Early warning sign attributes for the safety of drinking water treatment works

A proactive risk management strategy seeks to prevent accidents from taking place and maintain the safety of a system. In this context, the task of identifying and disseminating early warning signs and signals is among the most important. The problem is that warning signs that are present before an accident takes place are often being overlooked and not picked up or identified as warning signs. If these warning signs were responded to, then an accident may be averted. Accidents occuring in the critical domain of a drinking water treatments works can have serious implications for the public health of consumers of the water supplied. Realising and comprehending early warning signs is a major challenge for the domain of systems safety and especially in the domain of a water treatment works. The approaches that are typically used to enhance the realisation, comprehension and dissemination of early warning signs in the water treatment domain in Ireland mainly involves the creation of accident scenarios, the use of monitoring data and procedures for the dissemination of warnings. While all of these approaches are all useful to inform the mental or process models of possible accident scenarios, nevertheless, accidents are still occurring in this domain. Therefore, a new approach to enhance the comprehension of and effective dissemination of early warning signs is required in order to improve safety and proactive risk management strategies. The contributions of this thesis is the provision of a set of attributes associated with the early warning sign concept that provides meaningful data on the early warning signs and allows recipients to better comprehend them. The values of these attributes were customised for application in the water treatment domain. This research proves that early warning signs at a water treatment works received with information on their attributes are comprehended and communicated more effectively and efficiently than the usual pragmatic approach and thereby improves the safety and proactive risk management strategies.

Cancer associated malnutrition: prevalence of cachexia, sarcopenia and impact on treatment outcomes, survival and health related quality of life

Malnutrition, sarcopenia and cancer cachexia (CC) are prevalent among cancer patients and can have detrimental effects on clinical outcomes such as quality of life (QoL) and overall survival. Cachexia is associated with lower tolerance for chemotherapy, which limits the total dose that can be delivered, the number of symptomatic responses and any survival advantage that might be accrued. Moreover, for the majority who do not respond, cachexia may be exacerbated by systemic chemotherapy, thus increasing the net symptom burden experienced by patients. The multitude of interactions between cancer location, treatments, nutritional status and QoL has never been thoroughly explored in an Irish cancer cohort. The objectives of this thesis were to further understand nutritional status, especially body composition in ambulatory cancer patients and determine the relationship between nutritional status using different assessment criteria and QoL, chemotherapy toxicity and survival among cancer patients undergoing chemotherapy. Results aimed to identify baseline factors that may be predictive of poor outcome, toxicities to chemotherapy and disease-free and overall survival. This thesis broadly divides into two sections. The first section (Chapters 3 & 4) focuses on improving our knowledge of the nutritional status of Irish cancer outpatients using a cross sectional study design. A study of 517 patients referred for chemotherapy was conducted using computed tomography (CT) imaging (body composition) and a survey that documented oncologic data, weight loss (WL) data and QoL data. We revealed that a significant proportion of Irish cancer patients undergoing chemotherapy experience unintentional WL over the previous 6 months (62%), sarcopenia (45%) and CC (43%), and the distribution of WL and nutritional risk were associated with site of primary tumour and treatment intent. Patients that had sarcopenia, nutritional risk, or CC had significantly reduced functional abilities, more symptoms and adverse global QoL. In the second section of this thesis (Chapters 5 & 6) the potential link between developing toxicity to antineoplastic regimens in patients with sarcopenia was conducted by way of retrospective studies. A retrospective serial CT analysis defined the prevalence of sarcopenia in patients with metastatic renal cell carcinoma (mRCC) and metastatic castrate resistant prostate cancer (mCRPC), which was then correlated with dose limiting toxicities of sunitinib and docetaxel respectively. Sarcopenia was prevalent in patients with mRCC and mCRPC, was an occult condition in patients with normal/high BMI, was associated with less treatment days, was a significant predictor of DLT in patients receiving sunitinib and a significant predictor of neutropenia and neurosensory toxicities in patients receiving docetaxel. This thesis attempted to address the underlying research deficiencies in Irish oncology nutritional data at national level. The findings from this thesis have implications for the planning of cancer care interventions and indicate that further research is required to improve nutritional screening, in particular for CC and sarcopenia, in the hope that timely intervention can improve both patient-centered and oncologic outcomes.