Managing and treating per- and polyfluoroalkyl substances (PFAS) in membrane concentrates.

Per- and polyfluoroalkyl substances (PFAS), which are present in many waters, have detrimental impacts on human health and the environment. Reverse osmosis (RO) and nanofiltration (NF) have shown excellent PFAS separation performance in water treatment; however, these membrane systems do not destroy PFAS but produce concentrated residual streams that need to be managed. Complete destruction of PFAS in RO and NF concentrate streams is ideal, but long-term sequestration strategies are also employed. Because no single technology is adequate for all situations, a range of processes are reviewed here that hold promise as components of treatment schemes for PFAS-laden membrane system concentrates. Attention is also given to relevant concentration processes because it is beneficial to reduce concentrate volume prior to PFAS destruction or sequestration. Given the costs and challenges of managing PFAS in membrane concentrates, it is critical to evaluate both established and emerging technologies in selecting processes for immediate use and continued research.

Which outcomes are most important to measure in patients with COVID-19 and how and when should these be measured? Development of an international standard set of outcomes measures for clinical use in patients with COVID-19: a report of the International Consortium for Health Outcomes Measurement (ICHOM) COVID-19 Working Group.

OBJECTIVES: The COVID-19 pandemic has resulted in widespread morbidity and mortality with the consequences expected to be felt for many years. Significant variation exists in the care even of similar patients with COVID-19, including treatment practices within and between institutions. Outcome measures vary among clinical trials on the same therapies. Understanding which therapies are of most value is not possible unless consensus can be reached on which outcomes are most important to measure. Furthermore, consensus on the most important outcomes may enable patients to monitor and track their care, and may help providers to improve the care they offer through quality improvement. To develop a standardised minimum set of outcomes for clinical care, the International Consortium for Health Outcomes Measurement (ICHOM) assembled a working group (WG) of 28 volunteers, including health professionals, patients and patient representatives. DESIGN: A list of outcomes important to patients and professionals was generated from a systematic review of the published literature using the MEDLINE database, from review of outcomes being measured in ongoing clinical trials, from a survey distributed to patients and patient networks, and from previously published ICHOM standard sets in other disease areas. Using an online-modified Delphi process, the WG selected outcomes of greatest importance. RESULTS: The outcomes considered by the WG to be most important were selected and categorised into five domains: (1) functional status and quality of life, (2) mental functioning, (3) social functioning, (4) clinical outcomes and (5) symptoms. The WG identified demographic and clinical variables for use as case-mix risk adjusters. These included baseline demographics, clinical factors and treatment-related factors. CONCLUSION: Implementation of these consensus recommendations could help institutions to monitor, compare and improve the quality and delivery of care to patients with COVID-19. Their consistent definition and collection could also broaden the implementation of more patient-centric clinical outcomes research.

Description of Technique and Short-Term Outcomes of Radial Artery Access for Vascular Disease.

OBJECTIVES: Radial artery access is widely utilized in coronary angiography with reported lower rates of vascular complications and better patient comfort. There is limited data in the literature regarding radial access in peripheral endovascular procedures. We hypothesize that radial access is safe and feasible for peripheral endovascular procedures. METHODS: A retrospective chart review was performed for all patients who underwent angiography using radial artery access between August 2013 and December 2017. Patient demographics and perioperative data were recorded and analyzed. PATIENT SELECTION: The operating surgeon screened patients presenting for elective angiography for possible radial artery access. Ultrasound guidance was used in all cases. Upon cannulation, the sheath was infused with an antispasmodic cocktail, and the patients were systemically anticoagulated. RESULTS: Forty-seven out of 52 patients successfully completed their procedure (90% success rate). The patients were mostly female (60%), elderly (mean age of 71 years), and had several comorbidities. Preoperative diagnoses were variable. Procedures were both diagnostic (58%) and interventional (42%) with maximum sheath size used being 7F and median fluoroscopy time of 7.5 minutes. Only 2 patients experienced perioperative complications, and both of these were minor hematomas that resolved with manual pressure. CONCLUSIONS: Transradial arterial access for peripheral vascular angiography and interventions is safe and feasible. With low complication rates and increased patient comfort, transradial access serves as an excellent alternative to transfemoral access for a variety of endovascular procedures.

Addressing challenges for future strategic-level emergency management: reframing, networking, and capacity-building.

The mounting frequency and intensity of natural hazards, alongside growing interdependencies between social-technical and ecological systems, are placing increased pressure on emergency management. This is particularly true at the strategic level of emergency management, which involves planning for and managing non-routine, high-consequence events. Drawing on the literature, a survey, and interviews and workshops with Australia's senior emergency managers, this paper presents an analysis of five core challenges that these pressures are creating for strategic-level emergency management. It argues that emphasising 'emergency management' as a primary adaptation strategy is a retrograde step that ignores the importance of addressing socio-political drivers of vulnerabilities. Three key suggestions are presented that could assist the country's strategic-level emergency management in tackling these challenges: (i) reframe emergency management as a component of disaster risk reduction rather than them being one and the same; (ii) adopt a network governance approach; and (iii) further develop the capacities of strategic-level emergency managers.

Services for children with developmental co-ordination disorder: an evaluation against best practice principles.

PURPOSE: The National Health Service in Scotland published a best practice framework to support occupational therapists and physiotherapists to deliver effective services for children with developmental co-ordination disorder (DCD); however, adherence is variable. To highlight areas for development, this study compared the care pathway within a paediatric DCD service against the NHS Scotland framework. METHODS: A partnership of researchers and clinicians based in the United Kingdom conducted a qualitative study with 37 participants (N = 13 interview participants, N = 24 workshop participants). In-depth interviews and/or workshops were used to map the DCD service against the NHS framework. Identified gaps were aligned with four key stages of the care pathway. Qualitative analysis software was used to analyse the data. RESULTS: Core principles to guide future development were identified for each phase of the pathway. These core principles related to the NHS framework and focused on issues such as involving the family, defining clear pathways and enhancing children's participation. Participants identified potential strategies for service improvement such as developing community-based interventions and information provision. CONCLUSION: Challenges when providing services for children with DCD include confusing service pathways and poor partnership working. It is, therefore, important that clinicians utilise collaborative working strategies that support children's participation. IMPLICATIONS FOR REHABILITATION: There are numerous challenges related to the implementation of best practice principles into the provision of therapy services for children with developmental coordination disorder (DCD). It is important that AHPs seek ways of engaging parents and educational professionals at all stages of the care pathway in order to ensure optimum service provision for the child. Addressing participation is an important aspect and community-based strategies may be particularly beneficial, both as a preventative activity and as an intervention approach.

Participation in Physical Play and Leisure in Children With Motor Impairments: Mixed-Methods Study to Generate Evidence for Developing an Intervention.

BACKGROUND: Participation in physical play/leisure (PPP) is an important therapy goal of children with motor impairments. Evidence for interventions promoting PPP in these children is scarce. The first step is to identify modifiable, clinically meaningful predictors of PPP for targeting by interventions. OBJECTIVE: The study objective was to identify, in children with motor impairments, body function and structure, activity, environmental, and personal factors related to PPP and modifiable by therapists. DESIGN: This was a mixed-methods, intervention development study. The World Health Organization framework International Classification of Functioning, Disability and Health was used. METHODS: Participants were children (6-8 years old) with motor impairments, mobilizing independently with or without equipment and seen by physical therapists or occupational therapists in 6 regions in the United Kingdom, and their parents. Self-reported PPP was assessed with the Children's Assessment of Participation and Enjoyment. Modifiable-factor data were collected with therapists' observations, parent questionnaires, and child-friendly interviews. The Children's Assessment of Participation and Enjoyment, therapist, and parent data were analyzed using descriptive statistics and linear regression. Interview data were analyzed for emerging themes. RESULTS: Children's (n=195) PPP (X=18 times per week, interquartile range=11-25) was mainly 'recreational' (eg, pretend play, playing with pets) rather than 'active physical' (eg, riding a bike/scooter). Parents (n=152) reported positive beliefs about children's PPP but various levels of family PPP. Therapists reported 23 unique impairments (eg, muscle tone), 16 activity limitations (eg, walking), and 3 personal factors (eg, child's PPP confidence). Children interviewed (n=17) reported a strong preference for active play but indicated that adults regulated their PPP. Family PPP and impairment in the child's movement-related body structures explained 18% of the variation in PPP. Family PPP explained most of the variation. LIMITATIONS: It is likely that the study had a degree of self-selection bias, and caution must be taken in generalizing the results to children whose parents have less positive views about PPP. CONCLUSIONS: The results converge with wider literature about the child's social context as a PPP intervention target. In addition, the results question therapists' observations in explaining PPP.

Breakdowns in coordinated decision making at and above the incident management team level: an analysis of three large scale Australian wildfires.

Emergency situations are by their nature difficult to manage and success in such situations is often highly dependent on effective team coordination. Breakdowns in team coordination can lead to significant disruption to an operational response. Breakdowns in coordination were explored in three large-scale bushfires in Australia: the Kilmore East fire, the Wangary fire, and the Canberra Firestorm. Data from these fires were analysed using a top-down and bottom-up qualitative analysis technique. Forty-four breakdowns in coordinated decision making were identified, which yielded 83 disconnects grouped into three main categories: operational, informational and evaluative. Disconnects were specific instances where differences in understanding existed between team members. The reasons why disconnects occurred were largely consistent across the three sets of data. In some cases multiple disconnects occurred in a temporal manner, which suggested some evidence of disconnects creating states that were conducive to the occurrence of further disconnects. In terms of resolution, evaluative disconnects were nearly always resolved however operational and informational disconnects were rarely resolved effectively. The exploratory data analysis and discussion presented here represents the first systematic research to provide information about the reasons why breakdowns occur in emergency management and presents an account of how team processes can act to disrupt coordination and the operational response.

A theoretical framework for negotiating the path of emergency management multi-agency coordination.

Multi-agency coordination represents a significant challenge in emergency management. The need for liaison officers working in strategic level emergency operations centres to play organizational boundary spanning roles within multi-agency coordination arrangements that are enacted in complex and dynamic emergency response scenarios creates significant research and practical challenges. The aim of the paper is to address a gap in the literature regarding the concept of multi-agency coordination from a human-environment interaction perspective. We present a theoretical framework for facilitating multi-agency coordination in emergency management that is grounded in human factors and ergonomics using the methodology of core-task analysis. As a result we believe the framework will enable liaison officers to cope more efficiently within the work domain. In addition, we provide suggestions for extending the theory of core-task analysis to an alternate high reliability environment.

Chronic disease self-management and exercise in COPD as pulmonary rehabilitation: a randomized controlled trial.

PURPOSE: Both exercise and self-management are advocated in pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD). The widely used 6-week, group-based Chronic Disease Self-Management Program (CDSMP) increases self-reported exercise, despite supervised exercise not being a program component. This has been little explored in COPD. Whether adding supervised exercise to the CDSMP would add benefit is unknown. We investigated the CDSMP in COPD, with and without a formal supervised exercise component, to address this question. PATIENTS AND METHODS: Adult outpatients with COPD were randomized to the CDSMP with or without one hour of weekly supervised exercise over 6 weeks. The primary outcome measure was 6-minute walk test distance (6MWD). Secondary outcomes included self-reported exercise, exercise stage of change, exercise self-efficacy, breathlessness, quality of life, and self-management behaviors. Within- and between-group differences were analyzed on an intention-to-treat basis. RESULTS: Of 84 subjects recruited, 15 withdrew. 6MWD increased similarly in both groups: CDSMP-plus-exercise (intervention group) by 18.6±46.2 m; CDSMP-alone (control group) by 20.0±46.2 m. There was no significant difference for any secondary outcome. CONCLUSION: The CDSMP produced à small statistically significant increase in 6MWD. The addition of a single supervised exercise session did not further increase exercise capacity. Our findings confirm the efficacy of a behaviorally based intervention in COPD, but this would seem to be less than expected from conventional exercise-based pulmonary rehabilitation, raising the question of how, if at all, the small gains observed in this study may be augmented.

Participation in physical play and leisure: developing a theory- and evidence-based intervention for children with motor impairments.

BACKGROUND: Children with motor impairments (e.g. difficulties with motor control, muscle tone or balance) experience significant difficulties in participating in physical play and leisure. Current interventions are often poorly defined, lack explicit hypotheses about why or how they might work, and have insufficient evidence about effectiveness. This project will identify (i) the 'key ingredients' of an effective intervention to increase participation in physical play and leisure in children with motor impairments; and (ii) how these ingredients can be combined in a feasible and acceptable intervention. METHODS/DESIGN: The project draws on the WHO International Classification of Functioning, Disability and Health and the UK Medical Research Council guidance for developing 'complex interventions'. There will be five steps: 1) identifying biomedical, personal and environmental factors proposed to predict children's participation in physical play and leisure; 2) developing an explicit model of the key predictors; 3) selecting intervention strategies to target the predictors, and specifying the pathways to change; 4) operationalising the strategies in a feasible and acceptable intervention; and 5) modelling the intervention processes and outcomes within single cases. DISCUSSION: The primary output from this project will be a detailed protocol for an intervention. The intervention, if subsequently found to be effective, will support children with motor difficulties to attain life-long well-being and participation in society. The project will also be an exemplar of methodology for a systematic development of non-drug interventions for children.

Lost in translation: maximizing handover effectiveness between paramedics and receiving staff in the emergency department.

OBJECTIVE: The purpose of the present study is to investigate perceptions by paramedics and hospital receiving staff about what enables and constrains handover in the ED. METHODS: This is a qualitative study of interviews with 19 paramedics, 15 nurses and 16 doctors (n = 50) from ambulance services and ED in two states of Australia. RESULTS: Three main themes emerged that were evident at both sites and in the three professional groups. These were: difficulties in creating a shared cognitive picture, tensions between 'doing' and 'listening' and fragmenting communication. CONCLUSION: Recommendations arising from the present study as to how handover could be improved are the need for a common language between paramedics and staff in the ED, for shared experiences and understanding between the members of the team and for the development of a standardized approach to handover from paramedics to ED receiving staff.

Contemplating the Pentagon attack after five years of space and time: unheard voices from the ramparts of our burn center.

Marking the fifth year after the attack on the Pentagon, staff at the burn center in Washington, DC, memorialize in a contemplative frame of mind. These reflections are drawn from members of the extended burn team and render an interwoven sketch in prose that previously has not been heard.