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Objective: The authors undertook a qualitative study with open-ended, structured interviews to understand patient's educational needs for patients undergoing total hip and total knee arthroplasty (THA/TKA). Design: Provider interviews explored their approach with THA/TKA patients on: pain management; barriers to opioid tapering; and recommendations/changes on educational materials to support pain management and opioid reduction. Patient interviews explored their experience, understanding, beliefs surrounding opioids, and recommendations on important content. A qualitative methodologist conducted interviews and content analysis to identify key themes. Setting: Kaiser Permanente Northwest, community setting. Patients, Participants: A purposeful sampling method identified interviewees (surgeons, advice nurses, physical therapists, physician assistants, and patients). Patients were recent THA/TKA cases in the top third of opioid use after surgery. Interventions: N/A. Main Outcome Measure(s): Qualitative study. Results: Recommendations for patient educational content included: (1) clear descriptions of how opioids work in the body, how to taper, nonopioid pain management options, and problems from overuse; (2) messaging on how long to expect to use opioids and type of pain to expect; (3) visual timeline to illustrate opioid tapering and exercise expectations; (4) emphasize that pain management is multimodal, and stress the balance between opioids for recovery versus overuse; (5) provide educational messaging multiple times prior to and after surgery. Conclusions: Patients and providers agreed that clearly stated verbal and written messaging is needed beyond what has typically been done regarding opioid expectations.

To determine whether a pharmacist-led, patient-directed intervention can reduce opioid use following total hip arthroplasty (THA) or total knee arthroplasty (TKA).Randomized trial.Patients scheduled to undergo THA or TKA (during 2015 and 2016) were randomized to usual care or intervention. We ranked patients according to predicted risk of persistent opioid use and selected the top 60% for inclusion (n = 561); all contributed to the analysis. Intervention patients were mailed materials 2 weeks before and after surgery, plus they received telephone intervention from specially trained pharmacists if they filled opioid prescriptions in the 28 to 90 days following surgery. Our primary outcome was the dispensed morphine equivalents (DME) in the 90 days following surgery, modeled using a natural log transformation.A total of 561 patients were randomized (286 usual care, 118 THA and 168 TKA; 275 intervention, 107 THA and 168 TKA); the mean age was 66 years, and 60% were female. Overall, we found no meaningful reduction in DME for intervention versus usual care (geometric mean ratio, 0.92 [95% CI, 0.69-1.21]). However, there was effect modification by whether the patient had TKA or THA (interaction P.01). Those undergoing THA in the intervention group used significantly less DME than did those undergoing THA in the usual care group (geometric mean ratio, 0.52 [95% CI, 0.33-0.82]).Our pharmacist-led, patient-directed intervention to reduce opioid use demonstrated a reduction in opioid dispensings in the 90 days following THA but not TKA.

Phosphorus (P) is essential for crop growth and food production, and most of the phosphorus applied to agricultural land comes from phosphate rock (PR), a non-renewable resource. The distribution of PR reserves and the share of current production are both concentrated in a handful of countries, notably Morocco and China. Individual countries operate their phosphate mining industries at different reserve-to-production (R/P) ratios, which determines the lifetime of PR reserves in that country and, in turn, the global distribution of both reserves and production in the future. This research uses U.S. Geological Survey data (released in January 2011) to derive R/P ratios for individual countries and combines this with a scenario for increasing global demand to investigate how the global distribution of PR reserves and production will change between now and the year 2100. The results show that 70% of global production is currently produced from reserves which will be depleted within 100 years and combining this with increasing demand will result in a significant global production deficit, which by 2070 will be larger than current production. Morocco, with nearly 77% of global reserves, will need to increase production by around 700% by 2075 in order to meet most of this deficit. If this is possible, Morocco will obtain a much greater share of worldwide production, from around 15% in 2010 to around 80% by 2100, which implies more control over market prices. Also, since Morocco operates the highest R/P ratio throughout the analysis period, its share of the global reserves continues to increase, from 77% in 2011 to 89% by 2100. Overall, the research concludes that, unless additional sources of phosphorus can be accessed or society can significantly increase phosphorus recycling, future global phosphorus security will be increasingly reliant on a single country.

Sustainable land management often requires redevelopment of existing and often contaminated Brownfield sites over use of Greenfield or agricultural land. Stabilisation / solidification (S/S) offer a viable remediation option with particular suitability in treating heavy metal contaminants. However, uncertainties over long-term durability and previously cheap landfill disposal costs resulted in limited use in many countries. There is a need to characterise treated material and assess components containment and release, to improve S/S confidence and inform remedial design, using the evaluation of the leaching controlling mechanisms. To improve understanding of key features that will enable improvements to such designs, this paper presents an evaluation of leaching for CEM II stabilised kaolin, using the leaching behaviour of 4 main components—aluminium, silicon, calcium and sulphur. Results show no detrimental implications on chemical durability due to kaolin degradation with hydration under induced alkalinity, with increased formation of stable cementitious minerals. Availabilities for components show that aluminium and silicon had minimal leachability compared to total content, whilst calcium and sulphur show almost total leaching availability. Decreasing calcium and silicon leachability under natural chemical conditions with increased hydration duration supports the increased formation of stable cementitious products with time, using the products of kaolin dissociation.

Every year 90 million tonnes of housed livestock manures are produced in the UK. This is a valuable reservoir of global phosphorus (P) and a point in the cycle where it is vulnerable to being lost from the terrestrial system. Improved manure management for the effective reuse of phosphorus is vital to simultaneously tackle a major source of water pollution and reduce our dependence on imported fertilisers. This paper quantifies, for the first time, the spatial and temporal challenges of recycling the required amount of manure P from areas of livestock production to areas of crop production in eight regions of England. The analysis shows that England has a P deficit and therefore the capacity to fully utilise the manure P on arable land, but that uneven spatial distribution of livestock poses a significant challenge to closing the P loop in agriculture. Two of the eight regions were shown to have surplus manure P, with the remaining six regions having P deficits, indicating that an annual export of 4.7 thousand tonnes P (2.8 million tonnes manure) must take place from the west to the east of the country each year to balance P supply and demand. Moreover, housed manure production peaks between October and February, requiring an excess of 23.0 thousand tonnes P (15 million tonnes manure) to be stored until it can be used for crop fertilisation from March onwards. The results demonstrate the scale of the challenge in managing manure P in an agricultural system that has separated livestock production from crop production, a pattern that is echoed throughout the developed world. To overcome the spatial and temporal challenges, a logistical system is recommended that will balance the nutrient potential (nitrogen and P content and availability) and pollution potential (eutrophication, greenhouse gas emissions, particulates and nitrous oxide from transport) for cost-effective and environmentally compatible redistribution of manure P from areas of surplus to areas of deficit, when required.

Mineralogical and petrographical investigation of two loessic brickearth profiles from Ospringe and Pegwell Bay in north Kent, UK have differentiated two types of brickearth fabric that can be correlated with different engineering behaviour. Both sequences comprise metastable (collapsing) calcareous brickearth, overlain by non collapsing ‘non-calcareous’ brickearth. This study has demonstrated that the two types of brickearth are discretely different sedimentary units, with different primary sedimentary characteristics and an erosional junction between the two units. A palaeosol is developed on the calcareous brickearth, and is associated with the formation of rhizolithic calcrete indicating an arid or semi-arid environment. No evidence has been found for decalcification being responsible for the fabric of the upper ‘non-calcareous’ brickearth. Optically-stimulated dates lend further support for the calcareous and ‘non-calcareous’ brickearth horizons being of different age or origins. The calcareous brickearth is metastable in that it undergoes rapid collapse settlement when wetted under applied stresses. It is characterised by an open-packed arrangement of clay-coated, silt-sized quartz particles and pelletised aggregate grains (peds) of compacted silt and clay, supported by an interped matrix of loosely packed, silt/fine-grained sand, in which the grains are held in place by a skeletal framework of illuviated clay. The illuviated clay forms bridges and pillars separating and binding the dispersed component silt/sand grains. There is little direct grain-to-grain contact and the resultant fabric has a very high voids ratio. Any applied load is largely supported by these delicate clay bridge and pillar microfabrics. Collapse of this brickearth fabric can be explained by a sequence of processes involving: (1) dispersion and disruption of the grain-bridging clay on saturation, leading to initial rapid collapse of the loose packed inter-ped silt/sand; (2) rearrangement and closer stacking of the compact aggregate silt/clay peds; (3) with increasing stress further consolidation may result from deformation and break up of the peds as they collapse into the inter-ped regions. Smectite is a significant component of the clay assemblage and will swell on wetting, further encouraging disruption and breaking of the clay bonds. In contrast, the ‘non-calcareous’ brickearth already possesses a close-packed and interlocking arrangement of silt/sand grains with only limited scope for further consolidation under load. Minor authigenic calcite and dolomite may also form meniscus cements between silt grains. These have either acted as ‘‘scaffolds’’ on which illuviated clay has subsequently been deposited or have encrusted earlier formed grain-bridging clay. In either case, the carbonate cements may help to reinforce the clay bridge fabrics. However, these carbonate features are a relatively minor feature and not an essential component of the collapsible brickearth fabric. Cryoturbation and micromorphological features indicate that the calcareous brickearth fabric has probably been developed through periglacial freeze–thaw processes. Freezing could have produced the compact silt/clay aggregates and an open porous soil framework containing significant inter-ped void space. Silt and clay were remobilised and translocated deeper into the soil profile by water percolating through the active layer of the sediment profile during thawing cycles, to form the loosed packed inter-ped silt matrix and grain-bridging meniscus clay fabrics. In contrast, the upper ‘non-calcareous’ brickearth may represent a head or solifluction deposit. Mass movement during solifluction will have destroyed any delicate grain-bridging clay microfabrics that may have been present in this material.

In order to rapidly screen and select lead candidates for in vivo evaluation of lipid nanoparticles (LNPs) for systemic small interfering RNA (siRNA) delivery, an in vitro assay amenable to high-throughput screening (HTS) is developed. The strategy is to mimic the in vivo experience of LNPs after systemic administration, such as interactions with serum components, exposure to endosomal pH environments, and interactions with endosomal membrane lipids. It is postulated that the amount of siRNA released from LNPs after going through these treatments can be used as a screening tool to rank order the effectiveness of siRNA delivery by lipid nanoparticles in vivo. LNPs were incubated with 50% serum from different species (i.e. mouse, rat, or rhesus) at 37°C. The resulting samples were then reacted with anionic, endosomal-mimicking lipids at different pHs. The amount of siRNA released from LNPs was determined using spectrophotometry employing the fluorescent indicator SYBR Gold. Our results indicated that the amount of siRNA liberated was highly dependent upon the species of serum used and the pH to which it was exposed. LNPs treated with mouse serum showed higher levels of siRNA release, as did those subjected to endosomal pH (6.0), compared to physiological pH. Most interestingly, a good correlation between the amount of siRNA released and the in vivo efficacy was observed. In conclusion, an in vitro siRNA release assay was developed to screen and rank order LNPs for in vivo evaluation.

Requirements for sustainable waste management and environmental protection have yielded recent EU regulations, which actively encourage the use of source control remedial approaches such as stabilization/solidification (S/S). S/S has proven particularly viable for heavy metal containment, relying on interactions between introduced reagents and contaminated media to induce containment. However, there is a need to validate long-term performance of the method to prevent accidental releases and subsequent environmental pollution. This requires evaluation of leaching controlling mechanisms for treated contaminated media to address time and equilibrium pH dependent leaching characteristics. The selection of a suitable suite of leaching tests to evaluate leaching is essential to ensure confidence in the applied techniques, and can be used to expedite durable and effective mix design and application. This paper presents findings from leaching evaluations for CEM II (Portland limestone cement) treated chromium contaminated kaolin clay. Leaching tests were undertaken at 28, 150, and 300 days of sample curing, for time dependent, equilibrium, and porewater leaching characteristics. Evaluations were also undertaken for influences of sulfate and organic content (as humic acid) on chromium containment. Chromium was found to be contained effectively within the stabilized contaminated matrix, with leaching and availability comparable to those observed for the stabilized uncontaminated specimen. The primary solubility controlling mineral was found to be chromium hydroxide, and increasing hydration improved chromium containment. Increased organic content resulted in an initial increase in chromium availability at 28 and 150 days of hydration, a trend also observed for an increase in sulfate content. However, after hydration for 300 days, the availabilities for chromium were comparable for all matrices, and comparable to measures observed for leaching from the uncontaminated clay.

Sustainable redevelopment to meet increasing urban expansion has mandated the increased redevelopment of contaminated land. Current national / international environmental regulations, and increased disposal costs for landfilling, has necessitated a need for sustainable and cost efficient in situ remediation alternatives. Stabilization / Solidification (S/S) techniques offer a viable solution for the amelioration of unacceptable environmental risk, particularly effective in heavy metal remediation. However, uncertainties over long term effectiveness and durability, and previously low landfill disposal costs had limited its utilization. Effective characterization of the stabilized material and evaluation of its leaching and containment properties are required, to ensure long term effectiveness and improve design confidence. Zinc contaminated kaolin clay, stabilized with CEM II Portland Limestone cement, was tested using a suite of leaching tests designed for monolith specimens. Evaluations of leaching for zinc and selected master species (Al, Si and Ca) were undertaken, at different intervals of hydration (28, 150 and 300days). Results show that zinc is successfully contained and partitioned within the cement stabilized kaolin clay, but does not exhibit amphoteric leaching. Increased hydration time increases the stabilized materials chemical durability regardless of kaolin degradation, but does not modify pH dependent leaching trends.