Voices from the field: exploring service providers' insights into service delivery and AAC use in Canada.

Use of augmentative and alternative communication (AAC) often relies on the involvement of AAC service providers; however little is known about how AAC services are delivered across Canada. This study aimed to explore AAC service provision and factors influencing use of AAC from the perspectives of service providers across Canada who are involved in providing and/or supporting use of AAC systems. The 22 participants from nine (of the 10) provinces participated in online focus groups. Participants were speech-language pathologists, occupational therapists, communicative disorders assistants, and a teacher. Transcripts of the audio recordings were analyzed using reflexive thematic analysis. Four themes were generated that reflect service-related factors contributing to the use of AAC in Canada: Support of Organizational Structures, Concordant Relationships and Goals, Making the Right Decisions, and Influence of Knowledge and Attitudes. These themes highlight how government systems, key stakeholders, assessment practices, and knowledge of AAC influence service provision and use of AAC. Voices from across Canada highlighted shared experiences of services providers as well as revealed variability in service delivery processes. The findings bring to attention a need for further research and development of service provision guidelines to support consistency, quality in practice, and equity in AAC services.

Barriers and facilitators to accommodations in the workplace for adults who use augmentative and alternative communication (AAC): a systematic review.

Workplace accommodations can reduce barriers to employment for people who use augmentative and alternative communication (AAC), however, the lack of accommodations continues to challenge participation in employment. This systematic review identified and analyzed barriers and facilitators to implementing workplace accommodations for adults (19 years and over) who use AAC. A systematic search of nine databases was conducted to identify relevant studies using the search terms "AAC" and "workplace accommodations" and variations of each term. Results were imported into Covidence. Seventeen studies met the inclusion criteria. Results were presented using the International Classification of Functioning, Disability, and Health (ICF) framework. The Oxford levels of evidence and Confidence in Evidence from Review of Qualitative Research (GRADE-CERQual) were used to assess the quality of the studies and confidence in findings, respectively. Environmental barriers related mainly to attitudes and technology, and personal barriers related to job qualifications, education, and work-related skills. A combination of facilitators such as personal strengths, access to technology, and supportive relationships contributed to successful implementation of accommodations. The findings of this review suggest that implementing workplace accommodations for adults who use AAC strategies is complex and further research is needed to advance practices and policies that support the implementation of workplace accommodations.

Modified reperfusion and ischemia-reperfusion injury in human lung transplantation.

OBJECTIVE: Ischemia-reperfusion injury remains a major cause of mortality and morbidity in clinical lung transplantation. Interaction of activated leukocytes with injured graft endothelial cells participates in the development of ischemia-reperfusion injury. We sought to determine if modification of the reperfusate (with depletion of leukocytes and alteration of its composition) would decrease the incidence of ischemia-reperfusion injury in human lung transplantation when compared with whole blood reperfusion in a historical group of patients. METHODS: Between June 1999 and July 2001, 23 adult patients undergoing lung transplantation consented to modified reperfusion. After implantation, a catheter was inserted into the main or individual pulmonary arteries, and modified reperfusate was administered at a pressure less than 20 mm Hg. The modified reperfusate was depleted of leukocytes, supplemented with nitroglycerin, adjusted for pH and calcium level, and enriched with aspartate, glutamate, and dextrose. After 10 minutes of modified reperfusion, the removal of pulmonary artery clamp or weaning of cardiopulmonary bypass was performed per usual protocol. Age- and diagnosis-matched historical patients served as the control group. Ischemia-reperfusion injury was defined as Pao(2)/Fio(2) < 150 with diffuse infiltrate on the radiograph in absence of other causes. RESULTS: There was no difference in donor age or oxygenation indices, recipient age, the number of patients requiring cardiopulmonary bypass, ischemia time, and recipient oxygenation indices between the modified reperfusate group and the control group. However, none of the patients in the modified reperfusate group developed ischemia-reperfusion injury in contrast to 5 patients in the control group (P <.05). The early survival in the modified reperfusate group was 96% versus 81% in the control group (P = NS). CONCLUSION: This study suggests that modification of the reperfusate content decreases the incidence of ischemia-reperfusion injury in human lung transplantation when compared with whole blood reperfusion in a historical group of patients. Modified reperfusate may allow acceptance of marginal lungs and expansion of the donor pool.

Liberalization of donor criteria in lung transplantation.

Donor shortage remains a major obstacle to widespread application of lung transplantation. In region 5, including California, Nevada, New Mexico, Utah, and Arizona, the United Network of Organ Sharing (UNOS) database median waiting time for lung transplant candidates in 2000-2001 exceeded 17 months. The purpose of this study was to determine the impact of liberalization of donor criteria on median waiting time and short-term outcome of lung transplantation. From September 1999 to October 2002, 42 patients underwent lung transplantation from nonstandard donors. The donors were classified as nonstandard due to (1) infiltrate on chest radiograph (n = 33), (2) PaO2 < 300 on FiO2 1.0 and PEEP 5 (n = 3), (3) PaO2 < 100 on FiO2 0.4 and PEEP 5 (n = 3), (4) purulent sputum on bronchoscopy (n = 22), and (5) smoking history greater than 50 pack-years (n = 1). Perioperative characteristics and short-term outcome of this group was analyzed. The median waiting time for this cohort was 114 days (range, 10-1267), as compared with the national UNOS database median waiting time of 24 months between 1996 and 2001. The incidence of ischemia reperfusion injury was 2.3 per cent. None of the recipients developed pneumonia. The median ventilator support time was 2 days (range, 1-95). The median ICU stay and hospital stay were 4 days (range, 2-103) and 14 days (range, 5-194), respectively. The 3-month survival was 97.6 per cent. Selective liberalization of donor lung criteria can decrease the waiting time and is associated with favorable short-term outcome. Utilization of nonstandard lungs can expand the donor pool.