Evaluating variation in pre-operative evaluation and planning for children undergoing atrial or ventricular septal defect repair.

BACKGROUND: CHD care is resource-intensive. Unwarranted variation in care may increase cost and result in poorer health outcomes. We hypothesise that process variation exists within the pre-operative evaluation and planning process for children undergoing repair of atrial septal defect or ventricular septal defect and that substantial variation occurs in a small number of care points. METHODS: From interviews with staff of an integrated congenital heart centre, an initial process map was constructed. A retrospective chart review of patients with isolated surgical atrial septal defect and ventricular septal defect repair from 7/1/2018 through 11/1/2020 informed revisions of the process map. The map was assessed for points of consistency and variability. RESULTS: Thirty-two surgical atrial septal defect/ventricular septal defect repair patients were identified. Ten (31%) were reviewed by interventional cardiology before surgical review. Of these, 6(60%) had a failed catheter-based closure and 4 (40%) were deemed inappropriate for catheter-based closure. Thirty (94%) were reviewed in case conference, all attended surgical clinic, and none were admitted prior to surgery. The process map from interviews alone identified surgery rescheduling as a point of major variability; however, chart review revealed this was not as prominent a source of variability as pre-operative interventional cardiology review. CONCLUSIONS: Significant variation in the pre-operative evaluation and planning process for surgical atrial septal defect/ventricular septal defect patients was identified. If such process variation is widespread through CHD care, it may contribute to variations in outcome and cost previously documented within CHD surgery. Future research will focus on determining whether the variation is warranted or unwarranted, associated health outcomes and cost variation attributed to these variations in care processes.

Determining Unmet Needs Among Workers' Compensation Stakeholders to Prevent Work Disability in the State of Vermont.

PURPOSE: Vermont has high rates of young people receiving federal disability benefits leading to substantial gaps in the workforce. The purpose of this project was to determine the unmet needs of interested parties in the workers' compensation (WC) process. METHODS: A type of focus group, experience groups, was used to elicit key parties' experiences in the WC system. Facilitators used open-ended prompts to encourage discussion among participants about their experience with the WC system. Data were analyzed using thematic coding procedures to identify common motifs. RESULTS: Common themes emerged including challenges in navigating the WC system, lack of communication among stakeholders, and providing and receiving appropriate health care to facilitate RTW. CONCLUSIONS: Understanding unmet needs of interested parties in the WC process allows for the creation of targeted, high-value, early intervention strategies to reduce long-term work disability.

What is the best design approach for estimating effluent concentrations from horizontal flow treatment wetlands: the use of volumetric (kV) or areal (kA) removal rate coefficients?

Effluent concentrations from horizontal flow (HF) treatment wetlands can be estimated by using the Tanks-In-Series model for describing hydraulics and first-order removal rate coefficients for describing pollutant removal. In the design of conventional wastewater treatment plants, volumetric removal rate coefficients (kV) are traditionally used in conjunction with the theoretical hydraulic retention time. Areal removal rate coefficients (kA) coupled with the applied areal hydraulic loading rate are widely used in the literature. Despite this, supporting evidence of its appropriateness is scarce in the literature. The objective of this study is to investigate the adequacy of both approaches by analyzing the influence of liquid depth on kV and kA. Data from 74 HF wetlands were collected, covering biochemical oxygen demand and chemical oxygen demand, and diverse types of influents (raw sewage and primary, secondary and tertiary effluents). For these conditions, kV decreased with depth of the wetland system. Regression analyses between depth and removal rate coefficients were performed, and the equations indicated that kV was approximately related to the inverse of depth, while kA was almost independent of depth. These findings endorse the utilization of the areal-based approach for design purposes. The volumetric-based approach can also be used, but the value of kV must be provided together with the depth being considered.

A Model for Evaluating Total Costs of Care and Cost Savings of Specialty Condition-Based Care for Hip and Knee Osteoarthritis in an Integrated Practice Unit.

OBJECTIVES: The viability of specialty condition-based care via integrated practice units (IPUs) requires a comprehensive understanding of total costs of care. Our primary objective was to introduce a model to evaluate costs and potential costs savings using time-driven activity-based costing comparing IPU-based nonoperative management with traditional nonoperative management and IPU-based operative management with traditional operative management for hip and knee osteoarthritis (OA). Secondarily, we assess drivers of incremental cost differences between IPU-based care and traditional care. Finally, we model potential cost savings through diverting patients from traditional operative management to IPU-based nonoperative management. METHODS: We developed a model to evaluate costs using time-driven activity-based costing for hip and knee OA care pathways within a musculoskeletal IPU compared with traditional care. We identified differences in costs and drivers of cost differences and developed a model to demonstrate potential cost savings through diverting patients from operative intervention. RESULTS: Weighted average costs of IPU-based nonoperative management were lower than traditional nonoperative management and lower in IPU-based operative management than traditional operative management. Key drivers of incremental cost savings included care led by surgeons in partnership with associate providers, modified physical therapy programs with self-management, and judicious use of intra-articular injections. Substantial savings were modeled by diverting patients toward IPU-based nonoperative management. CONCLUSIONS: Costing models involving musculoskeletal IPUs demonstrate favorable costs and cost savings compared with traditional management of hip or knee OA. More effective team-based care and utilization of evidence-based nonoperative strategies can drive the financial viability of these innovative care models.

What is the best procedure for determining removal rate coefficients in horizontal flow treatment wetlands: influent and effluent concentrations or longitudinal concentration profiles?

First-order removal rate coefficients (k) are used in predictive equations for estimating effluent concentrations from horizontal flow (HF) wetlands. Due to limited resources, influent and effluent concentration data from existing systems are frequently used in the estimation of k values from operating systems, but another choice is to use concentration data along the longitudinal profile of the HF wetland. Based on a dataset with 41 HF wetlands/studies obtained from a literature survey, with chemical oxygen demand (COD) measurements at different sampling points, volumetric (kV) and areal (kA) removal rate coefficients for the Tanks-In-Series (TIS) model have been obtained using the two estimation methods. In general, removal rate coefficients derived from longitudinal profiles of concentrations were higher than those obtained by using data from influent and effluent concentrations, reflecting the fact that constituent removal is mostly accomplished before the wastewater reaches the outlet zone. Deriving coefficients from longitudinal profiles is more comprehensive, providing a better explanation of the internal removal taking place in the treatment wetland. However, the more widely used approach of calculating kV and kA from influent/effluent concentrations may lead to a safer design of horizontal flow wetlands, because of underestimation of the actual removal rate coefficients.

Senior Aviator Medical Qualification Status.

INTRODUCTION: Aviation personnel are expensive to train and challenging for the services to retain because of lucrative opportunities in the civilian aviation sector and a desire among pilots for agency. The military services' retention efforts have typically utilized a combination of high continuation pays and longer service commitments of up to 10 years following initial training. One area that the services have overlooked in their attempts to retain senior aviators is quantifying and reducing medical disqualifications. Much as aging aircraft require increasing maintenance to retain full operational capability, so may pilots and other aircrew members. MATERIALS AND METHODS: This article reports on a prospectively collected cross-sectional research study evaluating the medical status of senior aviation personnel who reported being considered or selected for command. The study was deemed exempt from human subjects research by the Institutional Review Board and a waiver of Health Insurance Portability and Accountability Act was granted. The study, which collected data at the Pentagon Flight Medical Clinic over 1 year, used a chart review of routine medical encounters and flight physicals to collect descriptive data. The goals of the study were to establish the prevalence of medically disqualifying conditions, assess the association between disqualifying conditions and age, and generate hypotheses for further research. Logistic regression of waiver need was performed for variables including prior waivers, waiver count, service, platform, age, and gender. ANOVA of readiness percentages vs. DoD targets were assessed between the services individually and in aggregate. RESULTS: The study demonstrated medical readiness rates among command-eligible senior aviators ranging from 74% for the Air Force to 40% for the Army with the Navy and Marine Corps in the middle. The sample was insufficiently powered to demonstrate differences in readiness between the services; however, the population as a whole was significantly below the DoD's readiness target of >90% (P = .000). CONCLUSIONS: None of the services met the DoD minimum readiness target of 90%. Markedly higher readiness was observed in the Air Force, the only service with a medical screening incorporated into its command selection process, but this difference was not statistically significant. Waivers increased with age and musculoskeletal concerns were common. A larger prospective cohort study should be considered to further elucidate and confirm the findings of this study. If further research confirms these findings, consideration should be made of screening command applicants for medical readiness.

Examining the Real-Life Journey of Individuals and Families Affected by Single-Ventricle Congenital Heart Disease.

Background The lifetime journey of patients with single-ventricle congenital heart disease is characterized by long-term challenges that are incompletely understood and still unfolding. Health care redesign requires a thorough understanding of this journey to create and implement solutions that improve outcomes. This study maps the lifetime journey of individuals with single-ventricle congenital heart disease and their families, identifies the most meaningful outcomes to them, and defines significant challenges in the journey. Methods and Results This qualitative research study involved experience group sessions and 1:1 interviews of patients, parents, siblings, partners, and stakeholders. Journey maps were created. The most meaningful outcomes to patients and parents and significant gaps in care were identified across the life journey. A total of 142 participants from 79 families and 28 stakeholders were included. Lifelong and life-stage specific journey maps were created. The most meaningful outcomes to patients and parents were identified and categorized using a "capability (doing the things in life you want to), comfort (experience of physical/emotional pain/distress), and calm (experiencing health care with the least impact on daily life)" framework. Gaps in care were identified and classified into areas of ineffective communication, lack of seamless transitions, lack of comprehensive support, structural deficiencies, and insufficient education. Conclusions There are significant gaps in care during the lifelong journey of individuals with single-ventricle congenital heart disease and their families. A thorough understanding of this journey is a critical first step in developing initiatives to redesign care around their needs and priorities. This approach can be used for people with other forms of congenital heart disease and other chronic conditions. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04613934.

Peaks, pores, and dragon eggs: Uncovering and quantifying the heterogeneity of treatment wetland biofilm matrices.

Biofilms serve to house diverse microbial communities, which are responsible for the majority of wastewater constituent degradation and transformation in treatment wetlands (TWs). TW biofilm has been generally conceptualized as a relatively uniform film covering available surfaces. However, no studies attaining direct visual 3D representations of biofilm morphology have been conducted. This study focuses on imaging the morphology of detached, gravel-associated, and rhizospheric (Phalaris arundinacea) biofilms from subsurface TW mesocosms. Images obtained through both traditional light microscopy, environmental scanning electron microscopy (E-SEM) and Wet-SEM revealed that TW biofilms are structurally heterogeneous ranging from corrugated films to clusters of aggregates. Features such as water channels and pores were observed suggesting that pollutant transport inside biofilms is complex, and that the interfacial surface area between water and biofilm is much larger than previously understood. Biofilm thickness generally ranged between 170 and 240 µm, with internal biofilm porosities estimated as 34 ± 10 %, reaching a maximum of 50 %. Internal biofilm matrix pore diameters ranged from 1 to 205.2 µm, with a distribution that favored pores and channels smaller than 10 µm, and a mean equivalent spherical diameter of 8.6 µm. Based on the large variation in pore and channel sizes it is expected that a variety of flow regimes and therefore pollutant dynamics are likely to occur inside TW biofilm matrices. Based on the visual evidence and analysis, a new conceptual model was created to reflect the microscale TW biofilm dynamics and morphology. This new conceptual model will serve to inform future biokinetic modelling, microscale hydrology, microbial community assessment, and pollutant treatment studies.

Evapotranspiration dynamics in aerated and non-aerated subsurface flow treatment wetlands.

This study reports the seasonal dynamics of evapotranspiration (ET) and evaporation (E) in different subsurface flow treatment wetlands operating in a temperate European climate. Daily water balances were compiled over the course of ten years (August 2010-July 2020). The study includes non-aerated horizontal flow wetlands (25 cm deep and 50 cm deep) as well as horizontal flow and vertical flow wetlands. The pilot systems were operated in planted and unplanted pairs, enabling Phragmites evapotranspiration rates (for planted systems) and evaporation rates (for unplanted systems) to be calculated. Evapotranspiration rates are highly seasonal. Aeration was observed to increase both evaporation and evapotranspiration rates. The overall percentage of inflow lost to ET was highest in non-aerated wetlands, due to the lower hydraulic load that they received compared to the aerated systems. Plant coefficients (Kp) relate measured evapotranspiration with the calculated reference evapotranspiration ETo. Wetlands planted with Phragmites display dynamic and highly seasonal values of Kp which are well-characterized by a sinusoidal curve during the growing season paired with a minimum (stable) value in the non-growing season. Aeration was observed to increase both evapotranspiration and evaporation rates. The concept of a Plant Scaling Factor (PSF) is introduced as a way of quantifying the "clothesline effect" observed in small treatment wetlands. Whereas unplanted systems effectively have a PSF of zero, the systems in this study (ranging in size from 5.6 to 6.2 m2) exhibited PSF values between 3.8 and 4.8 when the vegetation was fully mature.

On Protection of U.S. Forces From Global Health Threats: The Role of Health Security Advisors.

The coronavirus disease 2019 pandemic has exposed a health security gap within our nation and around the world. Recent national laws and policies have outlined the ends and means to improve health security. A decisive way is to achieve this objective is through health-related security cooperation efforts by increasing Health Services Support capacity.

What are People That Seek Care for Rotator Cuff Tendinopathy Experiencing in Their Daily Life?

This qualitative study sought to answer three questions: What is it like to live with rotator cuff tendinopathy? What are the barriers and facilitators of a healthy lifestyle with an aging shoulder? And, what are the outcomes that matter most to people seeking care for rotator cuff tendinopathy? Patients diagnosed with rotator cuff tendinopathy participated in group discussions using semi-structured guides that focus on diagnosis, daily experiences living with rotator cuff tendinopathy, goals, concerns, and clinical care experiences. A hybrid of initial inductive coding of themes and subsequent deductive consideration of these themes within the capability, comfort, and calm framework was utilized. Themes associated with rotator cuff tendinopathy were less restful sleep, difficulty with work and life transitions, loss of baseline abilities, and limitation in social roles in the capability realm; physical pain, despair, and loneliness in the comfort realm; and lack of direction or progress and feeling uncared for in the calm realm. Barriers identified included: the sense that rotator cuff tendinopathy is something correctable rather than age-associated and the sense that painful activities will make the tendinopathy worse (common misconceptions); tenuous relationships and limited trust with clinicians; loss of hope; and a sense that care is directionless. What matters most to a person seeking specialty care for shoulder pain are feeling that they are getting effective care and not being dismissed; maintaining meaningful activity and life roles; and replacing despair and frustration with hope and progress. Anticipating these needs may facilitate the design of more effective care models. Level of Evidence: N/A.

Hydraulic characterization and removal of metals and nutrients in an aerated horizontal subsurface flow "racetrack" wetland treating primary-treated oil industry effluent.

Constructed wetlands (CW) are an attractive technology due to their operational simplicity and low life-cycle cost. It has been applied for refinery effluent treatment but mostly single-stage designs (e.g., vertical or horizontal flow) have been tested. However, to achieve a good treatment efficiency for industrial effluents, different treatment conditions (both aerobic and anaerobic) are needed. This means that hybrid CW systems are typically required with a respectively increased area demand. In addition, a strong aerobic environment that facilitates the formation of iron, manganese, zinc and aluminum precipitates cannot be established with passive wetland systems, while the role of these oxyhydroxide compounds in the further co-precipitation and removal of heavy metals such as copper, nickel, lead, and chromium that can simplify the overall treatment of industrial wastewaters is poorly understood in CW. Therefore, this study tests for the first time an innovative CW design that combines an artificially aerated section with a non-aerated section in a single unit applied for oil refinery wastewater treatment. Four pilot units were tested with different design (i.e., planted/unplanted, aerated/non-aerated) and operational (two different hydraulic loading rates) characteristics to estimate the role of plants and artificial aeration and to identify the optimum design configuration. The pilot units received a primary refinery effluent, i.e., after passing through a dissolved air flotation unit. The first-order removal of heavy metals under aerobic conditions is evaluated, along with the removal of phenols and nutrients. High removal rates for Fe (96-98%), Mn (38-81%), Al (49-73%), and Zn (99-100%) generally as oxyhydroxide precipitates were found, while removal of Cu (61-80%), Ni (70-85%), Pb (96-99%) and Cr (60-92%) under aerobic conditions was also observed, likely through co-precipitation. Complete phenols and ammonia nitrogen removal was also found. The first-order rate coefficient (k) calculated from the collected data demonstrates that the tested CW represents an advanced wetland design reaching higher removal rates at a smaller area demand than the common CW systems.

Ethical Considerations for Surgical Planners from the Lessons Learned on USNS COMFORT (T-AH 20) Deployment 2019.

Ethical issues can arise when planning for direct patient care surgical missions. Based on the lessons learned from the USNS COMFORT Deployment 2019, the authors present concise considerations and recommendations for future hospital ship surgical mission planning.

Outcomes That Matter Most to Young Adults Diagnosed with Cancer: A Qualitative Study.

Purpose: The purpose of this study is to provide insight for improvement in care for young adults diagnosed with cancer (YADC), by identifying underemphasized outcomes that strongly matter to YADC and the gaps in care that may limit achieving these outcomes for this unique and vulnerable population. Methods: Twenty-seven YADC, ages 25-39, participated in unstructured discussions focusing on topics relating to diagnosis, daily experiences living with cancer outside of the clinical setting, goals, concerns, and clinical care experience. Most participants engaged in group discussions using Experience Group methodology. Discussions were designed to collect information on three dimensions of health: capability, comfort, and calm (CCC). Data were coded using thematic analysis with NVivo software. Results: Several themes were identified within the CCC framework: capability in terms of confronting mortality at a young age, losing youthful identity and control over major life course decisions, especially fertility, and debilitating side effects, comfort in terms of the lack of understanding from peers and family and the fear of cancer recurrence, and calm was discussed as the difficulty of making complex medical decisions, financial toxicity, and loss of clinical support in survivorship. Conclusion: This research highlighted four care additions that are important for YADC: (1) concise and understandable education about their condition and treatment; (2) same-age support groups; (3) fertility support; and (4) better care transitions for life after cancer. These findings emphasize the importance of creating a collaborative, multidisciplinary care team and a holistic approach with care innovations that support clinicians to meet the unique needs of YADC.

Spontaneous Vitreous Hemorrhage in a Naval Aviator.

BACKGROUND: Spontaneous vitreous hemorrhage is uncommon in the general population. Of cases, 1020% are idiopathic or due to occult causes and a majority of the remainder are associated with diabetic disease. The evaluation and disposition of an aviator has not been reported previously. This case will document the work-up and safe return to flight of a patient.CASE REPORT: A 33-yr-old male MH-60R pilot presented with acute blurred vision in the left eye and eye pain which began at his desk. His review of systems was otherwise negative. His medical history was noncontributory. On initial examination his vital signs and external ocular exam were normal. He was immediately referred to the optometry clinic, where a dilated funduscopic examination (DFE) with scleral depression demonstrated a large floater OS composed of streaks of blood and tobacco dust. His DFE was otherwise normal with no retinal tears or vitreous detachments. On repeated DFEs, his intraoccular pressures remained normal and his hemorrhage resorbed without decreased visual acuity or field deficits. A hematologic work-up was negative. After 4 mo of observation, the patient was returned to flight status without further recurrence.DISCUSSION: No known associations exist between aeronautical duties and spontaneous vitreous hemorrhages. The stressors aviators are subjected to, such as high vibrations and increased g forces, may make them more likely to suffer intraocular microvascular damage that could lead to retinal detachment, vitreous detachment, and bleeding. Further reports are needed to determine the risks of recurrence in aviators and their differences from typical spontaneous vitreous hemorrhage patients.Wallace SA. Spontaneous vitreous hemorrhage in a naval aviator. Aerosp Med Hum Perform. 2020; 91(11):904907.

A review of emerging organic contaminants (EOCs), antibiotic resistant bacteria (ARB), and antibiotic resistance genes (ARGs) in the environment: Increasing removal with wetlands and reducing environmental impacts.

Emerging organic contaminants (EOCs) include a diverse group of chemical compounds, such as pharmaceuticals and personal care products (PPCPs), pesticides, hormones, surfactants, flame retardants and plasticizers. Many of these compounds are not significantly removed in conventional wastewater treatment plants and are discharged to the environment, presenting an increasing threat to both humans and natural ecosystems. Recently, antibiotics have received considerable attention due to growing microbial antibiotic-resistance in the environment. Constructed wetlands (CWs) have proven effective in removing many EOCs, including different antibiotics, before discharge of treated wastewater into the environment. Wastewater treatment systems that couple conventional treatment plants with constructed and natural wetlands offer a strategy to remove EOCs and reduce antibiotic resistant bacteria (ARB) and antibiotic resistance genes (ARGs) far more efficiently than conventional treatment alone. This review presents as overview of the current knowledge on the efficiency of different wetland systems in reducing EOCs and antibiotic resistance.

Defining and Implementing Value-Based Health Care: A Strategic Framework.

Value in health care is the measured improvement in a person's health outcomes for the cost of achieving that improvement. While some descriptions conflate value-based health care and cost reduction, quality improvement, or patient satisfaction, those efforts-while important-are not the same as value, which focuses primarily on improving patient health outcomes. A decade of research into organizations that have achieved better outcomes while often lowering costs suggests a strategic framework for value-based health care implementation that starts with identifying and understanding a segment of patients whose health and related circumstances create a consistent set of needs. An interdisciplinary team of caregivers then comes together to design and deliver comprehensive solutions to address those needs. The team measures the health outcomes and costs of its care for each patient and uses that information to drive ongoing improvements. Care provided in this way aligns delivery with how patients experience their health and reconnects clinicians to their purpose as healers. It also asks physicians to think differently about their role within the larger care team and about the services that team provides. The authors suggest medical schools should incorporate education on the principles and implementation of value-based health care throughout the undergraduate medical curriculum to prepare their graduates to lead the transformation to value-based health care as they enter the physician workforce.

Side-by-side comparison of 15 pilot-scale conventional and intensified subsurface flow wetlands for treatment of domestic wastewater.

This study reports a systematic assessment of treatment efficacy for 15 pilot-scale subsurface flow constructed wetlands of different designs for CBOD5, TSS, TOC, TN, NH4-N, NO3-N, NO2-N, and E. coli over the course of one year in an outdoor study to evaluate the effects of design and plants. The systems consisted of a range of designs: horizontal flow (HF) with 50 and 25 cm depth, unsaturated vertical flow (VF) with sand or fine gravel, and intensified systems (horizontal and saturated vertical flow with aeration, and reciprocating fill and drain). Each system was built in duplicate: one was planted with Phragmites and one was left unplanted (with the exception of the reciprocating system, of which there was only one and it was unplanted). All systems were fed with the same primary-treated domestic wastewater. Effluent concentrations, areal and volumetric mass removal rates, and percent mass removal for the 15 systems are discussed. HF wetlands removed CBOD5, TSS, TN, NH4-N and E. coli by 73-83%, 93-95%, 17-41%, 0-27% and 1.5 log units, respectively. Unsaturated VF and aerated VF wetlands removed CBOD5, TSS, TN, NH4-N and E. coli by 69-99%, 76-99%, 17-40%, 69-99% and 0.9-2.4 log units, respectively. The aerated HF and reciprocating systems removed CBOD5, TSS, TN, NH4-N and E. coli by 99%, 99%, 43-70%, 94-99% and 3.0-3.8 log units, respectively. The aerated HF and reciprocating systems achieved the highest TN removal rate of all of the designs. Design complexity clearly enhanced treatment efficacy (HF < VF < Intensified, p < 0.001) during the first two years of plant growth while the presence of plants had minor effects on TN and NH4-N removal in the shallow HF design only.