Using CollaboRATE, a brief patient‐reported measure of shared decision making: Results from three clinical settings in the United States

Abstract Introduction: CollaboRATE is a brief patient survey focused on shared decision making. This paper aims to (i) provide insight on facilitators and challenges to implementing a real‐time patient survey and (ii) evaluate CollaboRATE scores and response rates across multiple clinical settings with varied patient populations. Method All adult patients at three United States primary care practices were eligible to complete CollaboRATE post‐visit. To inform key learnings, we aggregated all mentions of unanticipated decisions, problems and administration errors from field notes and email communications. Mixed‐effects logistic regression evaluated the impact of site, clinician, patient age and patient gender on the CollaboRATE score. Results: While CollaboRATE score increased only slightly with increasing patient age (OR 1.018, 95% CI 1.014‐1.021), female patient gender was associated with significantly higher CollaboRATE scores (OR 1.224, 95% CI 1.073‐1.397). Clinician also predicts CollaboRATE score (random effect variance 0.146). Site‐specific factors such as clinical workflow and checkout procedures play a key role in successful in‐clinic implementation and are significantly related to CollaboRATE scores, with Site 3 scoring significantly higher than Site 1 (OR 1.759, 95% CI 1.216 to 2.545) or Site 2 (z=−2.71, 95% CI −1.114 to −0.178). Discussion This study demonstrates that CollaboRATE can be used in diverse primary care settings. A clinic's workflow plays a crucial role in implementation. Patient experience measurement risks becoming a burden to both patients and administrators. Episodic use of short measurement tools could reduce this burden

Assessing sources, fate, and the potential risk of UV filters in the aquatic environment

UV filters are compounds used in sunscreen and personal care products as well as in some plastics, paints and textiles. Because of their frequent use in personal care products, they are regularly released into the environment. Release into the aquatic environment occurs via two main pathways; direct wash-off of sunscreen and other personal care products during recreational water activities, or through the release of wastewater effluent. The release of UV filters into the environment is of concern due to potential harm to aquatic species as many UV filters are known to cause endocrine disrupting effects. Despite the high usage of sunscreens, there is limited research on the environmental prevalence and risk of UV filters in many countries, including Australia. This thesis aims to investigate the sources, occurrence and fate of UV filters in the aquatic environment by determining concentrations in wastewater influent and effluent, as well as at recreational waterbodies. The resulting occurrence and fate data are then used to evaluate the risk of UV filters released from these primary sources.Chapter 2 investigates the concentrations of UV filters in 24-hour composite samples collected from 36 wastewater treatment plants (WWTPs) in Australia. The sampled WWTPs were spread across the country and their catchments cover more than 48% of the Australian population. Phenylbenzimidazole sulfonic acid (PBSA) and benzophenone-4 (BP4), used in a wide range of products, were the most prevalent of six detected UV filters in wastewater influent. Summed UV filter loads of up to 3.4 mg person-1 day-1 were estimated in influent. Findings revealed that these summed per capita UV filter loads correlate positively with a site’s proximity towards the equator.Chapter 3 investigates wastewater effluent as a source of UV filters released into the aquatic environment. Removal efficiencies were calculated using matched influent and effluent samples, and measured UV filter concentrations and per capita loads were determined. The highest removal rates were found for benzophenone-1 (BP1) and benzophenone-3 (BP3) (74 ± 22 % and 71 ± 24 % respectively), followed by 4-methylbenzylidene camphor (4-MBC) (59 ± 24 %), BP4 (51 ± 43 %), and PBSA (11 ± 36 %). The highest removal efficiencies were observed at sites with secondary treatment processes together with a disinfection process. Concentrations of UV filters in effluent were dominated by PBSA and BP4. Across the sampled WWTPs, combined per capita loads of the detected UV filters averaged 820 ± 650 mg d-1 1000 p-1. Using the calculated per capita loads an estimated 20 kg of UV filters is released into the environment daily from wastewater effluent in Australia.The occurrence and fate of UV filters at a recreational waterbody was investigated through diurnal sampling and controlled degradation experiments. At the chosen site (Enoggera Reservoir, Queensland, Australia) seven UV filters were detected, of which octocrylene (OC) was the most abundant. The observed UV filter profile in surface water was different to that in effluent samples and was associated with prevalence in Australian commercial sunscreens. UV filter concentrations declined substantially (29 – 85 %) between samples collected at 17:00 and at 21:00, several hours after recreation ceased. The controlled experiments investigated the degradation of UV filters in surface water under both natural sunlight and dark conditions. Results showed no significant change over time (up to 144 h) for OC, PBSA, BP3 and BP4 in any treatment. Estimated half-lives for the other tested UV filters under natural sunlight conditions ranged from 6.6 to 140 hours.Using the observed environmental concentrations, a preliminary risk assessment was conducted using predicted no effect concentrations (PNECs) calculated using literature data. At two recreational sites (Enoggera Reservoir and Brown Lake, Queensland, Australia), BP3 presented the highest risk of the investigated UV filters. Further investigation is recommended at Enoggera Reservoir as several UV filters exceeded PNEC values based on data from the collected samples. Additional sampling, including transects are recommended to fully assess the environmental risk at these sites. For aquatic environments receiving wastewater effluent, measured UV filter concentrations in effluent are unlikely to pose a high risk, provided dilution upon discharge is greater than a factor of ten. However, several UV filters have limited toxicity data and may require future review.\ua0This project provides national knowledge of the occurrence of UV filters in wastewater influent and effluent in Australia on a per capita basis. Concentrations of UV filters measured at a recreational waterbody in Australia are reported for the first time together with the first measured environmental half-lives for several UV filters. The preliminary risk assessment provides an initial assessment of the potential risk of eight detected UV filters entering the aquatic environment in Australia. Future research to further understand the fate and variability of UV filters in fresh and marine waterbodies is recommended together with additional toxicity testing to allow for the development of water quality guidelines for UV filters identified as a potential risk

Point-of-use water filters can effectively remove disinfection by-products and toxicity from chlorinated and chloraminated tap water

Epidemiological risk estimates point toward potential health risks posed by disinfection by-products (DBPs) in chlorinated drinking water. Point-of-use filters can effectively remove regulated DBPs from tap water but the removal of unknown DBPs and toxicity has not yet been assessed. We evaluated 11 tap water filters for their efficacy to abate fluoride, bacteria, and adsorbable organic halogens (AOX) as the sum parameter of known and unknown halogenated DBPs. Biological effects were quantified in water samples enriched with solid phase extraction by use of the Microtox assay for bacterial cytotoxicity, the AREc32 assay for oxidative stress response, and the umuC assay for genotoxicity. Six out of 11 filters effectively removed chlorinated and brominated organic halogens by >60%. Reverse osmosis and one activated carbon based gravity filter were most effective (>94% AOX removal). Four out of five non-membrane pressure filters were less effective for AOX abatement than four out of five activated carbon based gravity filters. Renewal of the filter cartridges significantly improved AOX removal efficacies. Fluoride was removed by >83% only by reverse osmosis and two filters specifically designed for fluoride removal by use of activated alumina. Bacterial counts increased after filtration with most filters, indicating biofilm growth on the filter matrix. Cartridge renewal decreased bacterial counts. Seven out of 11 filters reduced cytotoxicity, oxidative stress response, and genotoxicity by >60%. Activated carbon based tap water filters could provide an important short-term public health benefit through removal of halogenated DBPs, but regular filter cartridge exchange is critical to maintain a good filter efficacy

Annual release of selected UV filters via effluent from wastewater treatment plants in Australia

Studies conducted globally have identified wastewater effluent as a key source of UV filters released into the aquatic environment. We assessed the annual release of UV filters from wastewater treatment plant effluent in Australia and evaluated the removal of these chemicals during wastewater treatment. Effluent samples were collected from 33 sites alongside matching influent samples. Sample collection predominately occurred during the Australian Census in August 2016, which allowed for accurate per capita normalisation of the results. A subset of sites was also sampled over the Southern Hemisphere summer (December-February) period. Five UV filters were detected with at least one detected in 95% of effluent samples. The summed concentration of UV filters ranged from 130\ua0ng\ua0L to 8400\ua0ng\ua0L and averaged 2800 (±1900) ng L. Of the target UV filters, 2-phenylbenzimidazole-5-sulfonic acid (PBSA) and benzophenone 4 (BP4) showed the lowest removal efficiencies (11\ua0±\ua036% and 51\ua0±\ua043%, respectively) across all sites and were the most abundant in effluent. Average estimated removal efficiencies of the other compounds were between 59 (±24) % (4-methylbenzylidene camphor (4-MBC)) and 74 (±22) % (benzophenone 1 (BP1)). We did not find a trend in seasonal differences in the per capita release of UV filters in effluent samples. We estimate that approximately 40% of UV filter loads measured in influent are breaking through to the effluent resulting in the release of approximately 20\ua0kg day of the selected UV filters into the aquatic environment from treated wastewater effluent in Australia

Fingerprinting the reactive toxicity pathways of 50 drinking water disinfection by-products

A set of nine in vitro cellular bioassays indicative of different stages of the cellular toxicity pathway was applied to 50 disinfection by-products (DBPs) to obtain a better understanding of the commonalities and differences in the molecular mechanisms of reactive toxicity of DBPs. An Eschericia coli test battery revealed reactivity towards proteins/peptides for 64% of the compounds. 98% activated the NRf2-mediated oxidative stress response and 68% induced an adaptive stress response to genotoxic effects as indicated by the activation of the tumor suppressor protein p53. All DBPs reactive towards DNA in the E. coli assay and activating p53 also induced oxidative stress, confirming earlier studies that the latter could trigger DBP's carcinogenicity. The energy of the lowest unoccupied molecular orbital ELumo as reactivity descriptor was linearly correlated with oxidative stress induction for trihalomethanes (r(2) = 0.98) and haloacetamides (r(2) = 0.58), indicating that potency of these DBPs is connected to electrophilicity. However, the descriptive power was poor for haloacetic acids (HAAs) and haloacetonitriles (r(2) 0.80, indicating that HAAs' potency is connected to both, electrophilicity and speciation. Based on the activation of oxidative stress response and the soft electrophilic character of most tested DBPs we hypothesize that indirect genotoxicity e.g., through oxidative stress induction and/or enzyme inhibition is more plausible than direct DNA damage for most investigated DBPs. The results provide not only a mechanistic understanding of the cellular effects of DBPs but the effect concentrations may also serve to evaluate mixture effects of DBPs in water samples. (C) 2016 Elsevier Ltd. All rights reserved

Mixture effects of drinking water disinfection by-products: implications for risk assessment

Disinfection by-products (DBPs) in drinking water have been associated with increased cancer risk but single DBPs cannot explain epidemiological cancer occurrences. To test if combined effects of DBPs are plausible to explain epidemiological evidence for adverse health effects, we assessed if mixture effects of DBPs can be predicted using the concentration addition (CA) model. We prepared 12 mixtures of DBPs (trihalomethanes, halonitromethanes, haloacetonitriles, haloketones, haloacetic acids, chloral hydrate, haloacetamides, 3-chloro-4-(dichloromethyl)-5-hydroxy-5H-furan-2-one (MX)) in equipotent concentration ratios. We determined effect concentrations with three reporter gene bioassays (AREc32, ARE-bla, and p53-bla) based on human cell lines and one bacterial assay (Microtox). The experimental effect concentrations agreed well with the effect concentrations predicted with the CA model, which suggests that the CA model is applicable for reactive DBPs despite different molecular mechanisms because the reporter gene assays are only detecting one mechanism each. Modelling of mixture effects of DBPs in ratios detected in drinking water revealed that haloacetonitriles, haloketones, and mono-haloacetic acids contributed the most to the total effect indicating a higher health relevance of these DBP groups. In drinking water samples the sum of the detected DBPs explaine

Calibration parameters for the passive sampling of organic UV filters by silicone; diffusion coefficients and silicone–water partition coefficients

In recent years, organic ultraviolet filters (UVFs) received considerable attention as a group of emerging contaminants, including in Australia where the use of UVFs is particularly relevant. Passive sampling using polymers has become widely used for routine monitoring of chemicals in the aquatic environment. Application of passive samplers for monitoring chemicals in the water relies on calibration data such as chemical's polymer-water partition coefficient (K) and diffusion coefficients in the sampling material (D), for understanding uptake and kinetic limitations. In the present study, K and D for nine UVFs were estimated. K values were determined in different water - polymer partition experiments where (1) a given mass of chemicals was dosed into the water and (2) into the polymer. Diffusion coefficients were determined using the stacking method. The estimated log K and log D ranged from 2.9 to 6.4 L kg and -11.1 to\ua0-10.5 ms, respectively. The sufficient high D allows application of kinetic models that only consider water boundary-controlled uptake for converting silicone sampler uptake into an aqueous phase concentration using the presented K

Per capita loads of organic UV filters in Australian wastewater influent

Per capita loads of six UV filters were estimated in wastewater influent samples from 36 wastewater treatment plants in Australia collected over a weekend period during the 2016 Australian Census. Of the analysed samples, 99% contained at least one of the target compounds. Phenyl benzimidazole sulfonic acid (PBSA) was the most prevalent (99%), followed by benzophenone 4 (BP4) (97%), benzophenone 3 (BP3) (87%), benzophenone 1 (BP1) (84%), 4-methylbenzylidene camphor (4-MBC) (22%) and isoamyl 4-methoxycinnamate (IMC) (1.5%). The highest concentrations were 3780 and 5070 ng L-1 for PBSA and BP4, respectively. Total per capita UV filter loads in influent across all plants were calculated using population data from the Australian Census and ranged from 0.21 to 3.4 mg day(-1) person(-1). Notably, a relationship was found between latitude and total per capita daily mass load of UV filters with an increase in mass load from southern to northern catchments. Compared to international studies, mass loads were generally similar with higher loads of BP4 found in Australia. This study provides insight into the occurrence of UV filters in influent wastewater from across Australia and provides the first comprehensive nationwide baseline of UV filter loads. (C) 2019 Elsevier B.V. All rights reserved