Participants: Adults with AF and a measure of estimated glomerular filtration rate (eGFR); using administrative data from 5 jurisdictions across Australia and Canada (2011-2018). Kidney function was categorized as eGFR ≥60, 45-59, 30-44, and

Abstract Background In critically ill patients with acute kidney injury, renal replacement therapy (RRT) modality and treatment protocols may affect kidney recovery. This study explored whether RRT modality and treatment protocol affected RRT dependence in the ‘Randomized Evaluation of Normal versus Augmented Level of RRT’ and the ‘Acute Renal Failure Trial Network’ (ATN) trials. Methods Primary outcome was 28-day RRT dependence. Secondary outcomes included RRT dependence among survivors and in different SOFA-based treatment protocol groups. We used the Fine-Gray competing-risk model sub-distribution hazard ratio (SHR) to assess the primary outcome. Analyses were adjusted for confounders. Results Of 2542 patients, 2175 (85.5%) received continuous RRT (CRRT) and 367 (14.4%) received intermittent hemodialysis (IHD) as first RRT modality. CRRT-first patients had greater illness severity. After adjustment, there was no between-group difference in 28-day RRT dependence (SHR, 0.96 [95% CI 0.84–1.10]; p = 0.570) or hospital mortality (odds ratio [OR], 1.14 [95% CI 0.86–1.52]; p = 0.361) However, among survivors, CRRT-first was associated with decreased 28-day RRT dependence (OR, 0.54 [95% CI 0.37–0.80]; p = 0.002) and more RRT-free days (common OR: 1.38 [95% CI 1.11–1.71]). Moreover, among CRRT-first patient, the ATN treatment protocol was associated with fewer RRT-free days, greater mortality, and a fourfold increase in RRT dependence at day 28. Conclusions There was no difference in RRT dependence at day 28 between IHD and CRRT. However, among survivors and after adjustment, both IHD-first and the ATN treatment protocol were strongly associated with greater risk of RRT dependence at 28 days after randomization. Trial registration NCT00221013 registered September 22, 2005, and NCT00076219 registered January 19, 2004.

Introduction Shared treatment decision-making and planning of care are fundamental in advanced chronic kidney disease (CKD) management. There are limited data on several key outcomes for the elderly population including survival, quality of life, symptom burden, changes in physical functioning and experienced burden of healthcare. Patients, caregivers and clinicians consequently face significant uncertainty when making life-impacting treatment decisions. The Elderly Advanced CKD Programme includes quantitative and qualitative studies to better address challenges in treatment decision-making and planning of care among this increasingly prevalent elderly cohort.Methods and analysis The primary component is OUTcomes of Older patients with Kidney failure (OUTLOOK), a multicentre prospective observational cohort study that will enrol 800 patients ≥75 years with kidney failure (estimated glomerular filtration rate ≤15 mL/min/1.73 m2) across a minimum of six sites in Australia. Patients entered are in the decision-making phase or have recently made a decision on preferred treatment (dialysis, conservative kidney management or undecided). Patients will be prospectively followed until death or a maximum of 4 years, with the primary outcome being survival. Secondary outcomes are receipt of short-term acute dialysis, receipt of long-term maintenance dialysis, changes in biochemistry and end-of-life care characteristics. Data will be used to formulate a risk prediction tool applicable for use in the decision-making phase. The nested substudies Treatment modalities for the InfirM ElderLY with end stage kidney disease (TIMELY) and Caregivers of The InfirM ElderLY with end stage kidney disease (Co-TIMELY) will longitudinally assess quality of life, symptom burden and caregiver burden among 150 patients and 100 caregivers, respectively. CONsumer views of Treatment options for Elderly patieNts with kiDney failure (CONTEND) is an additional qualitative study that will enrol a minimum of 20 patients and 20 caregivers to explore experiences of treatment decision-making and care.Ethics and dissemination Ethics approval was obtained through Sydney Local Health District Human Research Ethics Committee (2019/ETH07718, 2020/ETH02226, 2021/ETH01020, 2019/ETH07783). OUTLOOK is approved to have waiver of individual patient consent. TIMELY, Co-TIMELY and CONTEND participants will provide written informed consent. Final results will be disseminated through peer-reviewed journals and presented at scientific meetings.

Biological particulate matter (BioPM) is a poorly constrained, ubiquitous, and diverse subset of atmospheric aerosols. They influence climate, air quality, and health via many mechanisms, spurring renewed interest in constraining their emissions to elucidate their impacts. In order to build the framework required to assess the role of BioPM in these multidisciplinary areas, it is necessary to develop robust, high time-resolution detection methodologies so that BioPM emissions can be understood and characterized. In this study, we present ambient results from intensive monitoring at UK peri-urban and coastal ground sites using high time-resolution real-time bioaerosol spectrometers. We demonstrate the utility of a new dimensional reduction-driven BioPM classification scheme, where laboratory sample training data collected at the ChAMBRe facility were used to generate broad taxonomic class time series data of key species of interest. We show the general trends of these representative classes, spanning spring, early summer, and autumn periods between 2019 and 2021. Diurnal behaviors and meteorological relationships were investigated and contextualized; a key result arising from this study was the demonstration of rainfall-induced enhancement of nighttime Penicillium-like aerosol, where rainfall crucially only acts to enhance the quantity emitted without significantly influencing the early morning timing of peak spore liberation.

A 57-year-old man had presented with a 6-month history of worsening dyspnea, renal failure, hypertension, pancytopenia, and a continuous machinery murmur. Imaging studies revealed pleuropericardial effusions that recurred despite aspiration and suprarenal mid-thoracic aortic occlusion (AO) with extensive collateral vessels to the chest wall, rectus sheath, and diaphragm. A right axillofemoral bypass transformed his clinical course. The murmurs, renal failure, pleuropericardial drainage, and pancytopenia resolved, and his hypertension had markedly improved. The association of chronic AO with pleuropericardial effusions without peripheral edema or ascites was most likely due to increased supradiaphragmatic interstitial pressure, and the bone marrow hypoperfusion likely explains the pancytopenia. In addition to posing diagnostic challenges, chronic AO reveals unique insights into the pathogenesis of pleuropericardial effusions and pancytopenia.

The burden of chronic kidney disease (CKD) is growing globally, particularly in low- and lower-middle-income countries (LLMICs) where access to treatment is poor and the largest increases in disease burden will occur. The individual and societal costs of kidney disease are well recognized, especially in developed health care systems where treatments for the advanced stages of CKD are more readily available. The consequences of CKD are potentially more catastrophic in developing health care systems where such resources are often lacking. Central to addressing this challenge is the availability of data to understand disease burden and ensure that investments in treatments and health resources are effective at a local level. Use of routinely collected administrative data is helpful in this regard, however, the barriers to developing a more systematic focus on data collection should not be underestimated. This article reviews the current tools that have been used to measure the burden of CKD and considers limitations regarding their use in LLMICs. A review of the literature investigating the use of registries, disease specific databases and administrative data to identify populations with CKD in LLMICs, which indicate these to be underused resources, is included. Suggestions regarding the potential use of administrative data for measuring CKD burden in LLMICs are explored.

BackgroundTo develop a risk prediction model for the occurrence of severe acute kidney injury (AKI) in intensive care unit (ICU) patients receiving fluid resuscitation.MethodsWe conducted a secondary analysis of the Crystalloid vs. Hydroxyethyl Starch Trial (CHEST) trial, a blinded randomized controlled trial that enrolled ICU patients who received intravenous fluid resuscitation. The primary outcome was the first event in a composite outcome of doubling of serum creatinine and/or treatment with renal replacement treatment (RRT) within 28 days of randomization. The final model developed using multivariable logistic regression with backwards elimination was validated internally and then translated into a predictive equation.ResultsSix thousand seven hundred twenty-seven ICU participants were studied, among whom 745 developed the study outcome. The final model having six variables, including admission diagnosis of sepsis, illness severity score, mechanical ventilation, tachycardia, baseline estimated glomerular filtration rate and emergency admission. The model had good discrimination (c-statistic = 0.72, 95% confidence interval 0.697–0.736) and calibration (Hosmer-Lemeshow test, χ2 = 14.4, p = 0.07) for the composite outcome, with a c-statistic after internal bootstrapping validation of 0.72, which revealed a low degree of over-fitting. The positive predictive value and negative predictive value were 58.8 and 89.1%, respectively. The decision curve analysis indicates a net benefit in prediction of severe AKI using the model across a range of threshold probabilities between 5 and 35%.ConclusionsOur model, using readily available clinical variables to identify ICU patients at high risk of severe AKI achieved good predictive performance in a clinically relevant population.

Background: Numerous factors influence patient recruitment to, and retention on, peritoneal dialysis (PD), but a major challenge is a perceived “inaccessibility” to treating clinicians. It has been suggested that remote patient monitoring (RPM) could be a means of improving such oversight and, thereby, uptake of PD. Objective: To describe patient and clinician perspectives toward RPM and the use of applications (Apps) suitable for mobiles, tablets, or computers to support the provision of PD care. Design: Qualitative design using semi-structured interviews. Setting: All patient participants perform PD treatment at home under the oversight of an urban PD unit in Sydney, Australia. Patient and clinician interviews were conducted within the PD unit. Participants: 14 participants (5 clinicians [2 nephrologists, 3 PD nurses] and 9 patients treated with PD). Methods: Semi-structured interviews were conducted using interview guides tailored for clinician and patient participants. Transcripts were coded and analyzed by a single researcher using thematic analysis. Results: Six themes were identified: perceived benefits of RPM implementation (offering convenience and efficiency, patient assurance through increased surveillance, more complete data and monitoring adherence), uncertainty regarding data governance (protection of personal data, data reliability), reduced patient engagement (transfer of responsibility leading to complacency), changing patient-clinician relationships (reduced patient-initiated communication, the need to maintain patient independence), increased patient and clinician burden (inadequate technological literacy, overmanagement leading to frequent treatment changes), and clinician preference influencing patient behavior. Limitations: The interviews were conducted in English only and with participants from a single urban dialysis unit, which may limit generalizability. Conclusions: For patients and clinicians, advantages from the use of RPM in PD may include increased patient confidence and assurance, improved treatment oversight, more complete data capture, and overcoming barriers to data documentation. Careful patient selection and patient and clinician education may help to optimize the benefits of RPM, maintain patient independence, and reduce the risks of patient disengagement. The use of an App may support RPM; however, participants expressed concerns about increasing the burden on some patients through the use of unfamiliar technology. Human Research Ethics Committee Approval Number: CH62/6/2019-028

New observations of anomalously high cloud ice crystal concentrations at the Jungfraujoch research station (Switzerland, 3.5 km a.s.l.) are presented. High-resolution measurements of these ice crystals using a high-speed 2D imaging cloud particle spectrometer confirm that the concentrations far exceed those expected from any known primary ice production mechanisms and are at temperatures well below those for known secondary ice production processes to contribute. The most likely explanation is due to a strong surface source generated by the interaction of turbulent deposition of supercooled droplets to fragile ice-covered snow surfaces. This process enhances the detachment of crystal fragments wherein the smaller size mode is turbulently re-suspended even at low wind speeds below expected blowing snow thresholds. These then continue to grow, adding significantly to the ice crystal number concentrations whose size and habit is determined by the transport time between the ice crystal source and measurement location and liquid water profile within the cloud. We confirm, using eddy covariance measurements of ice particle number fluxes, that the likely source is significantly far upwind to preclude flow distortion effects such that the source plume has homogenised by the time they are measured at the mountain top summit.

Abstract Background The role of intravenous hydration at the time of primary percutaneous intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) remains unclear. Guidelines are vague, supported by low level evidence, and hydration is used less often than other clinical settings.To perform a systematic review and meta-analysis of all randomized controlled trials assessing intravenous hydration compared with non-hydration for prevention of contrast induced nephropathy (CIN) and In-hospital mortality in patients with STEMI undergoing primary PCI. Methods Medline, EMBASE and the Cochrane Register were searched to September 2018. Included studies reported the incidence of CIN, In-hospital mortality, requirement for dialysis and heart failure. Relative risks with 95% confidence intervals (CIs) for individual trials were pooled using a random effects model. Results Three moderate quality trials were identified including 1074 patients. Overall, compared with no hydration, intravenous hydration significantly reduced the incidence of CIN by 42% (RR 0.58; 95% CI: 0.45 to 0.74, p

Bioaerosols often contain human pathogens and allergens affecting public health. However, relatively little attention has been given to bioaerosols compared with non-biological aerosols. In this study, we aimed to identify bioaerosol compositions in Manchester, UK by applying high throughput sequencing methods and to find potential sources. Samples were collected at Manchester Air Quality Super Site at the Firs Environmental Research Station in November 2019 and in February 2020. Total DNA has been extracted and sequenced targeting the 16S rRNA gene of prokaryotes, ITS region of fungal DNA and 18S rRNA gene of eukaryotes. We found marine environment-associated bacteria and archaea were relatively more abundant in the February 2020 samples compared with the November 2019 samples, consistent with the North West marine origin based on wind back-trajectory analysis. In contrast, an OTU belonging to Methylobacterium, which includes many species resistant to heavy metals, was relatively more abundant in November 2019 when there were higher metal concentrations. Fungal taxa that fruit all year were relatively more abundant in the February 2020 samples while autumn fruiting species generally had higher relative abundance in the November 2019 samples. There were higher relative abundances of land plants and algae in the February 2020 samples based on 18S rRNA gene sequencing. One of the OTUs belonging to the coniferous yew genus Taxus was more abundant in the February 2020 samples agreeing with the usual pollen season of yews in the UK which is from mid-January until late April. The result from this study suggests a potential application of bioaerosol profiling for tracing the source of atmospheric particles.

Background: Most studies addressing hemodialysis initiation with a dialysis catheter focus on patients entering maintenance dialysis programs and exclude other patients, such as those with acute kidney injury (AKI), making interpretation and application of the results difficult for clinicians managing patients at the time of dialysis commencement. Objective: To compare the survival of all patients requiring a catheter for hemodialysis access according to the nature of clinical presentation. Design: Prospective observational. Setting: An Australian tertiary renal unit. Patients: All patients requiring a central venous catheter (CVC) for hemodialysis access between 2005 and 2015. Measurements: Baseline comorbidities, demographics, and nature of clinical presentation. Data regarding each episode of dialysis access insufficiency and each CVC were collected. The primary outcome was all-cause mortality. Methods: Patients were classified into 1 of 3 groups based on physician assessment at the time of presentation: patients believed to have AKI with expected renal recovery (AKI), patients considered to be entering the maintenance dialysis program without a functioning dialysis access (Maintenance Dialysis), patients unable to perform peritoneal dialysis, or use their existing hemodialysis access (Access Failure). Time-split multivariable Cox regression analyses were used to compare survival between groups. Results: A total of 557 eligible patients had complete prospective data regarding CVC use and were included in the analyses. The majority of patients were in the AKI (246/557, 44%) and Maintenance Dialysis groups (182/557, 33%) compared with the Access Failure group (129/557, 23%). During a median follow-up of 3 years, 302 (54%) of the 557 patients died. Following adjustment, risk of all-cause mortality was higher in the AKI group (hazard ratio [HR]: 2.01, 95% confidence interval [CI]: 1.31-3.60, P = .001) during the first 2 years after catheter insertion and lower in years 2 to 4 (HR: 0.42, 95% CI: 0.20-0.88, P = .02) than in the reference Maintenance Dialysis group. No difference in mortality risk between the Access Failure and reference group was found. Limitations: Single-center study. Possible residual confounding owing to the observational study design. Conclusions: Patients requiring acute or unplanned hemodialysis experience high mortality, and the nature of clinical presentation does influence outcomes. Most notable is the greater early mortality experienced by patients with AKI compared to other patient groups. Prospective definition of the nature of unplanned dialysis initiation is important to accurately measure and improve outcomes in this high-risk patient population. Human Research Ethics Committee Approval Number CH62/6/2017-042.

Aims: To use linked routinely-collected health data to estimate diabetes prevalence and incidence in an Australian cohort of adults aged ≥45 years, and examine risk factors associated with incident disease. Research design and methods: The EXamining ouTcomEs in chroNic Disease in the 45 and Up Study (EXTEND45) Study is a linked data study that combines baseline questionnaire responses from the population-based 45 and Up Study (2006–2009, n = 267,153) with multiple routinely-collected health databases up to December 2014. Among participants with ≥1 linked result for any laboratory test, diabetes status was determined from multiple data sources according to standard biochemical criteria, use of glucose-lowering medication or self-report, and the prevalence and incidence rate calculated. Independent risk factors of incident diabetes were examined using multivariable Cox regression. Results: Among 152,169 45 and Up Study participants with ≥1 linked laboratory result in the EXTEND45 database (mean age 63.0 years; 54.9% female), diabetes prevalence was 10.8% (95% confidence interval [CI] 10.6%–10.9%). Incident disease in those without diabetes at baseline (n = 135,810; mean age 62.5 years; 56.1% female) was 10.0 per 1,000 person-years (95% CI 9.8–10.2). In all age groups, diabetes incidence was lower in women compared to men, an association that persisted in the fully adjusted analyses. Other independent risk factors of diabetes were older age, being born outside of Australia (with the highest rate of 19.2 per 1,000 person-years observed in people born in South and Central Asia), lower education status, lower annual household income, residence in a major city, family history of diabetes, personal history of cardiovascular disease or hypertension, higher body mass index, smoking and long sleeping hours. Conclusions: Our study represents an efficient approach to assessing diabetes frequency and its risk factors in the community. The infrastructure provided by the EXTEND45 Study will be useful for diabetes surveillance and examining other important clinical and epidemiological questions.

Introduction Despite global concerns about the safety and quality of health care, population-wide studies of hospital outcomes are uncommon. The SAFety, Effectiveness of care and Resource use among Australian Hospitals (SAFER Hospitals) study seeks to estimate the incidence of serious adverse events, mortality, unplanned rehospitalisations and direct costs following hospital encounters using nationwide data, and to assess the variation and trends in these outcomes.Methods and analysis SAFER Hospitals is a cohort study with retrospective and prospective components. The retrospective component uses data from 2012 to 2018 on all hospitalised patients age ≥18 years included in each State and Territories’ Admitted Patient Collections. These routinely collected datasets record every hospital encounter from all public and most private hospitals using a standardised set of variables including patient demographics, primary and secondary diagnoses, procedures and patient status at discharge. The study outcomes are deaths, adverse events, readmissions and emergency care visits. Hospitalisation data will be linked to subsequent hospitalisations and each region’s Emergency Department Data Collections and Death Registries to assess readmissions, emergency care encounters and deaths after discharge. Direct hospital costs associated with adverse outcomes will be estimated using data from the National Cost Data Collection. Variation in these outcomes among hospitals will be assessed adjusting for differences in hospitals’ case-mix. The prospective component of the study will evaluate the temporal change in outcomes every 4 years from 2019 until 2030.Ethics and dissemination Human Research Ethics Committees of the respective Australian states and territories provided ethical approval to conduct this study. A waiver of informed consent was granted for the use of de-identified patient data. Study findings will be disseminated via presentations at conferences and publications in peer-reviewed journals.

Abstract Background Little is known about how patient reported barriers to health care impact the quality of life (HRQoL) of patients with comorbid disease. We investigated patient reported barriers to health care and low physical and mental well-being among people with diabetes and chronic kidney disease (CKD). Methods Adults with diabetes and CKD (estimated Glomerular Filtration Rate

This article considers recent developments across the western world in the lethality of lone wolf terrorists during 2016 against the contextual framework of Rapoport’s theory regarding the existence of waves of terrorism, mirroring current extreme political and social situations. It highlights the similarities in terms of world conditions coupled to modus operandi that existed during the first wave of terrorism, the Anarchist wave, and currently, while highlighting recent increased lethality. The paper illustrates that current lone wolf behaviours, and the decreasing ‘Religiosity’ of fourth wave participants indicate that the wave’s breakwater may have been reached. A discussion of the role of mental health in influencing the behaviour of ‘lone wolf’ terrorists follows. It concludes that Islamic State’s current territorial losses, coupled to increased populism across the west may be potential areas where extreme social reactionary trends occur, that will ultimately manifest themselves as ‘Fifth Wave’ Terrorism; however cautions that any predictions in this regard are extremely difficult. It recommends that policy makers and law enforcement bodies closely monitor developments amongst those reacting to these significant geo political changes; and that there is an acknowledgement that mental health considerations must be included when discussing terrorist acts, and looking at mitigation measures.

Background: There are limited studies on the effects of statins on outcomes in the moderate chronic kidney disease (CKD) population and their trajectory to end-stage kidney disease. Objective: To examine the long-term effects of lipid-lowering therapy on all-cause mortality, cardiovascular morbidity, CKD progression, and socioeconomic well-being in Australian, New Zealand, and Malaysian SHARP (Study of Heart and Renal Protection) trial participants—a randomized controlled trial of a combination of simvastatin and ezetimibe, compared with placebo, for the reduction of cardiovascular events in moderate to severe CKD. Design: Protocol for an extended prospective observational follow-up. Setting: Australian, New Zealand, and Malaysian participating centers in patients with advanced CKD. Patients: All SHARP trial participants alive at the final study visit. Measurements: Primary outcomes were measured by participant self-report and verified by hospital administrative data. In addition, secondary outcomes were measured using a validated study questionnaire of health-related quality of life, a 56-item economic survey. Methods: Participants were followed up with alternating face-to-face visits and telephone calls on a 6-monthly basis until 5 years following their final SHARP Study visit. In addition, there were 6-monthly follow-up telephone calls in between these visits. Data linkage to health registries in Australia, New Zealand, and Malaysia was also performed. Results: The SHARP-Extended Review (SHARP-ER) cohort comprised 1136 SHARP participants with a median of 4.6 years of follow-up. Compared with all SHARP participants who originally participated in the Australian, New Zealand, and Malaysian regions, the SHARP-ER participants were younger (57.2 [48.3-66.4] vs 60.5 [50.3-70.7] years) with a lower proportion of men (61.5% vs 62.8%). There were a lower proportion of participants with hypertension (83.7% vs 85.0%) and diabetes (20.0% vs 23.5%). Limitations: As a long-term follow-up study, the surviving cohort of SHARP-ER is a selected group of the original study participants, which may limit the generalizability of the findings. Conclusion: The SHARP-ER study will contribute important evidence on the long-term outcomes of cholesterol-lowering therapy in patients with advanced CKD with a total of 10 years of follow-up. Novel analyses of the socioeconomic impact of CKD over time will guide resource allocation. Trial Registration: The SHARP trial was registered at ClinicalTrials.gov NCT00125593 and ISRCTN 54137607.

Data on hyperkalemia frequency among chronic kidney disease (CKD) patients receiving renin-angiotensin aldosterone system inhibitors (RAASis) and its impact on subsequent RAASi treatment are limited. This population-based cohort study sought to assess the incidence of clinically significant hyperkalemia among adult CKD patients who were prescribed a RAASi and the proportion of patients with RAASi medication change after experiencing incident hyperkalemia. We conducted a retrospective, population-based cohort study (1 January 2013-30 June 2017) using Australian national general practice data from the NPS MedicineWise's MedicineInsight program. The study included adults aged ≥18 years who received ≥1 RAASi prescription during the study period and had CKD (estimated glomerular filtration rate [eGFR] 6 mmol/L or a record of hyperkalemia diagnosis) and among patients who experienced incident hyperkalemia, the proportion who had RAASi medication changes (cessation or dose reduction during the 210-day period after the incident hyperkalemia event). Among 20,184 CKD patients with a median follow-up of 3.9 years, 1,992 (9.9%) patients experienced an episode of hyperkalemia. The overall incidence rate was 3.1 (95% CI: 2.9-3.2) per 100 person-years. Rates progressively increased with worsening eGFR (e.g. 3.5-fold increase in patients with eGFR

BackgroundTo address guideline-practice gaps and improve management of patients with both diabetes and chronic kidney disease (CKD), we involved patients, health professionals and patient advocacy groups in the co-design and implementation of an integrated diabetes-kidney service.ObjectiveIn this study, we explored the experiences of patients and health-care providers, within this integrated diabetes and kidney service.Methods5 focus groups and 2 semi-structured interviews were conducted amongst attending patients, referring primary health professionals, and attending specialist health professionals. Maximal variation sampling was used for both patients and referring primary health professionals to ensure an equal representation of males and females, and patients of different CKD stages. All discussions were audiotaped and transcribed verbatim, before being thematically analysed independently by 2 researchers.ResultsThe mean age (SD) for specialist health professionals, primary care professionals and patients who participated was 45 (11), 44 (15) and 68 (5) years with men being 50%, 80% and 76% of the participants respectively. Key strengths of the diabetes and kidney service were noted to be better integration of care and a perception of improved health and management of health. Whilst some aspects of access such as time between referral and initial appointment and having fewer appointments improved, other aspects such as in-clinic waiting times and parking remained problematic. Specialist health professionals noted that health professional education could be improved. Patient self-management was also noted by to be an issue with some patients requesting more information and some health professionals expressing difficulty in empowering some patients.ConclusionsHealth professionals and patients reported that a co-designed integrated diabetes kidney service improved integration of care and improved health and management of health. However, some aspects of the process of care, health professional education and patient self-management remained challenging.

Observations of high-altitude cirrus clouds are reported from measurements made during the routine monitoring of cloud properties on commercial aircraft as part of the In-Service Aircraft for a Global Observing System. The increasing global scale of the measurements is revealed, with 7 years of in situ data producing a unique and rapidly growing dataset. We find that cloud fractions measured ≥ 10 km at aircraft cruise altitude are representative of seasonal trends associated with the mid-latitude jet stream in the Northern Hemisphere, and the relatively higher cloud fractions are found in tropical regions such as the Inter-Tropical Convergence Zone and South East Asia. Both stratospheric and tropospheric data were used to calculate the cloud fractions routinely experienced by commercial aircraft. Further work is needed for a direct comparison with previous studies that limit cloud fraction calculations to tropospheric data only. The characteristics of these clouds are discussed and the potential different formation mechanisms in different regions assessed.

We present results from a study evaluating the utility of supervised machine learning to classify single particle ultraviolet laser-induced fluorescence (UV-LIF) signatures to investigate airborne primary biological aerosol particle (PBAP) concentrations in a busy, multifunctional building using a Multiparameter Bioaerosol Spectrometer. First we introduce and demonstrate a gradient boosting ensemble decision tree algorithm’s ability to accurately classify laboratory generated PBAP samples into broad taxonomic classes with a high level of accuracy. We then develop a framework to appraise the classification accuracy and performance using the Hellinger distance metric to compare product parameter probability density function similarity; this framework showed that key training classes were sufficiently different in terms of particle fluorescence and morphology to facilitate classification. We also demonstrate the utility of including advanced morphological parameters to minimise inter-class conflation and improve classification confidence, where relying on the fluorescent spectra alone would likely result in misattribution. Finally, we apply these methods to ambient data collected within a large multi-functional building where ambient bacterial- and fungal-like classes were identified to display trends corresponding to human activity; fungal-like classes displayed a consistent diurnal trend with a maximum at midday and hourly peaks correlating to movements within the building; bacteria-like aerosol displayed complex, episodic events during opening hours. All PBAP classes fell to low baseline concentrations when the building was unoccupied overnight and at weekends.

Hong Kong is an area of complex topography, with mixtures of urban and greenbelt spaces. Local bioaerosol concentrations are multifaceted, depending on seasonal variations of meteorological conditions and emission sources. This study is the first known attempt at both quantitatively measuring and identifying airborne bioaerosol contributions, by utilising multiple single particle ultraviolet light-induced fluorescence spectrometers. Based in the Hong Kong University of Science and Technology’s super-site, a WIBS-NEO and PLAIR Rapid-E were operated from June to November, 2018. The purpose of this long-term campaign was to observe the shift in wind patterns and meteorological conditions as the seasons changed, and to investigate how, or if, this impacted on the dispersion and concentrations of bioaerosols in the area. Bioaerosol concentrations based on the particle auto-fluorescence spectra remained low through the summer and autumn months, averaging 4.2 L−1 between June and October. Concentrations were greatest in October, peaking up to 23 L−1. We argued that these concentrations were dominated by dry-weather fungal spores, as evidenced by their spectral profile and relationship with meteorological variables. We discuss potential bioaerosol source regions based on wind-sector cluster analysis and believe that this study paints a picture of bioaerosol emissions in an important region of the world.

Primary biological aerosols often include allergenic and pathogenic microorganisms posing potential risks to human health. Moreover, there are airborne plant and animal pathogens that may have ecological and economic impact. In this study, we used high-throughput sequencing techniques (Illumina, MiSeq) targeting the 16S rRNA genes of bacteria and the 18S rRNA genes of eukaryotes, to characterize airborne primary biological aerosols. We used a filtration system on the UK Facility for Airborne Atmospheric Measurements (FAAM) research aircraft to sample a range of primary biological aerosols across southern England overflying surface measurement sites from Chilbolton to Weybourne. We identified 30 to 60 bacterial operational taxonomic units (OTUs) and 108 to 224 eukaryotic OTUs per sample. Moreover, 16S rRNA gene sequencing identified significant numbers of genera that have not been found in atmospheric samples previously or only been described in limited number of atmospheric field studies, which are rather old or published in local journals. This includes the genera Gordonia, Lautropia, and Psychroglaciecola. Some of the bacterial genera found in this study include potential human pathogens, for example, Gordonia, Sphingomonas, Chryseobacterium, Morganella, Fusobacterium, and Streptococcus. 18S rRNA gene sequencing showed Cladosporium to be the major genus in all of the samples, which is a well-known allergen and often found in the atmosphere. There were also genetic signatures of potentially allergenic taxa; for example, Pleosporales, Phoma, and Brassicales. Although there was no significant clustering of bacterial and eukaryotic communities depending on the sampling location, we found meteorological factors explaining significant variations in the community composition. The findings in this study support the application of DNA-based sequencing technologies for atmospheric science studies in combination with complementary spectroscopic and microscopic techniques for improved identification of primary biological aerosols.

Measurements of cloud ice crystal size distributions have been made by a backscatter cloud probe (BCP) mounted on five commercial airliners flying international routes that cross five continents. Bulk cloud parameters were also derived from the size distributions. As of 31 December 2014, a total of 4399 flights had accumulated data from 665 hours in more than 19 000 cirrus clouds larger than 5 km in length. The BCP measures the equivalent optical diameter (EOD) of individual crystals in the 5–90 µm range from which size distributions are derived and recorded every 4 seconds. The cirrus cloud property database, an ongoing development stemming from these measurements, registers the total crystal number and mass concentration, effective and median volume diameters and extinction coefficients derived from the size distribution. This information is accompanied by the environmental temperature, pressure, aircraft position, date and time of each sample. The seasonal variations of the cirrus cloud properties measured from 2012 to 2014 are determined for six geographic regions in the tropics and extratropics. Number concentrations range from a few per litre for thin cirrus to several hundreds of thousands for heavy cirrus. Temperatures range from 205 to 250 K and effective radii from 12 to 20 µm. A comparison of the regional and seasonal number and mass size distributions, and the bulk microphysical properties derived from them, demonstrates that cirrus properties cannot be easily parameterised by temperature or by latitude. The seasonal changes in the size distributions from the extratropical Atlantic and Eurasian air routes are distinctly different, showing shifts from mono-modal to bi-modal spectra out of phase with one another. This phase difference may be linked to the timing of deep convection and cold fronts that lead to the cirrus formation. Likewise, the size spectra of cirrus over the tropical Atlantic and Eastern Brazil differ from each other although they were measured in adjoining regions. The cirrus crystals in the maritime continental tropical region over Malaysia form tri-modal spectra that are not found in any of the other regions measured by the IAGOS aircraft so far, a feature that is possibly linked to biomass burning or dust. Frequent measurements of ice crystal concentrations greater than 1×105 L−1, often accompanied by anomalously warm temperature and erratic airspeed readings, suggest that aircraft often experience conditions that affect their sensors. This new instrument, if used operationally, has the potential of providing real-time and valuable information to assist in flight operations as well as providing real-time information for along-track nowcasting.

The European Research Infrastructure IAGOS (In-service Aircraft for a Global Observing System) operates a global-scale monitoring system for atmospheric trace gases, aerosols and clouds utilising the existing global civil aircraft. This new monitoring infrastructure builds on the heritage of the former research projects MOZAIC (Measurement of Ozone and Water Vapour on Airbus In-service Aircraft) and CARIBIC (Civil Aircraft for the Regular Investigation of the Atmosphere Based on an Instrument Container). CARIBIC continues within IAGOS and acts as an important airborne measurement reference standard within the wider IAGOS fleet. IAGOS is a major contributor to the in-situ component of the Copernicus Atmosphere Monitoring Service (CAMS), the successor to the Global Monitoring for the Environment and Security – Atmospheric Service, and is providing data for users in science, weather services and atmospherically relevant policy. IAGOS is unique in collecting regular in-situ observations of reactive gases, greenhouse gases and aerosol concentrations in the upper troposphere and lowermost stratosphere (UTLS) at high spatial resolution. It also provides routine vertical profiles of these species in the troposphere over continental sites or regions, many of which are undersampled by other networks or sampling studies, particularly in Africa, Southeast Asia and South America. In combination with MOZAIC and CARIBIC, IAGOS has provided long-term observations of atmospheric chemical composition in the UTLS since 1994. The longest time series are 20 yr of temperature, H2O and O3, and 9–15 yr of aerosols, CO, NO y , CO2, CH4, N2O, SF6, Hg, acetone, ~30 HFCs and ~20 non-methane hydrocarbons. Among the scientific highlights which have emerged from these data sets are observations of extreme concentrations of O3 and CO over the Pacific basin that have never or rarely been recorded over the Atlantic region for the past 12 yr; detailed information on the temporal and regional distributions of O3, CO, H2O, NO y and aerosol particles in the UTLS, including the impacts of cross-tropopause transport, deep convection and lightning on the distribution of these species; characterisation of ice-supersaturated regions in the UTLS; and finally, improved understanding of the spatial distribution of upper tropospheric humidity including the finding that the UTLS is much more humid than previously assumed.

We present the features seen in the first 2 months (July and August 2012) of data collected over the Pacific by IAGOS (In-service Aircraft for a Global Observing System)-equipped aircraft. IAGOS is the continuation and development of the well-known MOZAIC (Measurement of Ozone and Water Vapour on Airbus in-service Aircraft) project where scientific instruments were carried on commercially operated A340 aircraft to make measurements of chemical species in the atmosphere. Here, we show data from an aircraft operated by China Airlines on routes from Taipei to Vancouver, which provided the first trans-Pacific measurements by an IAGOS-equipped aircraft. We describe the chemical composition of the extratropical upper troposphere/lower stratosphere (Ex-UTLS) across the Pacific basin in the Northern Hemisphere. The observed concentrations of ozone span a range from 18 to 500 ppbv indicating sources in the marine boundary layer and lowermost stratosphere, respectively. Concentrations of carbon monoxide (CO) greater than 400 ppbv are observed in the Ex-UTLS suggesting that plumes of pollution have been exported from the continent. These low concentrations of ozone and high concentrations of CO were rarely recorded in 8 yr of MOZAIC observations over the Atlantic.