Withholding and withdrawing life-sustaining medical treatment

• At common law, a competent adult can refuse life-sustaining medical treatment, either contemporaneously or through an advance directive which will operate at a later time when the adult’s capacity is lost. • Legislation in most Australian jurisdictions also provides for a competent adult to complete an advance directive that refuses life-sustaining medical treatment. • At common law, a court exercising its parens patriae jurisdiction can consent to, or authorise, the withdrawal or withholding of life-sustaining medical treatment from an adult or child who lacks capacity if that is in the best interests of the person. A court may also declare that the withholding or withdrawal of treatment is lawful. • Guardianship legislation in all jurisdictions allows a substitute decision-maker, in an appropriate case, to refuse life-sustaining medical treatment for an adult who lacks capacity. • In terms of children, a parent may refuse life-sustaining medical treatment for his or her child if it is in the child’s best interests. • While a refusal of life-sustaining medical treatment by a competent child may be valid, this decision can be overturned by a court. • At common law and generally under guardianship statutes, demand for futile treatment need not be complied with by doctors.

Compatibility of stormwater treatment performance data between different geographical areas

Using a case study approach, this paper presents a robust methodology for assessing the compatibility of stormwater treatment performance data between two geographical regions in relation to a treatment system. The desktop analysis compared data derived from a field study undertaken in Florida, USA, with South East Queensland (SEQ) rainfall and pollutant characteristics. The analysis was based on the hypothesis that when transposing treatment performance information from one geographical region to another, detailed assessment of specific rainfall and stormwater quality parameters is required. Accordingly, characteristics of measured rainfall events and stormwater quality in the Florida study were compared with typical characteristics for SEQ. Rainfall events monitored in the Florida study were found to be similar to events that occur in SEQ in terms of their primary characteristics of depth, duration and intensity. Similarities in total suspended solids (TSS) and total nitrogen (TN) concentration ranges for Florida and SEQ suggest that TSS and TN removal performances would not be very different if the treatment system is installed in SEQ. However, further investigations are needed to evaluate the treatment performance of total phosphorus (TP). The methodology presented also allows comparison of other water quality parameters.

Regional trade-offs between mine water and energy use : a water treatment case study

The mining industry faces concurrent pressures of reducing water use, energy consumption and greenhouse gas (GHG) emissions in coming years. However, the interactions between water and energy use, as well as GHG e missions have largely been neglected in modelling studies to date. In addition, investigations tend to focus on the unit operation scale, with little consideration of whole-of-site or regional scale effects. This paper presents an application of a hierarchical systems model (HSM) developed to represent water, energy and GHG emissions fluxes at scales ranging from the unit operation, to the site level, to the regional level. The model allows for the linkages between water use, energy use and GHG emissions to be examined in a fl exible and intuitive way, so that mine sites can predict energy and emissions impacts of water use reduction schemes and vice versa. This paper examines whether this approach can also be applied to the regional scale with multiple mine sites. The model is used to conduct a case study of several coal mines in the Bowen Basin, Australia, to compare the utility of centralised and decentralised mine water treatment schemes. The case study takes into account geographical factors (such as water pumping distances and elevations), economic factors (such as capital and operating cost curves for desalination treatment plants) and regional factors (such as regionally varying climates and associated variance in mine water volumes and quality). The case study results indicate that treatment of saline mine water incurs a trade-off between water and energy use in all cases. However, significant cost differences between centralised and decentralised schemes can be observed in a simple economic analysis. Further research will examine the possibility for deriving model up-scaling algorithms to reduce computational requirements.

Water heating and dehumidification with heat pump utilizing solar, ambient and waste heat

The low temperature operation of a heat pump makes it an excellent match for the use of solar energy. At the National University of Singapore, a solar assisted heat pump system has been designed, fabricated and installed to provide water heating and drying. The system also utilizes the air con waste heat, which would normally be released to atmosphere adding to global warming. Experimental results show that the twophase unglazed solar evaporator-collector, instead of losing energy to the ambient, gained a significant amount due to low operating temperature of the collector. As a result, the collector efficiency attains a value greater than 1, when conventional collector equations are used. With this evaporator-collector, the system can be operated even in the absence of solar irradiation. The waste heat was collected from an air-con system, which maintained a room at 20-22 oC. In the condenser side, water at 60 oC was produced at a rate of 3 liter/minute and the drying capacity was 2.2kg/hour. Maximum COP of the system was found to be about 5.5.

Artemisinin-induced parasite dormancy : a plausible mechanism for treatment failure

Background Artemisinin-combination therapy is a highly effective treatment for uncomplicated falciparum malaria but parasite recrudescence has been commonly reported following artemisinin (ART) monotherapy. The dormancy recovery hypothesis has been proposed to explain this phenomenon, which is different from the slower parasite clearance times reported as the first evidence of the development of ART resistance. Methods In this study, an existing P. falciparum infection model is modified to incorporate the hypothesis of dormancy. Published in vitro data describing the characteristics of dormant parasites is used to explore whether dormancy alone could be responsible for the high recrudescence rates observed in field studies using monotherapy. Several treatment regimens and dormancy rates were simulated to investigate the rate of clinical and parasitological failure following treatment. Results The model output indicates that following a single treatment with ART parasitological and clinical failures occur in up to 77% and 67% of simulations, respectively. These rates rapidly decline with repeated treatment and are sensitive to the assumed dormancy rate. The simulated parasitological and clinical treatment failure rates after 3 and 7 days of treatment are comparable to those reported from several field trials. Conclusions Although further studies are required to confirm dormancy in vivo, this theoretical study adds support for the hypothesis, highlighting the potential role of this parasite sub-population in treatment failure following monotherapy and reinforcing the importance of using ART in combination with other anti-malarials.

Artemisinin induced dormancy in Plasmodium falciparum : duration, recovery rates and implications in treatment failure

Background Despite the remarkable activity of artemisinin and its derivatives, monotherapy with these agents has been associated with high rates of recrudescence. The temporary arrest of the growth of ring-stage parasites (dormancy) after exposure to artemisinin drugs provides a plausible explanation for this phenomenon. Methods Ring-stage parasites of several Plasmodium falciparum lines were exposed to different doses of dihydroartemisinin (DHA) alone or in combination with mefloquine. For each regime, the proportion of recovering parasites was determined daily for 20 days. Results Parasite development was abruptly arrested after a single exposure to DHA, with some parasites being dormant for up to 20 days. Approximately 50% of dormant parasites recovered to resume growth within the first 9 days. The overall proportion of parasites recovering was dose dependent, with recovery rates ranging from 0.044% to 1.313%. Repeated treatment with DHA or with DHA in combination with mefloquine led to a delay in recovery and an ∼10-fold reduction in total recovery. Strains with different genetic backgrounds appeared to vary in their capacity to recover. Conclusions These results imply that artemisinin-induced arrest of growth occurs readily in laboratory-treated parasites and may be a key factor in P. falciparum malaria treatment failure.

In Response: "Oral versus IV treatment for catheter-related bloodstream infections - by Burke A. Cunha"

In his letter Cunha suggests that oral antibiotic therapy is safer and less expensive than intravenous therapy via central venous catheters (CVCs) (1). The implication is that costs will fall and increased health benefits will be enjoyed resulting in a gain in efficiency within the healthcare system. CVCs are often used in critically ill patients to deliver antimicrobial therapy, but expose patients to a risk of catheter-related bloodstream infection (CRBSI). Our current knowledge about the efficiency (i.e. costeffectiveness) of allocating resources toward interventions that prevent CRBSI in patients requiring a CVC has already been reviewed (2). If for some patient groups antimicrobial therapy can be delivered orally, instead of through a CVC, then the costs and benefits of this alternate strategy should be evaluated...

Health education and the control of intestinal worm infections in China : a new vision

Background: The transmission of soil-transmitted helminths (STHs) is associated with poverty, poor hygiene behaviour, lack of clean water and inadequate waste disposal and sanitation. Periodic administration of benzimidazole drugs is the mainstay for global STH control but it does not prevent re-infection, and is unlikely to interrupt transmission as a stand-alone intervention. Findings: We reported recently on the development and successful testing in Hunan province, PR China, of a health education package to prevent STH infections in Han Chinese primary school students. We have recently commenced a new trial of the package in the ethnically diverse Xishuangbanna autonomous prefecture in Yunnan province and the approach is also being tested in West Africa, with further expansion into the Philippines in 2015. Conclusions: The work in China illustrates well the direct impact that health education can have in improving knowledge and awareness, and in changing hygiene behaviour. Further, it can provide insight into the public health outcomes of a multi-component integrated control program, where health education prevents re-infection and periodic drug treatment reduces prevalence and morbidity.

Waste generations and efficiency measures in Japan

This study measures the efficiencies incorporating waste generation using Japanese prefecture level data. We apply and compare several models using directional distance functions. There are wide variations in the efficiency scores between the two orientations, "input, desirable and undesirable output orientation" and "undesirable output orientation". However, the difference in abatement factor does not result in wide variations in the efficiency scores. Our results show that there are wide differences in the efficiency scores among prefectures. © 2012 Springer.

Sensitivity of an Elekta iView GT a-Si EPID model to delivery errors for pre-treatment verification of IMRT fields

A Monte Carlo model of an Elekta iViewGT amorphous silicon electronic portal imaging device (a-Si EPID) has been validated for pre-treatment verification of clinical IMRT treatment plans. The simulations involved the use of the BEAMnrc and DOSXYZnrc Monte Carlo codes to predict the response of the iViewGT a-Si EPID model. The predicted EPID images were compared to the measured images obtained from the experiment. The measured EPID images were obtained by delivering a photon beam from an Elekta Synergy linac to the Elekta iViewGT a-Si EPID. The a-Si EPID was used with no additional build-up material. Frame averaged EPID images were acquired and processed using in-house software. The agreement between the predicted and measured images was analyzed using the gamma analysis technique with acceptance criteria of 3% / 3 mm. The results show that the predicted EPID images for four clinical IMRT treatment plans have a good agreement with the measured EPID signal. Three prostate IMRT plans were found to have an average gamma pass rate of more than 95.0 % and a spinal IMRT plan has the average gamma pass rate of 94.3 %. During the period of performing this work a routine MLC calibration was performed and one of the IMRT treatments re-measured with the EPID. A change in the gamma pass rate for one field was observed. This was the motivation for a series of experiments to investigate the sensitivity of the method by introducing delivery errors, MLC position and dosimetric overshoot, into the simulated EPID images. The method was found to be sensitive to 1 mm leaf position errors and 10% overshoot errors.

Effectiveness of policy against illegal disposal of waste

Our objective is to analyze the effectiveness, against the illegal disposal of waste, of a licensing system that has been introduced in a waste management policy. We theoretically find enforcement leverage in the licensing system, and then examine the theoretical result empirically. The results suggest that extending liability to disposers, which forms the basis of the enforcement leverage, deters illegal disposal more effectively than increasing penalties for illegal disposal. We also obtain evidence of transboundary movement of illegal disposal, and find how the court determines penalties for illegal disposal.

License scheme : an optimal waste management policy under asymmetric information

A system requiring a waste management license from an enforcement agency has been introduced in many countries. A license system is usually coupled with fines, a manifest, and a disposal tax. However, these policy devices have not been integrated into an optimal policy. In this paper we derive an optimal waste management policy by using those policy devices. Waste management policies are met with three difficult problems: asymmetric information, the heterogeneity of waste management firms, and non-compliance by waste management firms and waste disposers. The optimal policy in this paper overcomes all three problems.

On the effectiveness of a license scheme for E-waste recycling : the challenge of China and India

It is well known that China and India have been recycling centers of WEEE, especially printed circuit boards, and that serious environmental pollution in these countries has been generated by improper recycling methods. After the governments of China and India banned improper recycling by the informal sector, improper recycling activities spread to other places. Then, these governments changed their policies to one of promoting proper recycling by introducing a scheme, under which E-waste recycling requires a license issued by the government. In this paper, the effectiveness of that license scheme is examined by means of an economic model. It can be shown that the license scheme can work effectively only if disposers of E-waste have a responsibility to sell E-waste to license holders. Our results run counter to the idea that international E-waste trade should be banned and provide an alternative solution to the problem.