Reimagining large river management using the Resist–Accept–Direct (RAD) framework in the Upper Mississippi River

Background: Large-river decision-makers are charged with maintaining diverse ecosystem services through unprecedented social-ecological transformations as climate change and other global stressors intensify. The interconnected, dendritic habitats of rivers, which often demarcate jurisdictional boundaries, generate complex management challenges. Here, we explore how the Resist–Accept–Direct (RAD) framework may enhance large-river management by promoting coordinated and deliberate responses to social-ecological trajectories of change. The RAD framework identifies the full decision space of potential management approaches, wherein managers may resist change to maintain historical conditions, accept change toward different conditions, or direct change to a specified future with novel conditions. In the Upper Mississippi River System, managers are facing social-ecological transformations from more frequent and extreme high-water events. We illustrate how RAD-informed basin-, reach-, and site-scale decisions could: (1) provide cross-spatial scale framing; (2) open the entire decision space of potential management approaches; and (3) enhance coordinated inter-jurisdictional management in response to the trajectory of the Upper Mississippi River hydrograph. Results: The RAD framework helps identify plausible long-term trajectories in different reaches (or subbasins) of the river and how the associated social-ecological transformations could be managed by altering site-scale conditions. Strategic reach-scale objectives may reprioritize how, where, and when site conditions could be altered to contribute to the basin goal, given the basin’s plausible trajectories of change (e.g., by coordinating action across sites to alter habitat connectivity, diversity, and redundancy in the river mosaic). Conclusions: When faced with long-term systemic transformations (e.g., \u3e 50 years), the RAD framework helps explicitly consider whether or when the basin vision or goals may no longer be achievable, and direct options may open yet unconsidered potential for the basin. Embedding the RAD framework in hierarchical decision-making clarifies that the selection of actions in space and time should be derived from basin-wide goals and reach-scale objectives to ensure that site-scale actions contribute effectively to the larger river habitat mosaic. Embedding the RAD framework in large-river decisions can provide the necessary conduit to link flexibility and innovation at the site scale with stability at larger scales for adaptive governance of changing social-ecological systems

Assessing Symptom Burden and Depression in Subjects With Chronic Respiratory Insufficiency

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Survival and end-of-life aspects among subjects on long-term noninvasive ventilation

Background: The need for noninvasive ventilation (NIV) is commonly considered a predictor of poor survival, but life expectancy may vary depending on the underlying disease. We studied the factors associated with decreased survival and end-of-life characteristics in an unselected population of subjects starting NIV. Methods: We conducted a retrospective study including 205 subjects initiating NIV from 1/1/2012-31/12/2015 who were followed up until 31/12/2017. Results: The median survival time was shorter in subjects needing help with activities of daily living than in independent subjects (hazard ratio (HR) for death 1.7, 95% CI 1.2-2.6, P = 0.008) and was also shorter in subjects on long-term oxygen therapy (LTOT) than in those not on LTOT (HR for death 2.8, 95% CI 1.9-4.3, P < 0.001). There was marked difference in survival according to the disease necessitating NIV, and subjects with amyotrophic lateral sclerosis or interstitial lung disease seemed to have the shortest survival. The two most common diseases resulting in the need for NIV were chronic obstructive pulmonary disease (COPD) and obesity hypoventilation syndrome (OHS). The median survival time was 4.4 years in COPD subjects, but the median survival time was not reached in subjects with OHS (HR for death COPD vs. OHS: 3.2, 95% CI 1.9-5.5, P < 0.001). Most of the deceased subjects (55.6%) died in the hospital, while only 20.0% died at home. The last hospitalization admission leading to death occurred through the emergency room in 44.4% of the subjects. Conclusions: Survival among subjects starting NIV in this real-life study varied greatly depending on the disease and degree of functional impairment. Subjects frequently died in the hospital after admission through the emergency department. A comprehensive treatment approach with timely advance care planning is therefore needed, especially for those needing help with activities of daily living and those with both NIV and LTOT.publishedVersionPeer reviewe

Palliation of Dyspnea with Mouthpiece Ventilation in Patients with Chronic Obstructive Pulmonary Disease: A Pilot Feasibility Study

Background: Mouthpiece ventilation (MPV) reduces hypoventilation, but its efficacy in relieving dyspnea in patients with acute chronic obstructive pulmonary disease exacerbation (AECOPD) is unclear. Objective: To assess the feasibility of MPV in relieving dyspnea among patients with AECOPD. Methods: In this prospective single-arm pilot study, the change in dyspnea on numeric rating scale (NRS) after using MPV and side effects of the treatment were studied in 18 patients with AECOPD. Results: The median decrease in dyspnea was 1.5 (95% confidence interval = 0.0–2.5, p = 0.006) on NRS after the intervention lasting a median of 16.9 minutes. Of the patients, 61% found MPV beneficial. The use of MPV did not increase the sense of anxiety or pain. Conclusions: MPV is feasible and may relieve dyspnea in patients with AECOPD, but the intervention needs further evaluation.Peer reviewe

A gamified mobile health intervention for children in day surgery care:protocol for a randomized controlled trial

Abstract Aims: To describe a study protocol for a randomized controlled trial which will evaluate the effectiveness of a gamified mobile health intervention for children in whole day surgery care. Design: A study protocol for a two-arm randomized controlled trial. Methods: Participants will be randomly assigned to the intervention group (N = 62), in which patients receive routine care and play a mobile game designed for children or the control group (N = 62), in which patients receive routine care, including a mobile phone application that supports parents during the care path. The primary outcome is children’s pre-operative anxiety, while the secondary outcome measures included fear and postoperative pain, along with parental satisfaction and anxiety. Data collection started in August 2020. Results: The results of the ongoing randomized controlled trial will determine whether the developed gamified mobile health intervention can be recommended for hospital use, and whether it could be used to educate children about their surgical treatment to decrease anxiety