Adaptation of a risk-based framework for evaluating indirect effects of dredging on sensitive habitats near federal navigation channels: An application of the framework to coral reefs at Honolulu Harbor, Hawai'i.

In major harbors and ports in the United States and its territories, the US Army Corps of Engineers maintains federal navigation channels in proximity to coral reefs (e.g., Honolulu Harbor, HI; Miami Harbor, FL; Apra Harbor, Guam) and other sensitive habitats. To effectively predict potential adverse impacts from dredging activities near these sensitive habitats, a holistic approach to improve understanding of the pressures on these habitats is needed to foster a more complete prediction of risk drivers. To achieve this, risk-based frameworks that account for the full range of natural and anthropogenic impacts need to be adapted and applied specifically for assessing and managing indirect dredging impacts on sensitive environments. In this article, we address this need by incorporating a drivers-pressures-stressors-condition-response (DPSCR4 ) conceptual framework to broaden a comprehensive conceptual model of the coupled human-ecological system. To help understand these complex interactions, DPSCR4 was applied to evaluate dredging and other unrelated environmental pressures (e.g., terrestrial runoff) in a proof-of-concept dredging project in Honolulu Harbor, Hawai'i, USA, with a focus on the indirect effects of dredge plumes. Particle tracking models and risk-based tools were used to evaluate sediment resuspended during a hypothetical mechanical dredging activity near sensitive coral habitats. Stoplight indicators were developed to predict indirect sediment plume impacts on coral and then compared to exposure modeling results. The strengths and limitations of the approach are presented and the incorporation of the risk framework into environmental management decisions is discussed. Integr Environ Assess Manag 2024;20:547-561. Published 2023. This article is a U.S. Government work and is in the public domain in the USA.

Assessing the barriers and enablers to the implementation of the diagnostic radiographer musculoskeletal X-ray reporting service within the NHS in England: a systematic literature review.

INTRODUCTION: The United Kingdom (UK) government's healthcare policy in the early 1990s paved the way adoption of the skills mix development and implementation of diagnostic radiographers' X-ray reporting service. Current clinical practice within the public UK healthcare system reflects the same pressures of increased demand in patient imaging and limited capacity of the reporting workforce (radiographers and radiologists) as in the 1990s. This study aimed to identify, define and assess the longitudinal macro, meso, and micro barriers and enablers to the implementation of the diagnostic radiographer musculoskeletal X-ray reporting service in the National Healthcare System (NHS) in England. METHODS: Multiple independent databases were searched, including PubMed, Ovid MEDLINE; Embase; CINAHL, and Google Scholar, as well as journal databases (Scopus, Wiley), healthcare databases (NHS Evidence Database; Cochrane Library) and grey literature databases (OpenGrey, GreyNet International, and the British Library EthOS depository) and recorded in a PRISMA flow chart. A combination of keywords, Boolean logic, truncation, parentheses and wildcards with inclusion/exclusion criteria and a time frame of 1995-2022 was applied. The literature was assessed against Joanna Briggs Institute's critical appraisal checklists. With meta-aggregation to synthesize each paper, and coded using NVivo, with context grouped into macro, meso, and micro-level sources and categorised into subgroups of enablers and barriers. RESULTS: The wide and diverse range of data (n = 241 papers) identified barriers and enablers of implementation, which were categorised into measures of macro, meso, and micro levels, and thematic categories of context, culture, environment, and leadership. CONCLUSION: The literature since 1995 has reframed the debates on implementation of the radiographer reporting role and has been instrumental in shaping clinical practice. There has been clear influence upon both meso (professional body) and macro-level (governmental/health service) policies and guidance, that have shaped change at micro-level NHS Trust organisations. There is evidence of a shift in culturally intrenched legacy perspectives within and between different meso-level professional bodies around skills mix acceptance and role boundaries. This has helped shape capacity building of the reporting workforce. All of which have contributed to conceptual understandings of the skills mix workforce within modern radiology services.

The Role of Dental Practitioners in the Management of Oncology Patients: The Head and Neck Radiation Oncology Patient and the Medical Oncology Patient.

This narrative review addresses the role of a dentist in the management of oncology patients, highlighting the oral complications that arise in head and neck radiation oncology patients and medical oncology patients. The prevention and management of these complications are discussed.

Patients' and clinicians' perspectives towards primary care consultations for shoulder pain: qualitative findings from the Prognostic and Diagnostic Assessment of the Shoulder (PANDA-S) programme.

BACKGROUND: Clinical management of musculoskeletal shoulder pain can be challenging due to diagnostic uncertainty, variable prognosis and limited evidence for long-term treatment benefits. The UK-based PANDA-S programme (Prognostic And Diagnostic Assessment of the Shoulder) is investigating short and long-term shoulder pain outcomes. This paper reports linked qualitative research exploring patients' and clinicians' views towards primary care consultations for shoulder pain. METHODS: Semi-structured interviews were conducted with 24 patients and 15 primary care clinicians. Twenty-two interviews (11 patients, 11 clinicians) were conducted as matched patient-clinician 'dyads'. Data were analysed thematically. RESULTS: Clinicians reported attempts to involve patients in management decisions; however, there was variation in whether patients preferred treatment choice, or for decisions to be clinician-led. Some patients felt uncertain about the decisions made, due to a lack of discussion about available management options. Many General Practitioners expressed a lack of confidence in diagnosing the underlying cause of shoulder pain. Patients reported either not being given a diagnosis, or receiving different diagnoses from different professionals, resulting in confusion. Whilst clinicians reported routinely discussing prognosis of shoulder pain, patients reported that prognosis was not raised. Patients also expressed concern that their shoulder pain could be caused by serious pathology; however, clinicians felt that this was not a common concern for patients. CONCLUSIONS: Findings showed disparities between patients' and clinicians' views towards shoulder pain consultations, indicating a need for improved patient-clinician communication. Findings will inform the design of an intervention to support treatment and referral decisions for shoulder pain that will be tested in a randomised controlled trial.

Engineering coastal structures to centrally embrace biodiversity.

Global environmental factors (e.g., extreme weather, climate action failure, natural disasters, human environmental damage) increasingly threaten coastal communities. Shorelines are often hardened (seawalls, bulkheads) to prevent flooding and erosion and protect coastal communities. However, hardened shorelines lead to environmental degradation and biodiversity loss. Developmental pressures that are growing in scale, scope, and complexity necessitate the development of sustainable solutions to work with, rather than against, nature. Such nature-based solutions (NBS) provide protection and improve environmental quality and enhance biodiversity. To further this pressing need into action, the US Army Corps of Engineers (USACE) began the Engineering With Nature (EWN) initiative to balance economic, environmental, and social benefits through collaboration with partners and stakeholders. This work shows how engineering practice can be advanced through structured decision-making and landscape architecture renderings that include ecological sciences and NBS into an integrated approach for enhancing biodiversity in coastal marine environments. This integrated approach can be applied when designing new infrastructure projects or modifying or repairing existing infrastructure. To help communicate designs incorporating NBS, drawings, and renderings showcasing EWN concepts can aid decision-making. Our experiences with implementing EWN in practice have revealed that involving landscape architects can play a crucial role in successful collaboration and lead to solutions that protect coastal communities while preserving or enhancing biodiversity.

Surgical management of intrathoracic wooden skewers migrating from the stomach and duodenum in dogs: 11 cases (2014-2020).

OBJECTIVES: To describe the clinical presentation, management and outcome of cases presenting with intrathoracic wooden skewers originating from the abdominal gastrointestinal tract. MATERIALS AND METHODS: Clinical records of dogs presented and treated for an intrathoracic wooden skewer were reviewed from June to August 2020. Data included signalment, clinical presentation, duration of clinical signs, haematological and biochemical abnormalities, diagnostic imaging findings, surgical procedure, postoperative complications and outcome. RESULTS: Eleven dogs were included in the study. In all cases, the foreign body was identified as a wooden skewer. The most common clinical signs were anorexia/hyporexia (n=7), vomiting/regurgitation (n=7), lethargy (n=6), pyrexia (n=4) and gait abnormalities/lameness (n=3). CT correctly identified a wooden skewer in all cases when performed (n=7). A coeliotomy combined with transdiaphragmatic thoracotomy was performed in six of 11 cases (55%), a coeliotomy combined with median sternotomy in four of 11 cases (36%) and a median sternotomy alone was performed in one case. Foreign bodies penetrated from the stomach (n=10) or the duodenum (n=1). Intrathoracic trauma was most commonly identified to the lungs (n=3) and pericardium (n=3). Complications occurred in three of 11 cases (27%), two minor and one resulting in death. Ten of the 11 cases (91%) survived to discharge. Long-term outcome was available for seven of 11 cases (66%), all of them excellent. CLINICAL SIGNIFICANCE: Despite the challenges of managing wooden skewers penetrating the thoracic cavity from the abdominal gastrointestinal tract, the majority of the patients are stable to undergo diagnostic procedures, surgical exploration and management with low morbidity and excellent short- and long-term prognosis.

Introduction to the Special Series, "Incorporating Nature-based Solutions into the Built Environment".

Incorporating nature-based solutions (NBSs) into the built environment supports the ongoing sustainability challenge as emphasized in the United Nations' Sustainable Development Goals (SDGs) and has particular relevance for SDG Goal #11 (Sustainable cities and communities), which seeks greater efficiencies in urban planning and management practices that address aging infrastructure and ongoing air, water, and soil pollution. The short communications and research articles in this special series exemplify many of these aspects, highlighting the application of NBSs and showcasing the latest environmental research and policy solutions to support this. Nature-based solutions in the built environment aim to promote the understanding of the transdisciplinary nature of NBSs and enhance the global awareness of the value of NBSs by providing a diversity of solutions to illustrate the positive economic, social, and environmental benefits of NBSs in the built environment. Integr Environ Assess Manag 2022;18:39-41. © 2021 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Nature-based solutions for improving navigation reliability on the Madeira River, Brazil.

The Madeira River Navigation and Improvement Project provides a unique opportunity to incorporate nature-based solutions (NbS) into the built environment to promote sustainable communities and water resources infrastructure. The Madeira River has no major physical interventions (river training structures, navigation locks and dams, etc.) to improve navigation, and so is one of the world's last remaining undeveloped megarivers that exhibits natural morphological processes. The objective of this study is to create a safe, reliable, and sustainable navigation channel in the Madeira River. This is being accomplished by designing navigation improvement measures that leverage natural geomorphic processes of the river while minimizing conventional engineering practices that alter the river's morphology. To meet this objective, fluvial geomorphology analysis and hydrodynamic modeling studies have been performed to improve understanding of the morphological behavior of the system. Measures that incorporate beneficial reuse of dredged sediment within the system are being prioritized and incorporated into the study's design. Natural processes are being leveraged through the implementation of an adaptive management process to shape the navigation channel by incorporating the use of dynamic structures using natural local materials (e.g., large woody debris already in the system), a direct application of NbS in practice. This process includes extensive stakeholder collaboration and utilizing nature's energy to balance navigation, ecological, and social benefits along the Madeira River. This project demonstrates that nature-based approaches not only provide navigation benefits but can also provide ecological and social benefits in ways that are sustainable in the long term, consistent with United Nations Sustainable Development Goals (SDGs) and the International Union for the Conservation of Nature's global standard for NbS. Integr Environ Assess Manag 2022;18:115-122. © 2021 SETAC. This article has been contributed to by US Government employees and their work is in the public domain in the USA.

Beneficial use of dredged sediment as a sustainable practice for restoring coastal marsh habitat.

Coastal Louisiana (USA) continues to sustain immense land and habitat losses due to subsidence, sea-level rise, and storm events. Approximately 65 million m3 (85 million cubic yards) of sediment is dredged annually from Gulf Coast federal navigation channels to maintain safe waterway passage. The beneficial use of these sediments continues to increase, and now this sediment is recognized as a critical resource in large-scale (estimated multibillion dollar) ecosystem restoration efforts to mitigate land and habitat losses along the US Gulf Coast. However, the documentation of restoration benefits where dredged sediments are the primary resource is lacking, which limits the potential for future applications. Therefore, this study documents the progress to restore marsh habitat and the resultant benefits in West Bay, Louisiana, and investigates how the restoration practices align with principles of the US Army Corps of Engineers (USACE) Engineering with Nature® (EWN® ) and UN Sustainable Development Goals (UN SDGs). West Bay, a 4964-ha subdelta adjacent to the Mississippi River, typifies risks of coastal land loss that also threatens the integrity of the adjacent federal navigation channel. To help restore coastal marsh habitat on a large spatial and temporal scale, the USACE constructed an uncontrolled diversionary channel from the Mississippi River and with subsequent direct and strategic placement of dredged sediment. Restoration performance was assessed through remotely sensed methods using data spanning approximately 70 years. To date, placement of dredged sediment in the bay has facilitated the creation of over 800 ha of new land in the formerly open waters of West Bay. The West Bay restoration project aligns with the principles of the EWN initiative, which supports more sustainable practices to deliver economic, environmental, and social benefits through collaborative processes and meaningfully integrates 10 of the UN SDGs designed to achieve a better and more sustainable future. Integr Environ Assess Manag 2022;18:1162-1173. Published 2021. This article is a U.S. Government work and is in the public domain in the USA.

Assessing the Impacts of Dry Blasting on Fish Eggs in Adjacent Spawning Habitat.

Blasting used in construction of waterborne infrastructure may impact fish eggs in adjacent spawning habitats through introduction of mechanical vibrations as peak particle velocities (PPV). However, there are limited studies applying risk-based approaches to evaluate and mitigate these impacts. A navigation improvement project in the Soo Locks near the St. Marys Rapids provided an opportunity to evaluate existing data to inform blasting risks to fish eggs. To assess this risk, existing data were used to calculate species sensitivity distributions that were used to estimate a hazardous concentration for 5% of the salmon and trout species evaluated (HC5) and predicted no effect concentrations (PNEC). The HC5 ranged from 14.0 to 89.2 cm/s PPV, and the 'safe level' PNEC thresholds ranged from 2.8 to 17.8 cm/s PPV. This study provides a demonstration of how a risk-based approach can be effectively used to assess and manage dry blasting effects on underwater biota.

A Hemimysis-driven novel ecosystem at a modified rubble-mound breakwater: An Engineering With Nature® Demonstration Project.

The US Army Corps of Engineers (USACE) repairs aging breakwater structures as part of routine maintenance to maintain safe navigation in Great Lakes commercial ports. A USACE repair to an existing breakwater structure in Milwaukee Harbor (WI) implementing Engineering With Nature (EWN) principles created complex rocky habitat by strategically placing cobble-sized stone over conventional 5.4 to 9.1 metric ton boulders, thus creating "control" (boulder) and "treatment" (cobble) habitats. We evaluated the resultant nature-based breakwater (NBBW) developing food web versus an adjacent reference site on the same breakwater and determined that, unexpectedly, locally abundant Hemimysis anomala were impacting the food-web dynamics and feeding ecology of fishes occupying the structure. Fish and forage communities were sampled using gillnets, night scuba diving surveys, rock collections, and a novel trap to capture invertebrates. The resultant NBBW became home to a prolific population of nonindigenous Hemimysis, with indications that they were more abundant on cobble versus boulders, based on rainbow smelt feeding. This lithophilic/cave swelling mysid provided an important new food resource in Milwaukee Harbor for two introduced pelagic prey fishes: alewife (Alosa pseudoharengus) and rainbow smelt (Osmerus mordax). Gillnetting and night scuba diving surveys confirmed that rainbow smelt preferred to forage on the cobble section (p < 0.05). Hemimysis were also the primary food item consumed by nearshore game fishes such as young-of-the-year (YOY) yellow perch (Perca flavescens), YOY largemouth bass (Micropterus salmoides), and juvenile rock bass (Ambloplites rupestris). We propose that those breakwaters that harbor abundant Hemimysis constitute novel ecosystems (ecosystems that include both native and non-native biota) that might benefit harbor fisheries if well-managed. This project demonstrated how a low-cost design modification could be applied during the repair of rubble-mound, breakwater structures to achieve benefits beyond safe navigation. Integr Environ Assess Manag 2022;18:49-62. Published 2021. This article is a US Government work and is in the public domain in the USA.

Long-term clinical and socio-economic outcomes following wrist fracture: a systematic review and meta-analysis.

A comprehensive review of studies shows that patients with wrist fracture, aged over 50 years, experience pain and functional limitation long after fracture. This is associated with increased healthcare costs, and reduced quality of life. Understanding factors that predict poor outcomes is important for future healthcare policy and planning. PURPOSE: To summarise and appraise evidence on the prognosis and long-term clinical and socio-economic outcomes following wrist fracture among adults aged 50 years and over. METHODS: Five databases (MEDLINE, EMBASE, AMED, CINAHL-P and PsycINFO) were comprehensively searched (supplemented by a grey-literature search) from inception till June 2021 for prospective/retrospective cohort studies of patients (≥ 50 years) with a history of wrist fracture and reporting long-term (≥ 6 months) outcomes. Peer study selection, data extraction and risk of bias assessment were conducted. A random effects meta-analysis was used to summarise estimates of pain and function outcomes. RESULTS: 78 studies (n = 688,041 patients) were included. Patients report persistent moderate to severe pain (range: 7.5%-62%) and functional limitations (range: 5.5-78%) up to 12-months or later after wrist fracture. Mean Patient-Rated Wrist Evaluation (PRWE) score for pain and function (9 studies, n = 1759 patients) was 15.23 (95%CI 12.77, 17.69) at 6-months to 13-years follow-up. Mean disabilities of the arm, shoulder and hand (DASH) score (9 studies, n = 1346 patients) was 13.82 (95%CI 12.71, 14.93)( at 6- to 17-months follow-up. A 10-20% increase in healthcare encounters in the first 12-months after fracture was observed. Twelve prognostic factors were associated with poor long-term outcomes. CONCLUSION: Evidence shows that a high proportion of people aged over 50 years with wrist fracture experience pain and functional limitation > 6 months after fracture. This is associated with increased healthcare costs, and reduced quality of life. Exploratory evidence was found for several candidate prognostic factors. Their predictive performance needs to be investigated further. PROSPERO: CRD42018116478.

Outcome of caudal superficial epigastric axial pattern flaps in dogs and cats: 70 cases (2007-2020).

OBJECTIVES: To describe the outcome and complications associated with the use of caudal superficial epigastric axial pattern flaps in dogs and cats. MATERIAL AND METHODS: Multicentre retrospective review and descriptive study of clinical records of dogs and cats having undergone caudal superficial epigastric axial pattern flaps between 2007 and 2020. Data retrieved included signalment, aetiology of surgical defect, tumour type, presence/absence of clean surgical margins, presence/absence of post-operative wound infection, use of peri- and post-operative antibiotics, duration of anaesthesia, duration of surgery, presence and duration of hypothermia, presence and duration of hypotension, presence/absence of post-operative surgical drain and length of caudal superficial epigastric axial pattern flap. The incidence of complications and outcomes were documented. RESULTS: Seventy cases met the inclusion criteria; 51 dogs and 19 cats. In dogs, 67% of cases developed complications (59% minor, 8% major) and 33% had uneventful wound healing. In cats, 53% of cases developed complications, (47% minor, 5% major) and 47% had uneventful wound healing. In dogs, the percentage of cases experiencing dehiscence, necrosis, seroma, oedema and post-operative infection was 31%, 29%, 26%, 26% and 16% respectively. In cats, this was 26%, 16%, 11%, 0% and 5% respectively. A good overall outcome was seen in 77% of dogs and 79% of cats. A poor overall outcome was seen in 4% of dogs and 0% of cats. CLINICAL SIGNIFICANCE: Caudal superficial epigastric axial pattern flaps are traditionally thought more robust than other flaps, yet complication rates remain high, despite a high overall success rate.

Using Engineering With Nature® (EWN® ) principles to manage erosion of watersheds damaged by large-scale wildfires.

The US Army Corps of Engineers (USACE) manages hundreds of reservoirs and thousands of miles of navigation channels that provide invaluable flood control, commercial transport of materials, water supply, recreation, and stream flow regulation. This capability is being threatened by the continued occurrence of large-scale wildfires across the western United States. The wildfires damage watersheds in part by denuding landscapes, reducing infiltration rates, and increasing runoff rates, thereby dramatically increasing the potential for the erosion of denuded slopes, destabilizing stream channels, increasing the infilling potential of reservoirs and, hence, reducing their capacity. The increased erosion rates highlight the need to develop innovative solutions to reduce erosion of watersheds laid bare after wildfires engulf the area. The Santa Clara Pueblo in northern New Mexico extends from the top of the eastern Jemez Mountains to the floodplains of the Rio Grande River. The Pueblo designed and constructed thousands of structures built from natural materials, consistent with Engineering With Nature (EWN) principles for erosion control incorporating low-cost and readily available materials such as logs, mulch, vegetation, and local rock to stabilize highly erodible parts of the watershed. The watersheds where these natural structures were constructed were monitored after construction to assess their effectiveness, guiding a series of recommendations for broader implementation. As part of a continued emphasis on updating USACE engineering guidance, research, and development, funding has been focused on developing sustainable and resilient project designs using natural materials like those implemented by the Santa Clara Pueblo. This paper focuses on the innovative EWN-based watershed stabilization practices that were implemented in the upper section of this wildfire affected canyon and tributary streams. Recommendations for future implementation based on lessons learned from this project are also provided. Integr Environ Assess Manag 2021;17:1194-1202. Published 2021. This article is a US Government work and is in the public domain in the USA.

Baseline PET/CT imaging parameters for prediction of treatment outcome in Hodgkin and diffuse large B cell lymphoma: a systematic review.

PURPOSE: To systematically review the literature evaluating clinical utility of imaging metrics derived from baseline fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) for prediction of progression-free (PFS) and overall survival (OS) in patients with classical Hodgkin lymphoma (HL) and diffuse large B cell lymphoma (DLBCL). METHODS: A search of MEDLINE/PubMed, Web of Science, Cochrane, Scopus and clinicaltrials.gov databases was undertaken for articles evaluating PET/CT imaging metrics as outcome predictors in HL and DLBCL. PRISMA guidelines were followed. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. RESULTS: Forty-one articles were included (31 DLBCL, 10 HL). Significant predictive ability was reported in 5/20 DLBCL studies assessing SUVmax (PFS: HR 0.13-7.35, OS: HR 0.83-11.23), 17/19 assessing metabolic tumour volume (MTV) (PFS: HR 2.09-11.20, OS: HR 2.40-10.32) and 10/13 assessing total lesion glycolysis (TLG) (PFS: HR 1.078-11.21, OS: HR 2.40-4.82). Significant predictive ability was reported in 1/4 HL studies assessing SUVmax (HR not reported), 6/8 assessing MTV (PFS: HR 1.2-10.71, OS: HR 1.00-13.20) and 2/3 assessing TLG (HR not reported). There are 7/41 studies assessing the use of radiomics (4 DLBCL, 2 HL); 5/41 studies had internal validation and 2/41 included external validation. All studies had overall moderate or high risk of bias. CONCLUSION: Most studies are retrospective, underpowered, heterogenous in their methodology and lack external validation of described models. Further work in protocol harmonisation, automated segmentation techniques and optimum performance cut-off is required to develop robust methodologies amenable for clinical utility.

Detection of SARS-CoV-2 within the healthcare environment: a multi-centre study conducted during the first wave of the COVID-19 outbreak in England.

BACKGROUND: Understanding how severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is spread within the hospital setting is essential in order to protect staff, implement effective infection control measures, and prevent nosocomial transmission. METHODS: The presence of SARS-CoV-2 in the air and on environmental surfaces around hospitalized patients, with and without respiratory symptoms, was investigated. Environmental sampling was undertaken within eight hospitals in England during the first wave of the coronavirus disease 2019 outbreak. Samples were analysed using reverse transcription polymerase chain reaction (PCR) and virus isolation assays. FINDINGS: SARS-CoV-2 RNA was detected on 30 (8.9%) of 336 environmental surfaces. Cycle threshold values ranged from 28.8 to 39.1, equating to 2.2 x 105 to 59 genomic copies/swab. Concomitant bacterial counts were low, suggesting that the cleaning performed by nursing and domestic staff across all eight hospitals was effective. SARS-CoV-2 RNA was detected in four of 55 air samples taken <1 m from four different patients. In all cases, the concentration of viral RNA was low and ranged from <10 to 460 genomic copies/m3 air. Infectious virus was not recovered from any of the PCR-positive samples analysed. CONCLUSIONS: Effective cleaning can reduce the risk of fomite (contact) transmission, but some surface types may facilitate the survival, persistence and/or dispersal of SARS-CoV-2. The presence of low or undetectable concentrations of viral RNA in the air supports current guidance on the use of specific personal protective equipment for aerosol-generating and non-aerosol-generating procedures.

Favourable outcomes for high-risk diffuse large B-cell lymphoma (IPI 3-5) treated with front-line R-CODOX-M/R-IVAC chemotherapy: results of a phase 2 UK NCRI trial.

BACKGROUND: Outcomes for patients with high-risk diffuse large B-cell lymphoma (DLBCL) treated with R-CHOP chemotherapy are suboptimal but, to date, no alternative regimen has been shown to improve survival rates. This phase 2 trial aimed to assess the efficacy of a Burkitt-like approach for high-risk DLBCL using the dose-intense R-CODOX-M/R-IVAC regimen. PATIENTS AND METHODS: Eligible patients were aged 18-65 years with stage II-IV untreated DLBCL and an International Prognostic Index (IPI) score of 3-5. Patients received alternating cycles of CODOX-M (cyclophosphamide, vincristine, doxorubicin and high-dose methotrexate) alternating with IVAC chemotherapy (ifosfamide, etoposide and high-dose cytarabine) plus eight doses of rituximab. Response was assessed by computed tomography after completing all four cycles of chemotherapy. The primary end point was 2-year progression-free survival (PFS). RESULTS: A total of 111 eligible patients were registered; median age was 50 years, IPI score was 3 (60.4%) or 4/5 (39.6%), 54% had a performance status ≥2 and 9% had central nervous system involvement. A total of 85 patients (76.6%) completed all four cycles of chemotherapy. There were five treatment-related deaths (4.3%), all in patients with performance status of 3 and aged >50 years. Two-year PFS for the whole cohort was 67.9% [90% confidence interval (CI) 59.9-74.6] and 2-year overall survival was 76.0% (90% CI 68.5-82.0). The ability to tolerate and complete treatment was lower in patients with performance status ≥2 who were aged >50 years, where 2-year PFS was 43.5% (90% CI 27.9-58.0). CONCLUSIONS: This trial demonstrates that R-CODOX-M/R-IVAC is a feasible and effective regimen for the treatment of younger and/or fit patients with high-risk DLBCL. These encouraging survival rates demonstrate that this regimen warrants further investigation against standard of care. TRIAL REGISTRATION: ClinicalTrials.gov (NCT00974792) and EudraCT (2005-003479-19).

A multicentre, randomised controlled trial to compare the clinical and cost-effectiveness of Lee Silverman Voice Treatment versus standard NHS Speech and Language Therapy versus control in Parkinson's disease: a study protocol for a randomised controlled trial.

BACKGROUND: Parkinson's disease (PD) affects approximately 145,519 people in the UK. Speech impairments are common with a reported prevalence of 68%, which increase physical and mental demands during conversation, reliance on family and/or carers, and the likelihood of social withdrawal reducing quality of life. In the UK, two approaches to Speech and Language Therapy (SLT) intervention are commonly available: National Health Service (NHS) SLT or Lee Silverman Voice Treatment (LSVT LOUD®). NHS SLT is tailored to the individuals' needs per local practice typically consisting of six to eight weekly sessions; LSVT LOUD® comprises 16 sessions of individual treatment with home-based practice over 4 weeks. The evidence-base for their effectiveness is inconclusive. METHODS/DESIGN: PD COMM is a phase III, multicentre, three-arm, unblinded, randomised controlled trial. Five hundred and forty-six people with idiopathic PD, reporting speech or voice problems will be enrolled. We will exclude those with a diagnosis of dementia, laryngeal pathology or those who have received SLT for speech problems in the previous 2 years. Following informed consent and completion of baseline assessments, participants will be randomised in a 1:1:1 ratio to no-intervention control, NHS SLT or LSVT LOUD® via a central computer-generated programme, using a minimisation procedure with a random element, to ensure allocation concealment. Participants randomised to the intervention groups will start treatment within 4 (NHS SLT) or 7 (LSVT LOUD®) weeks of randomisation. PRIMARY OUTCOME: Voice Handicap Index (VHI) total score at 3 months. Secondary outcomes include: VHI subscales, Parkinson's Disease Questionnaire-39; Questionnaire on Acquired Speech Disorders; EuroQol-5D-5 L; ICECAP-O; resource utilisation; adverse events and carer quality of life. Mixed-methods process and health economic evaluations will take place alongside the trial. Assessments will be completed before randomisation and at 3, 6 and 12 months after randomisation. The trial started in December 2015 and will run for 77 months. Recruitment will take place in approximately 42 sites around the UK. DISCUSSION: The trial will test the hypothesis that SLT is effective for the treatment of speech or voice problems in people with PD compared to no SLT. It will further test whether NHS SLT or LSVT LOUD® provide greater benefit and determine the cost-effectiveness of both interventions. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Number (ISRCTN) Registry, ID: 12421382. Registered on 18 April 2016.

Evaluation of dredged sediment for aquatic placement: interpreting contaminant bioaccumulation.

The potential bioaccumulation of sediment-associated contaminants is one of the primary concerns associated with the aquatic placement of dredged sediment. Laboratory bioaccumulation tests with representative infaunal organisms exposed to dredged sediment and reference sediment are used to assess the potential for contaminant-related bioaccumulation impacts. Dredged sediment testing and evaluation guidance provides statistical inferences and numerous assessment factors (e.g., the magnitude of difference (MOD)) to interpret results; however, detailed information for applying these factors is lacking. Therefore, the focus of this work was to provide context for the application of the MOD as a line of evidence for evaluating bioaccumulation risk associated with dredged material placement in aquatic environments by considering variance (as coefficient of variation (CV)), MOD, and statistical differences associated with bioaccumulation bioassay tissue concentrations in three case studies. Based on peer-reviewed data and dredged material monitoring data, relatively low within-sample variability (CVs < 50%) of tissue concentrations can be achieved for commonly assessed constituents (e.g., polychlorinated biphenyls (PCBs), polycyclic aromatic hydrocarbons (PAHs), metals, and butyl tins). Thus, statistical comparisons were generally able to detect significant differences (p < 0.05; α = 0.05) across tissue concentrations with relatively low MODs (< 2-fold difference). Based on the observed variance, MOD, and statistical differences associated with bioaccumulation bioassay tissue concentrations, a 2-fold MOD can provide an additional line of evidence to evaluate bioaccumulative risk when statistical significance is observed. These results indicated that a judicious consideration of the sample variance and MOD is a useful factor when discerning meaningful differences among contaminant tissue concentrations.