German Water Infrastructure in China: Colonial Qingdao 1898–1914

Within the colorful tapestry of colonial possessions the German empire acquired over the short period of its existence, Qingdao stands out because it fulfilled a different role from settlements in Africa—especially because of its exemplary planned water infrastructure: its technological model, the resulting (public) hygiene, and the adjunct brewery. The National Naval Office (Reichsmarineamt), which oversaw the administration of the future “harbour colony”—at first little more than a little fishing village—enjoyed a remarkable degree of freedom in implementing this project. The German government invested heavily in showing off its techno-cultural achievements to China and the world and thereby massively exploited the natural resources of the mountainous interior. This contribution focuses on Qingdao’s water infrastructure and its role in public hygiene and further area development. This article will not only use new empirical evidence to demonstrate that the water infrastructure was an ambivalent “tool of empire”. Relying on the concept of “urban metabolism,” this paper primarily traces the ecological consequences, particularly the landscape transformation of the mountains surrounding the bay and the implications for the region’s water resources. When evaluating colonial enterprises, changes in local ecology should play a significantly greater role.     

The integrated management for renal replacement therapy in Portugal

Portugal was the first European country to introduce an integrated management of end‐stage renal disease (IM ESRD). This new program integrates various dialysis services and products, which are reimbursed at a fixed rate/patient/week called “comprehensive price payment.” This initiative restructured the delivery of dialysis services, the monitoring of outcomes, and the funding of renal replacement therapy. This article described the implementation of a new model of comprehensive provision of hemodialysis (HD) services and aimed to assess its impact on dialysis care. Quality assessments and reports of patient satisfaction, produced by the Ministry of Health since 2008, as well as national registries and reports, provided the data for this review. Indicators of HD services in all continental facilities show positive results that have successively improved along the period of 2009–2011, in spite of an average annual growth of 3% of the population under HD treatment. Mortality rates for HD patients were 12.7%, 12%, and 11%, respectively in 2009, 2010, and 2011; annual hospitalization rates were 4.9%, 3.8%, and 4.4% for the same years; key performance indicators showed averages above the reference values such as hemoglobin, serum phosphorus, eKt/V, water quality, number of days of hospitalization per patient per year, and number of weekly dialysis sessions. The financing analysis of IM ESRD demonstrates a sustained control of global costs, without compromising quality. The IM ERSD program is an innovative and quality‐driven approach that benefits both dialysis patients and providers, contributing toward the rationalization of service provision and the efficient use of resources.     

Using water wisely: New, affordable, and essential water conservation practices for facility and home hemodialysis

Despite a global focus on resource conservation, most hemodialysis (HD) services still wastefully or ignorantly discard reverse osmosis (R/O) "reject water" (RW) to the sewer. However, an R/O system is producing the highly purified water necessary for dialysis, it rejects any remaining dissolved salts from water already prefiltered through charcoal and sand filters in a high-volume effluent known as RW. Although the RW generated by most R/O systems lies well within globally accepted potable water criteria, it is legally "unacceptable" for drinking. Consequently, despite being extremely high-grade gray water, under current dialysis practices, it is thoughtlessly "lost-to-drain." Most current HD service designs neither specify nor routinely include RW-saving methodology, despite its simplicity and affordability. Since 2006, we have operated several locally designed, simple, cheap, and effective RW collection and distribution systems in our in-center, satellite, and home HD services. All our RW water is now recycled for gray-water use in our hospital, in the community, and at home, a practice that is widely appreciated by our local health service and our community and is an acknowledged lead example of scarce resource conservation. Reject water has sustained local sporting facilities and gardens previously threatened by indefinite closure under our regional endemic local drought conditions. As global water resources come under increasing pressure, we believe that a far more responsible attitude to RW recycling and conservation should be mandated for all new and existing HD services, regardless of country or region.     

Dialysis Disequilibrium Syndrome Revisited

An aggressive dialysis in a grossly azotemic patient, especially one with severe metabolic acidosis, can lead to dialysis disequilibrium syndrome (DDS). Mild forms present as nausea, vomiting, restlessness, and headache. Severe manifestations include seizures, obtundation, coma, and even death. This clinical picture is caused by cerebral edema induced by one or more of the following mechanisms:

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Ultrapture water: More than membrane technology alone

The world market for Ultrapure water is currently estimated at around US$ 2.3 billion per annum. Specialised journals dedicated to this subject are published within the water treatment world, where “everybody” uses the term ultrapure water. However, the time when it was enough to use a reverse osmosis (RO) system followed by ion exchange to produce ultrapure water seems like a long time ago, although in fact it is only about 20 years! Today, the demand for purity comes from the semiconductor industry, which sometimes requires purities that are beyond the detection limit of existing analytical equipment. To counter this, the approach towards the production of Ultrapure water has shifted from a series of unit operations to an integrated system design. In this article, Dr Tony Franken from the Membraan Applicatie Centrum Twente (MACT) in The Netherlands gives an insight into the production of ultrapure water.     

Physical function was related to mortality in patients with chronic kidney disease and dialysis

Previous studies have shown that exercise improves aerobic capacity, muscular functioning, cardiovascular function, walking capacity, and health‐related quality of life (QOL) in patients with chronic kidney disease (CKD) and dialysis. Recently, additional studies have shown that higher physical activity contributes to survival and decreased mortality as well as physical function and QOL in patients with CKD and dialysis. Herein, we review the evidence that physical function and physical activity play an important role in mortality for patients with CKD and dialysis. During November 2016, Medline and Web of Science databases were searched for published English medical reports (without a time limit) using the terms “CKD” or “dialysis” and “mortality” in conjunction with “exercise capacity,” “muscle strength,” “activities of daily living (ADL),” “physical activity,” and “exercise.” Numerous studies suggest that higher exercise capacity, muscle strength, ADL, and physical activity contribute to lower mortality in patients with CKD and dialysis. Physical function is associated with mortality in patients with CKD and dialysis. Increasing physical function may decrease the mortality rate of patients with CKD and dialysis. Physicians and medical staff should recognize the importance of physical function in CKD and dialysis. In addition, exercise is associated with reduced mortality among patients with CKD and dialysis.     

The perspectives of Aboriginal patients and their health care providers on improving the quality of hemodialysis services: A qualitative study

Chronic kidney disease has a higher prevalence in Indigenous populations globally. The incidence of end‐stage kidney disease in Australian Aboriginal people is eight times higher than non‐Aboriginal Australians. Providing services to rural and remote Aboriginal people with chronic disease is challenging because of access and cultural differences. This study aims to describe and analyze the perspectives of Aboriginal patients' and health care providers' experience of renal services, to inform service improvement for rural Aboriginal hemodialysis patients. We conducted a thematic analysis of interviews with Aboriginal patients (n = 18) receiving hemodialysis in rural Australia and health care providers involved in their care (n = 29). An overarching theme of avoiding the “costly” crisis encompassed four subthemes: (1) Engaging patients earlier (prevent late diagnosis, slow disease progression); (2) flexible family‐focused care (early engagement of family, flexibility to facilitate family and cultural obligations); (3) managing fear of mainstream services (originating in family dialysis experiences and previous racism when engaging with government organizations); (4) service provision shaped by culture (increased home dialysis, Aboriginal support and Aboriginal‐led cultural education). Patients and health care providers believe service redesign is required to meet the needs of Aboriginal hemodialysis patients. Participants identified early screening and improving the relationship of Aboriginal people with health systems would reduce crisis entry to hemodialysis. These strategies alongside improving the cultural competence of staff would reduce patients' fear of mainstream services, decrease the current emotional and family costs of care, and increase efficiency of health expenditure on a challenging and increasingly unsustainable treatment system.     

SELECTIVE REMOVAL OF METALS FROM WASTEWATER USING AFFINITY DIALYSIS

ABSTRACT

In this paper, a new technique called “Affinity Dialysis” has been studied for removal of metal ions from solution using a membrane reactor. The basic technique requires a solution of macromolecular agents in water, which are capable of rapidly complexing metal ions. The macromolecular agent solution flows through the tube side of a hollow fiber dialysis membrane unit, with wastewater flowing through the shell side. Quantitative removal rates for metal ions can be achieved in a compact unit. The macromolecular agent can be regenerated by changing the pH of the solution. An experimental study and a detailed mathematical model for the affinity dialysis system are presented with examples using actual kinetic and permeation data.     

Scientific imaginaries and science diplomacy: The case of ocean exploitation

As technologies of ocean exploitation emerged during the late 1960s, science policy and diplomacy were formed in response to anticipated capabilities that did not match the realities of extracting deep‐sea minerals and of resource exploitation in the deep ocean at the time. Promoters of ocean exploitation in the late 1960s envisaged wonders such as rare mineral extraction and the stationing of divers in underwater habitats from which they would operate seabed machinery not connected to the turbulent surface waters. Their promises coincided with others' fears that nuclear weaponry would be placed on the seabed. Those who lacked the technological capability to extract minerals from the seabed also had concerns that other nations would exploit their resources. Scientific imaginaries caused uncertainty in the international community—especially in the “Global South.” The UN called the “Law of the Sea” conferences to mediate emerging geopolitical tensions caused by these imaginaries of exploitation of ocean resources. These conferences became a site where lawmakers projected futures rather than merely responding to past or present dilemmas. Diplomats' negotiations, with their basis in anticipation of the future uses of science and technology, reveal the role of scientific imaginaries within complex negotiations. Here, we see the impact of the distinction (or blurring) of the real and the imagined on the balance of relations between Global North and South increasing global imbalances of resources and power. This article's analysis of such scientific diplomacy provides a valuable example of the power of scientific imaginaries to have a global impact.     

Quality of water in hemodialysis centers in Baghdad,Iraq

Dialysis water quality is one of the important parameters all over the world because of its direct influence on the health of kidney patients. In Iraq, there are more than 20 dialysis centers; most of them contain identical units for the production of dialysis water. In this work, the quality of water used for dialysis in six dialysis centers located within Baghdad hospitals was evaluated. Samples of product water from each of the six dialysis centers were examined for total heterotrophic bacteria, endotoxin, and chemical contaminants. Endotoxin was measured on‐site using a portable instrument. Bacteriological and chemical examinations were done in the laboratory after collecting samples from each dialysis center. The results showed a fluctuation in the produced water quality that makes the produced water unaccepted when compared with international standards. Bacterial counts for 60% of the analyzed samples were above the action level (50 colony‐forming units[CFU]/mL), while five out of the six dialysis centers showed values higher than the maximum value (100 CFU/mL). Chemical analysis showed that the dialysis water quality suffers from elevated aluminum concentration for all dialysis centers. All hemodialysis centers need thorough monitoring and preventive maintenance to ensure good water quality. In addition, it is important to revise the design of the water treatment units according to the feed and product water quality.     

Barriers,biases, and beliefs about arteriovenous fistula placement in children: A survey of the International Pediatric Fistula First Initiative (IPFFI) within the Midwest Pediatric Nephrology Consortium (MWPNC)

There has been recent emphasis on increased arteriovenous fistula (AVF) use and decreased central venous catheter use in hemodialysis (HD) patients. The International Pediatric Fistula First Initiative was founded via collaborative effort with the Midwest Pediatric Nephrology Consortium to alert nephrologists, surgeons, and dialysis staff to consider fistulae as the best access in pediatric HD patients. A multidisciplinary educational DVD outlining expectations and strategies to increase AVF placement and usage in children was created. Participants were administered a survey previewing and postviewing to identify barriers to placement and usage of AVF in children. A total of 52 surveys were subdivided as either “dialysis staff” or “proceduralist” at five centers. Thirty‐three percent of respondents were unaware if their practice was following published guidelines. Sixty‐five percent of respondents stated they referred to a dedicated vascular access surgeon at their respective institutions. Methods used to monitor AVF function included physical exam, venous pressure monitoring, and ultrasound dilution. Vascular access was placed within 3 months in only 35% of patients. Interdisciplinary communication problems between surgeons, interventional radiologists, and nephrologists were identified as a major barrier. Lack of AVF usage was often due to maturation failure. Routine access rounds did not occur in any centers. Regarding monitoring, 74% of the respondents use physical exam, 26% use venous pressure monitoring, and 9% use ultrasound dilution. Ninety‐three percent of dialysis staff stated they would change practice patterns following the intervention; however, 12% of surgeons stated they would alter practice patterns. To our knowledge, this is the first report to identify barriers to placement of AVF in children from the perspectives of multidisciplinary team members including pediatric nephrologists, surgeons, interventional radiologists, and multidisciplinary dialysis staff.     

Fallacies of High‐Speed Hemodialysis

Chronic hemodialysis sessions, as developed in Seattle in the 1960s, were long procedures with minimal intra‐ and interdialytic symptoms. Financial and logistical pressures related to the overwhelming number of patients requiring hemodialysis created an incentive to shorten dialysis time to four, three, and even two hours per session in a thrice weekly schedule. This method spread rapidly, particularly in the United States, after the National Cooperative Dialysis Study suggested that time of dialysis is of minor importance as long as urea clearance multiplied by dialysis time and scaled to total body water (Kt/V_urea) equals 0.95–1.0. This number was later increased to 1.3, but the assumption remained unchanged that hemodialysis time is of minimal importance as long as it is compensated by increased urea clearance. Patients accepted short dialysis as a godsend, believing that it would not be detrimental to their well‐being and longevity. However, Kt/V_urea measures only removal of low molecular weight substances and does not consider removal of larger molecules. Besides, it does not correlate with the other important function of hemodialysis, namely ultrafiltration. Whereas patients with substantial residual renal function may tolerate short dialysis sessions, the patients with little or no urine output tolerate short dialyses poorly because the ultrafiltration rate at the same interdialytic weight gain is inversely proportional to dialysis time. Rapid ultrafiltration is associated with cramps, nausea, vomiting, headache, fatigue, hypotensive episodes during dialysis, and hangover after dialysis; patients remain fluid overloaded with subsequent poor blood pressure control, left ventricular hypertrophy, diastolic dysfunction, and high cardiovascular mortality. Short, high‐efficiency dialysis requires high blood flow, which increases demands on blood access. The classic wrist arteriovenous fistula, the access with the best longevity and lowest complication rates, provides “insufficient” blood flow and is replaced with an arteriovenous graft fistula or an intravenous catheter. Moreover, to achieve high blood flows, large diameter intravenous catheters are used; these fit veins “too tightly,” so predispose the patient to central‐vein thrombosis. Longer hemodialysis sessions (5–8 hrs, thrice weekly), as practiced in some centers, are associated with lower complication rates and better outcomes. Frequent dialyses (four or more sessions per week) provide better clinical results, but are associated with increased cost. It is my strong belief that a wide acceptance of longer, gentler dialysis sessions, even in a thrice weekly schedule, would improve overall hemodialysis results and decrease access complications, hospitalizations, and mortality, particularly in anuric patients.     

基于共生理论的社区“医康养护”共生服务系统设计研究

目的 改变老龄医疗资源零散化、碎片化的现状,使相关联的养老服务可以融合发展,形成一条连续的、多元一体化的、闭合循环的老龄医疗健康服务链。方法 基于共生理论,探讨医疗、康复、养生保健、照料护理服务之间的共生逻辑,并结合共生理论的三要素对其展开深入分析,促使各共生单元(服务供给主体)之间互补互助、互惠共生,最后在服务设计思维的驱动下依托“互联网+”技术整合构建共生服务系统。结论 共生理论的介入,打破了各服务供给主体之间的信息壁垒,使其朝着同一方向协同发展,可以最大限度地避免资源重叠所造成的浪费,实现“1+1＞2”的共生效益。同时,基于共生理论的社区“医康养护”服务共生系统的构建,为其他养老服务资源模块(衣、食、住、行等)的整合和嵌入带来了新的参考和发展方向。     

What Went Wrong with Home Hemodialysis in the United States and What Can Be Done Now?

In 1973, almost 40% of the more than 10 000 dialysis patients were treated by home hemodialysis. Today, with more than a quarter of a million dialysis patients in the United States, fewer than 2000 are on home hemodialysis. A number of factors have contributed to this change. First, many nephrologists and administrators who were developing new dialysis units had little or no practical experience with dialysis for chronic renal failure. Second, more elderly and diabetic patients were admitted to treatment. Home hemodialysis was more difficult for such patients, and often their helpers were themselves were elderly. Third, hemodialysis machines were difficult to learn and operate. Fourth, following publication of the results of the National Cooperative Dialysis Study, there developed the erroneous concept that a Kt/V equal to 1.0 was “adequate dialysis.” As bigger dialyzers became available, there was a widespread shortening of dialysis time. This decrease in time was embraced by for‐profit dialysis facilities and inadequately educated patients, and assembly‐line dialysis became generally accepted. Finally, continuous ambulatory peritoneal dialysis, with its simplicity and short training time, began to fill the need of many patients for home dialysis and independence, at least temporarily. Fortunately, the trend is now reversing. Two developments clearly have benefits for home hemodialysis. The first is an increasing interest in the use of more frequent dialysis. The second is the development of new equipment designed specifically for use by the patient, and requiring a minimum of effort on the patient's part.     

Wissenschaft, Medizin und Öffentlichkeit—Bemerkungen zu ihrem Wandel im 18. Jahrhundert

How did academic medicine come to dominate scientific and medical opinions in local public spheres far away from universities? This contribution—based mainly on material from Lübeck journals and printed books—deals with the transformation of the public sphere in eighteenth century. A closer look at publication strategies and carrers of physicians shows that the new forms of self-empowerment provided by the “Habermasian” public sphere could only prove successful because they ran together with traditional forms of representation such as titles and official posts. Local journals, books, instruments, and reputation could then provide “scientific capital” to be transformed into the “symbolic capital” of grades, titles and posts; which was in turn convertible into the “economic capital” of remunitions from patients or annual awards as town-, state- or court physicians. At the beginning of the nineteenth century professional organisation proved a still greater source of power than the individual strategies that had been developped before.     

医养结合型智慧居家养老服务平台设计

目的目前,我国已经正式迈入老龄化社会,老龄化问题也在很大程度上制约着我国的经济发展,因此,结合我国传统养老观念,推行居家养老模式来解决老龄化问题势在必行。方法为解决居家养老服务中医疗养老资源短缺的问题,以居家长者的需求为导向,医养结合的模式为基础,结合新兴的物联网技术和信息处理技术,构建医养结合型智慧居家养老服务平台。结论设计出了医养结合型居家养老服务平台的合作模式与服务模式,构建了医养结合型居家养老服务平台的层次结构、参与角色、服务流程、后台数据库及智能化功能。医养结合型智慧居家养老服务平台能够合理分配有限的医疗养老资源,将资源的使用效率发挥至最大化,使医疗养老资源与居家长者之间达到供需平衡,为居家长者提供高质量的居家养老服务。     

Safety analysis of intermittent hemodialysis in patients with continuous flow left ventricular assist devices

Dialysis centers adopt a cautious approach when it comes to performing intermittent hemodialysis (HD) on patients with continuous flow (CF) left ventricular assist devices (LVADs) because of the potential for volume flux‐related complications and absence of pulsatile blood pressure for monitoring. Many patients have to remain hospitalized because of the inability of the dialysis centers to accept them for outpatient dialysis. In this study, the effect of HD was observed in such patients. Between June 2009 and October 2012, 139 patients received LVADs, of which 10 patients (7%) required intermittent HD postoperatively. The mean age of the patients was 53 ± 14 years and 90% were men. A total of 281 dialysis sessions were administered amounting to 1025 hours of dialysis. The mean systolic blood pressure monitored with Doppler device was 97 ± 18 mmHg. Dialysis durations averaged 218 ± 18 minutes. Mean blood flow rate was 334 ± 38 cc/min, and 2.6 ± 1.1 L was ultrafiltrated during each session. Only 15 (5.3%) sessions were interrupted or terminated in six patients. The reasons for termination were symptomatic hypotension—6 (2.1%), asymptomatic hypotension—3 (1%), ventricular tachycardia—1 (0.36%), dialysis machine malfunction—2 (0.7%), low phosphorus—2 (0.7%), and abdominal cramps—1 (0.36%). Volume expansion was necessary on three occasions. Low‐flow device alarms were registered during two (0.71%) sessions. The results showed no serious adverse effects or deaths.     

Tailoring dialysis and resuming low‐protein diets may favor chronic dialysis discontinuation: Report on three cases

Renal function recovery (RFR), defined as the discontinuation of dialysis after 3 months of replacement therapy, is reported in about 1% of chronic dialysis patients. The role of personalized, intensive dialysis schedules and of resuming low‐protein diets has not been studied to date. This report describes three patients with RFR who were recently treated at a new dialysis unit set up to offer intensive hemodialysis. All three patients were females, aged 73, 75, and 78 years. Kidney disease included vascular‐cholesterol emboli, diabetic nephropathy and vascular and dysmetabolic disease. At time of RFR, the patients had been dialysis‐dependent from 3 months to 1 year. Dialysis was started with different schedules and was progressively discontinued with a “decremental” policy, progressively decreasing number and duration of the sessions. A moderately restricted low‐protein diet (proteins 0.6 g/kg/day) was started immediately after dialysis discontinuation. The most recent update showed that two patients are well off dialysis for 5 and 6 months; the diabetic patient died (sudden death) 3 months after dialysis discontinuation. Within the limits of small numbers, our case series may suggest a role for personalized dialysis treatments and for including low‐protein diets in the therapy, in enhancing long‐term RFR in elderly dialysis patients.     

Managing complexity: A competitive imperative

As America moves further away from a “smokestack” industrial base, it is becoming increasingly dependent upon high-technology products and services to carry it economically in the world marketplace. This dependency directly couples US competitiveness in the world market with the country's ability to manage complexity. Especially relevant is the “complexity barrier” currently faced by the computer industry. The nature of complexity is examined in the context of the hurdles faced by the micro-electronics field in constructing ever more sophisticated and higher performing products. The “pathological” effects of complexity on product development are explored through a general model. With this discussion as a basis, recommendations are made for enhancements to engineering and science curricula to provide the next generation of product developers with skills relevant to managing product development at the “complexity frontier.”     

Toward green dialysis: Focus on water savings

Hemodialysis is one of the most water and energy‐hungry medical procedures, and thus represents a clear opportunity where improvements should be made concerning the consumption and wastage of water. Three levels were investigated on which there are potential savings: the precise adjustment of water production according to specific needs, the reuse of reverse osmosis rejected water, and finally the huge volumes of post‐patient dialysate effluent. The “AURAL” (Association pour l′Utilisation du Rein Artificiel à Lyon), main unit in Lyon, was the site of investigation for this study, which cares for 173 chronic hemodialysis patients. Evaluation of the 3 levels described earlier was undertaken on this particular building, and on the water treatment currently used. Volumes of produced water can be improved by different hydraulic systems or by adjusting the pure water conductivity used for dialysis. Concerning the reject water, reuse for building sanitation became the focus of further attention. The technical feasibility, volume of saved water, and applicable work costs were considered. The results suggest that out of a possible 2834 m³/year of reject water, 1200 m³/year may be reused and return on investment recovered within 5.8 years. Finally, the reprocessing and feasibility of reuse of dialysate effluent were investigated. Initial calculations show that although technical solutions are available, such processing of the wastewater production is not profitable in the short term. Regarding the significant prior authorization and risk management analysis necessary for such a project, this avenue was pursued no further. From the perspective of a “green dialysis,” the reuse of reject water into sanitation is both viable and profitable in our unit, and must be the next step of our project. More widely, improvements can be made by defining a more precise range of pure water conductivity for dialysis and by applying reuse water project to new or to be renovated units.