Wastewater management decision-making: A literature review and synthesis.

Wastewater management decision-making is complicated because of: (1) a complex regulatory structure, (2) the wide variety of conflicting expectations by stakeholders external and internal to the responsible utility, and (2) constrains including regulatory requirements, available technologies and practices, and customer willingness to pay. This review synthesizes the results from over 200 papers published since 2000 and presents a decision-making structure and process which is (1) science and fact-based, (2) reflects sustainability, (3) clear and transparent, (4) inclusive, (5) produces an objective-oriented decision, (6) scalable, (7) repeatable, and (8) efficient. Tools supporting the decision-making process are reviewed, including Multi-Criteria Decision Analysis (MCDA), Data Envelopment Analysis (DEA), Analytic Hierarchy Process (AHP), process modeling, economic assessments, Life Cycle Assessment (LCA), and Social Life Cycle Assessment (SLCA). Ultimately it was determined that engagement of decision-makers and relevant stakeholders to assess their values and preferences, coupled with supporting data and analyses, is necessary to reach a decision that, critically, has the support needed for it to be implemented. The results demonstrate that an understanding of the components of the decision process, coupled with an orderly process, enables good wastewater management decision-making. PRACTITIONER POINTS: A decision-making structure and process leading to the selection of implementable solutions is presented. The process possesses the following attributes: (1) science and fact-based, (2) reflect sustainability, (3) clear and transparent, (4) inclusive, (5) produce an objective-oriented decision, (6) scalable, (7) repeatable, and (8) efficient An extensive summary and analysis of tools supporting the decision process are provided, including Multi-Criteria Decision Analysis (MCDA), Data Envelopment Analysis (DEA), Analytic Hierarchy Process (AHP), process modeling, economic assessments, Life Cycle Assessment (LCA), and Social Life Cycle Assessment (SLCA). The critical role of internal and external stakeholders and differentiating their involvement relative to decision-makers is emphasized.

Fate of perfluoroalkyl and polyfluoroalkyl substances (PFAS) through two full-scale wastewater sludge incinerators.

Perfluoroalkyl and polyfluoroalkyl substances (PFAS) are an emerging issue in wastewater treatment. High-temperature thermal processes, incineration being time-tested, offer the opportunity to destroy and change the composition of PFAS. The fate of PFAS has been documented through wastewater sludge incinerators, including a multiple hearth furnace (MHF) and a fluidized bed furnace (FBF). The dewatered wastewater sludge feedstock averaged 247- and 1280-µmol targeted PFAS per sample run in MHF and FBF feed, respectively. Stack emissions (reportable for all targeted PFAS from MHF only) averaged 5% of that value with shorter alkyl chain compounds comprising the majority of the targeted PFAS. Wet scrubber water streams accumulated nonpolar fluorinated organics from the furnace exhaust with an average of 0.740- and 0.114-mol F- per sample run, for the MHF and FBF, respectively. Simple alkane PFAS measured at the stack represented 0.5%-4.5% of the total estimated facility greenhouse gas emissions. PRACTITIONER POINTS: The MHF emitted six short chain PFAS from the stack, which were shorter alkyl chain compounds compared with sludge PFAS. The FBF did not consistently emit reportable PFAS from the stack, but contamination complicated the assessment. Five percent of the MHF sludge molar PFAS load was reported in the stack. MHF and FBF wet scrubber water streams accumulated nonpolar fluorinated organics from the furnace exhaust. Ultra-short volatile alkane PFAS measured at the stack represented 0.5%-4.5% of the estimated facility greenhouse gas emissions.

Evaluation of Vibration as an Extrinsic Variable in In Vivo Research.

Vibration is inherent in research animal facilities due to the mechanical systems and practices required for animal care and use. Ample evidence indicates that vibration can change behavior and physiology in multiple species, potentially altering the results of research studies. Although one cannot eliminate environmental vibration, its control is important in research animal environments to decrease the possibility of introducing a research variable due to vibration effects. To assess the potential for a vibration source to alter experimental results and variability, one must understand the principles of vibration, its likely sources, and control methods. The literature regarding the effects of vibration, as it applies in a practical sense, can be challenging to interpret because the vibration frequencies tested to date have often not been within or near the most sensitive ranges of the species being tested. Some previous studies have used unrealistic vibration magnitudes and provided insufficient detail to duplicate or build upon conclusions. Standardization is essential for research examining the effects of vibration on animals to validate knowledge of this extrinsic variable in animal research and identify ways to mitigate the variable in research facilities.

Cross-sectional analyses of online appointment booking and repeat prescription ordering user characteristics in general practices of England in the years 2018-2020.

OBJECTIVES: To explore the characteristics of the General Practice Patient Survey (GPPS) respondents using the different functionalities of the online services in the context of England's National Health Service General Practices. We hypothesised that respondents who are older, with lower socioeconomic status and non-white ethnicity would be less likely to use online services, while long-term conditions might increase their usage. DESIGN: Cross-sectional study using respondent-level data from the GPPS in England of the years 2018, 2019 and 2020. We assessed the association between online services use and respondent characteristics using two-level mixed-effects logistic regression. PARTICIPANTS: Survey respondents of the GPPS 2018-2020. PRIMARY OUTCOME MEASURES: Online appointment booking and online repeat prescription ordering. RESULTS: 1 807 049 survey respondents were included in this study. 15% (n=263 938) used online appointment booking in the previous 12 months, and 19% (n=339 449) had ordered a repeat prescription in the previous 12 months. Respondents with a long-term condition, on regular multiple medications, who have deafness or hearing loss and who are from the lowest deprivation quintile were more likely to have used online services. Male respondents (compared with females) and respondents with black and other ethnicity compared with white ethnicity were less likely to use online services. Respondents over 85 years old were less likely to use online appointment booking and online repeat prescription ordering compared with the younger age groups. CONCLUSIONS: Specific groups of respondents were more likely to use online services such as patients with long-term conditions or those with deafness or hearing loss. While online services could provide efficiency to patients and practices it is essential that alternatives continue to be provided to those that cannot use or choose not to use online services. Understanding the different patients' needs could inform solutions to increase the uptake and use of the services.

Targeting a free viral fraction enhances the early alert potential of wastewater surveillance for SARS-CoV-2: a methods comparison spanning the transition between delta and omicron variants in a large urban center.

Introduction: Wastewater surveillance has proven to be a valuable approach to monitoring the spread of SARS-CoV-2, the virus that causes Coronavirus disease 2019 (COVID-19). Recognizing the benefits of wastewater surveillance as a tool to support public health in tracking SARS-CoV-2 and other respiratory pathogens, numerous wastewater virus sampling and concentration methods have been tested for appropriate applications as well as their significance for actionability by public health practices. Methods: Here, we present a 34-week long wastewater surveillance study that covers nearly 4 million residents of the Detroit (MI, United States) metropolitan area. Three primary concentration methods were compared with respect to recovery of SARS-CoV-2 from wastewater: Virus Adsorption-Elution (VIRADEL), polyethylene glycol precipitation (PEG), and polysulfone (PES) filtration. Wastewater viral concentrations were normalized using various parameters (flow rate, population, total suspended solids) to account for variations in flow. Three analytical approaches were implemented to compare wastewater viral concentrations across the three primary concentration methods to COVID-19 clinical data for both normalized and non-normalized data: Pearson and Spearman correlations, Dynamic Time Warping (DTW), and Time Lagged Cross Correlation (TLCC) and peak synchrony. Results: It was found that VIRADEL, which captures free and suspended virus from supernatant wastewater, was a leading indicator of COVID-19 cases within the region, whereas PEG and PES filtration, which target particle-associated virus, each lagged behind the early alert potential of VIRADEL. PEG and PES methods may potentially capture previously shed and accumulated SARS-CoV-2 resuspended from sediments in the interceptors. Discussion: These results indicate that the VIRADEL method can be used to enhance the early-warning potential of wastewater surveillance applications although drawbacks include the need to process large volumes of wastewater to concentrate sufficiently free and suspended virus for detection. While lagging the VIRADEL method for early-alert potential, both PEG and PES filtration can be used for routine COVID-19 wastewater monitoring since they allow a large number of samples to be processed concurrently while being more cost-effective and with rapid turn-around yielding results same day as collection.

Wastewater surveillance beyond COVID-19: a ranking system for communicable disease testing in the tri-county Detroit area, Michigan, USA.

Introduction: Throughout the coronavirus disease 2019 (COVID-19) pandemic, wastewater surveillance has been utilized to monitor the disease in the United States through routine national, statewide, and regional monitoring projects. A significant canon of evidence was produced showing that wastewater surveillance is a credible and effective tool for disease monitoring. Hence, the application of wastewater surveillance can extend beyond monitoring SARS-CoV-2 to encompass a diverse range of emerging diseases. This article proposed a ranking system for prioritizing reportable communicable diseases (CDs) in the Tri-County Detroit Area (TCDA), Michigan, for future wastewater surveillance applications at the Great Lakes Water Authority's Water Reclamation Plant (GLWA's WRP). Methods: The comprehensive CD wastewater surveillance ranking system (CDWSRank) was developed based on 6 binary and 6 quantitative parameters. The final ranking scores of CDs were computed by summing the multiplication products of weighting factors for each parameter, and then were sorted based on decreasing priority. Disease incidence data from 2014 to 2021 were collected for the TCDA. Disease incidence trends in the TCDA were endowed with higher weights, prioritizing the TCDA over the state of Michigan. Results: Disparities in incidences of CDs were identified between the TCDA and state of Michigan, indicating epidemiological differences. Among 96 ranked CDs, some top ranked CDs did not present relatively high incidences but were prioritized, suggesting that such CDs require significant attention by wastewater surveillance practitioners, despite their relatively low incidences in the geographic area of interest. Appropriate wastewater sample concentration methods are summarized for the application of wastewater surveillance as per viral, bacterial, parasitic, and fungal pathogens. Discussion: The CDWSRank system is one of the first of its kind to provide an empirical approach to prioritize CDs for wastewater surveillance, specifically in geographies served by centralized wastewater collection in the area of interest. The CDWSRank system provides a methodological tool and critical information that can help public health officials and policymakers allocate resources. It can be used to prioritize disease surveillance efforts and ensure that public health interventions are targeted at the most potentially urgent threats. The CDWSRank system can be easily adopted to geographical locations beyond the TCDA.

Diagnosing and characterizing the mechanisms of biological phosphorus removal at the Great Lakes Water Authority (GLWA) water resource recovery facility (WRRF).

Previous research has demonstrated that biological phosphorus removal (bio-P) occurs in the Great Lakes Water Authority (GLWA) water resource recovery facility (WRRF) high purity oxygen activated sludge (HPO-AS) process, suggesting that sludge fermentation in the secondary clarifier sludge blanket is key to bio-P occurrence. This study, combining batch reactor testing, the development of a process model for the HPO-AS process using Sumo21 (Dynamita), and the analysis of eight and a half years of plant operating data, showed that bio-P consistently occurs at the GLWA WRRF. This occurrence is attributed to the unique configuration of the HPO-AS process, which has a relatively large secondary clarifier compared to the bioreactor, and the characteristics of the influent wastewater, primarily particulate matter with limited concentrations of dissolved biodegradable organic matter. The volatile fatty acids (VFAs) needed for polyphosphate accumulating organisms (PAOs) growth are produced in the secondary clarifier sludge blanket, which provides more than four times the anaerobic biomass inventory compared to the anaerobic zones in the bioreactor, thus facilitating bio-P in the current system. Opportunities exist to further optimize the phosphorus removal performance of the HPO-AS process and reduce the amount of ferric chloride used. These findings may be of interest to researchers investigating biological phosphorus removal in similar systems. PRACTITIONER POINTS: Fermentation in the clarifier sludge blanket an essential component of bio-P process at this facility. Results suggest simple adjustments to the system could lead to further improvements in bio-P. It is possible to decrease the use of chemical phosphorus removal methods (i.e., ferric chloride) while simultaneously increasing bio-P. Determining the phosphorus mass balance from sludge streams provides insight into evaluating the effectiveness of the phosphorus recovery system.

Improving Multidisciplinary Team Working to Support Integrated Care for People with Frailty Amidst the COVID-19 Pandemic.

Multidisciplinary team (MDT) working is essential to optimise and integrate services for people who are frail. MDTs require collaboration. Many health and social care professionals have not received formal training in collaborative working. This study investigated MDT training designed to help participants deliver integrated care for frail individuals during the Covid-19 pandemic. Researchers utilised a semi-structured analytical framework to support observations of the training sessions and analyse the results of two surveys designed to assess the training process and its impact on participants knowledge and skills. 115 participants from 5 Primary Care Networks in London attended the training. Trainers utilised a video of a patient pathway, encouraged discussion of it, and demonstrated the use of evidence-based tools for patient needs assessment and care planning. Participants were encouraged to critique the patient pathway, reflect on their own experiences of planning and providing patient care. 38% of participants completed a pre-training survey, 47% a post-training survey. Significant improvement in knowledge and skills were reported including understanding roles in contributing to MDT working, confidence to speak in MDT meetings, using a range of evidence-based clinical tools for comprehensive assessment and care planning. Greater levels of autonomy, resilience, and support for MDT working were reported. Training proved effective; it could be scaled up and adopted to other settings.

Simple methods for early warnings of COVID-19 surges: Lessons learned from 21 months of wastewater and clinical data collection in Detroit, Michigan, United States.

Wastewater-based epidemiology (WBE) has drawn great attention since the Coronavirus disease 2019 (COVID-19) pandemic, not only due to its capability to circumvent the limitations of traditional clinical surveillance, but also due to its potential to forewarn fluctuations of disease incidences in communities. One critical application of WBE is to provide "early warnings" for upcoming fluctuations of disease incidences in communities which traditional clinical testing is incapable to achieve. While intricate models have been developed to determine early warnings based on wastewater surveillance data, there is an exigent need for straightforward, rapid, broadly applicable methods for health departments and partner agencies to implement. Our purpose in this study is to develop and evaluate such early-warning methods and clinical-case peak-detection methods based on WBE data to mount an informed public health response. Throughout an extended wastewater surveillance period across Detroit, MI metropolitan area (the entire study period is from September 2020 to May 2022) we designed eight early-warning methods (three real-time and five post-factum). Additionally, we designed three peak-detection methods based on clinical epidemiological data. We demonstrated the utility of these methods for providing early warnings for COVID-19 incidences, with their counterpart accuracies evaluated by hit rates. "Hit rates" were defined as the number of early warning dates (using wastewater surveillance data) that captured defined peaks (using clinical epidemiological data) divided by the total number of early warning dates. Hit rates demonstrated that the accuracy of both real-time and post-factum methods could reach 100 %. Furthermore, the results indicate that the accuracy was influenced by approaches to defining peaks of disease incidence. The proposed methods herein can assist health departments capitalizing on WBE data to assess trends and implement quick public health responses to future epidemics. Besides, this study elucidated critical factors affecting early warnings based on WBE amid the COVID-19 pandemic.

Surveillance of SARS-CoV-2 in nine neighborhood sewersheds in Detroit Tri-County area, United States: Assessing per capita SARS-CoV-2 estimations and COVID-19 incidence.

Wastewater-based epidemiology (WBE) has been suggested as a useful tool to predict the emergence and investigate the extent of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In this study, we screened appropriate population biomarkers for wastewater SARS-CoV-2 normalization and compared the normalized SARS-CoV-2 values across locations with different demographic characteristics in southeastern Michigan. Wastewater samples were collected between December 2020 and October 2021 from nine neighborhood sewersheds in the Detroit Tri-County area. Using reverse transcriptase droplet digital polymerase chain reaction (RT-ddPCR), concentrations of N1 and N2 genes in the studied sites were quantified, with N1 values ranging from 1.92 × 102 genomic copies/L to 6.87 × 103 gc/L and N2 values ranging from 1.91 × 102 gc/L to 6.45 × 103 gc/L. The strongest correlations were observed with between cumulative COVID-19 cases per capita (referred as COVID-19 incidences thereafter), and SARS-CoV-2 concentrations normalized by total Kjeldahl nitrogen (TKN), creatinine, 5-hydroxyindoleacetic acid (5-HIAA) and xanthine when correlating the per capita SARS-CoV-2 and COVID-19 incidences. When SARS-CoV-2 concentrations in wastewater were normalized and compared with COVID-19 incidences, the differences between neighborhoods of varying demographics were reduced as compared to differences observed when comparing non-normalized SARS-CoV-2 with COVID-19 cases. This indicates when studying the disease burden in communities of different demographics, accurate per capita estimation is of great importance. The study suggests that monitoring selected water quality parameters or biomarkers, along with RNA concentrations in wastewater, will allow adequate data normalization for spatial comparisons, especially in areas where detailed sanitary sewage flows and contributing populations in the catchment areas are not available. This opens the possibility of using WBE to assess community infections in rural areas or the developing world where the contributing population of a sample could be unknown.

Lotteries, bookmaking and ancient randomizers: Local and global analyses of chance.

A local analysis of a chance system recovers the properties of the totality by accumulating the chance properties of its components. A global analysis considers only the properties of the chance system taken as a whole. It can sometimes provide an easier demonstration of the fitness for purpose of chance systems. Such is the case for the operators of lotteries and for bookmakers at a racetrack. Physical randomizers akin to dice were used extensively in antiquity for gambling, drawing lots and in divination. There is no ancient account of the fitness of these randomizers for these purposes and no ancient theory of the individual chances of outcomes. A global analysis can establish their fitness for purpose. If the rules of gambling and lot drawing are such that everyone has an equal opportunity, they are fair, independently of the individual, local chances. The randomizers are fit for the purposes of divination in so far as it is believed that the oracle has no control on the outcomes of the randomizers. In asking why some earlier culture did not discover probability theory, we presume incorrectly an inevitability to probability theory. The better question is why any culture found the theory at all.

Five-week warning of COVID-19 peaks prior to the Omicron surge in Detroit, Michigan using wastewater surveillance.

Wastewater-based epidemiology (WBE) is useful in predicting temporal fluctuations of COVID-19 incidence in communities and providing early warnings of pending outbreaks. To investigate the relationship between SARS-CoV-2 concentrations in wastewater and COVID-19 incidence in communities, a 12-month study between September 1, 2020, and August 31, 2021, prior to the Omicron surge, was conducted. 407 untreated wastewater samples were collected from the Great Lakes Water Authority (GLWA) in southeastern Michigan. N1 and N2 genes of SARS-CoV-2 were quantified using RT-ddPCR. Daily confirmed COVID-19 cases for the City of Detroit, and Wayne, Macomb, Oakland counties between September 1, 2020, and October 4, 2021, were collected from a public data source. The total concentrations of N1 and N2 genes ranged from 714.85 to 7145.98 gc/L and 820.47 to 6219.05 gc/L, respectively, which were strongly correlated with the 7-day moving average of total daily COVID-19 cases in the associated areas, after 5 weeks of the viral measurement. The results indicate a potential 5-week lag time of wastewater surveillance preceding COVID-19 incidence for the Detroit metropolitan area. Four statistical models were established to analyze the relationship between SARS-CoV-2 concentrations in wastewater and COVID-19 incidence in the study areas. Under a 5-week lag time scenario with both N1 and N2 genes, the autoregression model with seasonal patterns and vector autoregression model were more effective in predicting COVID-19 cases during the study period. To investigate the impact of flow parameters on the correlation, the original N1 and N2 gene concentrations were normalized by wastewater flow parameters. The statistical results indicated the optimum models were consistent for both normalized and non-normalized data. In addition, we discussed parameters that explain the observed lag time. Furthermore, we evaluated the impact of the omicron surge that followed, and the impact of different sampling methods on the estimation of lag time.

Discovery and Optimization of Pyrrolopyrimidine Derivatives as Selective Disruptors of the Perinucleolar Compartment, a Marker of Tumor Progression toward Metastasis.

The perinucleolar compartment (PNC) is a dynamic subnuclear body found at the periphery of the nucleolus. The PNC is enriched with RNA transcripts and RNA-binding proteins, reflecting different states of genome organization. PNC prevalence positively correlates with cancer progression and metastatic capacity, making it a useful marker for metastatic cancer progression. A high-throughput, high-content assay was developed to identify novel small molecules that selectively reduce PNC prevalence in cancer cells. We identified and further optimized a pyrrolopyrimidine series able to reduce PNC prevalence in PC3M cancer cells at submicromolar concentrations without affecting cell viability. Structure-activity relationship exploration of the structural elements necessary for activity resulted in the discovery of several potent compounds. Analysis of in vitro drug-like properties led to the discovery of the bioavailable analogue, metarrestin, which has shown potent antimetastatic activity with improved survival in rodent models and is currently being evaluated in a first-in-human phase 1 clinical trial.

High-temperature technology survey and comparison among incineration, pyrolysis, and gasification systems for water resource recovery facilities.

Solids from wastewater treatment undergo processing to reduce mass, minimize pathogens, and condition the products for specific end uses. However, costs and contaminant concerns (e.g., per- and polyfluoroalkyl substances [PFAS]) challenge traditional landfill and land application practices. Incineration can overcome these issues but has become complicated due to evolving emissions regulations, and it suffers from poor public perception. These circumstances are driving the re-emergence of pyrolysis and gasification technologies. A survey of suppliers was conducted to document differences with technologies. Both offer advantages over incineration with tailored production of a carbon-rich solid, currently less stringent air emission requirements, and lower flue gas flows requiring treatment. However, incineration more simply combines drying and thermal processing into one reactor. Equipment costs provided favor pyrolysis and gasification at lower capacities but converge with incineration at higher capacities. Long-term operational experience will confirm technology competitiveness and elucidate whether pyrolysis and gasification warrant widespread adoption. PRACTITIONER POINTS: Pyrolysis and gasification systems are gaining traction in the wastewater industry with several full-scale installations operating, in construction, or design Several advantages, but some disadvantages, are considered in comparison with incineration Organic contaminants, including PFAS, will undergo transformation and potentially complete mineralization through each process.

Pyrolysis and gasification at water resource recovery facilities: Status of the industry.

Wastewater treatment generates solids requiring subsequent processing. Costs and contaminant concerns (e.g., per- and polyfluoroalkyl substances [PFAS]) are challenging widely used landfilling and land application practices. These circumstances are partly driving the re-emergence of pyrolysis and gasification technologies along with beneficial reuse prospects of the char solid residual. Previously, technologies experienced operational challenges leading to revised configurations, such as directly coupling a thermal oxidizer to the reactor to destroy tar forming compounds. This paper provides an overview of pyrolysis and gasification technologies, characteristics of the char product, air emission considerations, and potential fate of PFAS and other pollutants through the systems. Results from a survey of viable suppliers illustrate differences in commercially available options. Additional research is required to validate performance over the long-term operation and confirm contaminant fate, which will help determine whether resurging interest in pyrolysis and gasification warrants widespread adoption. PRACTITIONER POINTS: Pyrolysis and gasification systems are re-emerging in the wastewater industry. Direct coupling of thermal oxidizers and other modifications offered by contemporary systems aim to overcome past failures. Process conditions when coupled with a thermal oxidizer will likely destroy most organic contaminants, including PFAS, but requires additional research. Three full-scale facilities recently operated, several in construction or design that will provide operating experience for widespread technology adoption consideration.

Imaging for the Initial Staging and Post-Treatment Surveillance of Penile Squamous Cell Carcinoma.

Although relatively rare in the United States, penile squamous cell carcinoma is encountered worldwide at a higher rate. Initial diagnosis is often made on clinical exam, as almost all of these lesions are externally visible and amenable to biopsy. In distinction to other types of malignancies, penile cancer relies heavily on clinical nodal staging of the inguinal lymph node chains. As with all cancers, imaging plays a role in the initial staging, restaging, and surveillance of these patients. The aim of this manuscript is to highlight the applications, advantages, and limitations of different imaging modalities in the evaluation of penile cancer, including ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography.

Medicines management at home during the COVID-19 pandemic: a qualitative study exploring the UK patient/carer perspective.

OBJECTIVES: To explore home medicine practices and safety for people shielding and/or over the age of 70 during the COVID-19 pandemic and to create guidance, from the patient/carer perspective, for enabling safe medicine practices for this population. METHODS: Semi-structured interviews were carried out with 50 UK participants who were shielding and/or over the age of 70 and who used medicines for a long-term condition, using telephone or video conferencing. Participants were recruited through personal/professional networks and through patient/carer organisations. Participants were asked about their experiences of managing medicines during the pandemic and how this differed from previous practices. Data were analysed using inductive thematic analysis. KEY FINDINGS: Patients' and their families' experiences of managing medicines safely during the pandemic varied greatly. Analysis suggests that this was based on the patient's own agency, the functioning of their medicines system pre-pandemic and their relationships with family, friends, community networks and pharmacy staff. Medicine safety issues reported included omitted doses and less-effective formulations being used. Participants also described experiencing high levels of anxiety related to obtaining medicines, monitoring medicines and feeling at risk of contracting COVID-19 while accessing healthcare services for medicine-related issues. Effects of the pandemic on medicines adherence were reported to be positive by some and negative by others. CONCLUSIONS: Pharmacy staff have a key role to play by establishing good relationships with patients and their families, working with prescribers to ensure medicines systems are as joined up as possible, and signposting to community networks that can help with medicines collection.

Depression and Somatic Symptoms in a Non-Western Physician.

Because of the high prevalence and association of somatic symptoms in depression, a holistic treatment plan that also targets the associated somatic symptoms can be the cornerstone for such patients. In this paper, we present the case of a 53-year-old male physician with depression associated with the somatic symptoms of dysphagia. The initial failure in treating his swallowing defect led to the deterioration in his condition. Moreover, his unique history, complicated by multifactorial life stressors, also raises the attention that there are a variety of presentations of depression.