Integrated Wastewater Management for Health and Valorization

"Adequate wastewater treatment in low to medium income cities worldwide has largely been a failure despite decades of funding. The still dominant end-of-pipe paradigm of treatment for surface water discharge, focusing principally on removal of organic matter, has not addressed the well-published problems of pathogen and nutrient release with continued contamination of surface waters. This book incorporates the new paradigm of integrated wastewater management for valorization without surface water discharge using waste stabilization pond systems and wastewater reservoirs. In this paradigm the purpose of treatment is to protect health by reducing pathogens to produce an effluent that is valorized for its fertilizer and water value for agriculture and aquaculture. Methane production as a sustainable energy source is also considered for those applications where it is appropriate. Emphasis is on sustainable engineering solutions for low to medium income cities worldwide. Chapters present the theory of design, followed by design procedures, example design problems, and case study examples with data, diagrams and photos of operating systems. Excel spreadsheets and the FAO program CLIMWAT/CROPWAT are included in examples throughout. Sections on engineering practice include technical training, operation and maintenance requirements, construction and sustainability. The book incorporates design and operating data and case studies from Africa, Australia, Latin America, Europe, New Zealand, and the US, including studies that have been published in French, Portuguese, and Spanish.

Integrated Wastewater Management for Health and Valorization

"Adequate wastewater treatment in low to medium income cities worldwide has largely been a failure despite decades of funding. The still dominant end-of-pipe paradigm of treatment for surface water discharge, focusing principally on removal of organic matter, has not addressed the well-published problems of pathogen and nutrient release with continued contamination of surface waters. This book incorporates the new paradigm of integrated wastewater management for valorization without surface water discharge using waste stabilization pond systems and wastewater reservoirs. In this paradigm the purpose of treatment is to protect health by reducing pathogens to produce an effluent that is valorized for its fertilizer and water value for agriculture and aquaculture. Methane production as a sustainable energy source is also considered for those applications where it is appropriate. Emphasis is on sustainable engineering solutions for low to medium income cities worldwide. Chapters present the theory of design, followed by design procedures, example design problems, and case study examples with data, diagrams and photos of operating systems. Excel spreadsheets and the FAO program CLIMWAT/CROPWAT are included in examples throughout. Sections on engineering practice include technical training, operation and maintenance requirements, construction and sustainability. The book incorporates design and operating data and case studies from Africa, Australia, Latin America, Europe, New Zealand, and the US, including studies that have been published in French, Portuguese, and Spanish.

Inpatient hypoglycaemia; should we should we focus on the guidelines, the targets or our tools?

In their thought‐provoking commentary, Levy et al. [1] explore the possible unintended consequences of United Kingdom (UK) guideline targets on the high frequency of hypoglycaemia in people with diabetes who are hospitalized. The authors cite the National Institute for Health and Care Excellence (NICE) and the Joint British Diabetes Societies (JBDS) guidelines pertaining to inpatient, surgical and pregnancy diabetes care. These guidelines suggest using lower limits of glucose targets varying from 4.0 to 6.0 mmol/l [2–4]. Levy et al. propose a lower glucose limit of 5 mmol/l with the catchphrase ‘stop at 5 and keep the inpatient alive’

The geochemical partitioning and bioavailability of trace metals in marine sediments

Trace metals in the aquatic environment are generally concentrated on the surface of solid geochemical phases which eventually become incorporated into estuarine and marine sediments. The mechanism of trace metal concentration is believed to be adsorption with various geochemical phases such as hydrous metal oxides, clays, and organic matter. Metals in estuarine or marine sediments can thus be expected to be partitioned between different phases, depending on the concentration of the phase and the strength of the adsorption bond. The bioavailability of sediment-bound metals to deposit-feeding organisms will depend on trace metal partitioning and the kinetics of biological metal uptake from each geochemical phase. The present study was undertaken to develop models for trace metal partitioning and bioavailability in marine sediments. An equilibrium adsorption model was developed that can be used to predict the partitioning of trace metals between different geochemical phases in aquatic sediments from laboratory studies. The model uses conditional equilibrium constants determined from the linear portion of an adsorption isotherm. Conditional equilibrium constants deterit mined for the adsorption of Cu and Cd on bentonite clay, Fe(OH)₃, Mn0₂, and humic acid in seawater show that the model is applicable for trace metal concentrations existing in the natural environment. Based on the laboratory results, the model predicts that the clay fraction may be a major sink for Cu and Cd in marine sediments. A kinetic bioavailability model was then developed which can be used to estimate the relative bioavailability of trace metals from both different sediment phases and seawater under short-term laboratory conditions. This model was used to determine the bioavailability of Cu and Cd from several sediment phases (bentonite clay, humic acid, Fe(OH)₃) and seawater to the deposit-feeding polychaete worm, Abarenicola pacifica. The results suggest that, under natural conditions similar to those used in this study, the bioavailability of sediment-bound Cu and Cd to A. pacifica can be much more significant than that of seawater

Protocol for a process evaluation of a cluster randomised controlled trial to improve management of multimorbidity in general practice:the 3D study

Introduction: As an increasing number of people are living with more than 1 long-term condition, identifying effective interventions for the management of multimorbidity in primary care has become a matter of urgency. Interventions are challenging to evaluate due to intervention complexity and the need for adaptability to different contexts. A process evaluation can provide extra information necessary for interpreting trial results and making decisions about whether the intervention is likely to be successful in a wider context. The 3D (dimensions of health, drugs and depression) study will recruit 32 UK general practices to a cluster randomised controlled trial to evaluate effectiveness of a patient-centred intervention. Practices will be randomised to intervention or usual care. Methods and analysis: The aim of the process evaluation is to understand how and why the intervention was effective or ineffective and the effect of context. As part of the intervention, quantitative data will be collected to provide implementation feedback to all intervention practices and will contribute to evaluation of implementation fidelity, alongside case study data. Data will be collected at the beginning and end of the trial to characterise each practice and how it provides care to patients with multimorbidity. Mixed methods will be used to collect qualitative data from 4 case study practices, purposively sampled from among intervention practices. Qualitative data will be analysed using techniques of constant comparison to develop codes integrated within a flexible framework of themes. Quantitative and qualitative data will be integrated to describe case study sites and develop possible explanations for implementation variation. Analysis will take place prior to knowing trial outcomes. Ethics and dissemination: Study approved by South West (Frenchay) National Health Service (NHS) Research Ethics Committee (14/SW/0011). Findings will be disseminated via a final report, peer-reviewed publications and practical guidance to healthcare professionals, commissioners and policymakers

Peer-mentoring for first-time mothers from areas of socio-economic disadvantage: A qualitative study within a randomised controlled trial

<p>Abstract</p> <p>Background</p> <p>Non-professional involvement in delivering health and social care support in areas of socio-economic deprivation is considered important in attempting to reduce health inequalities. However, trials of peer mentoring programmes have yielded inconsistent evidence of benefit: difficulties in implementation have contributed to uncertainty regarding their efficacy. We aimed to explore difficulties encountered in conducting a randomised controlled trial of a peer-mentoring programme for first-time mothers in socially disadvantaged areas, in order to provide information relevant to future research and practice. This paper describes the experiences of lay-workers, women and health professionals involved in the trial.</p> <p>Methods</p> <p>Thematic analysis of semi-structured interviews with women (n = 11) who were offered peer mentor support, lay-workers (n = 11) who provided mentoring and midwives (n = 2) who supervised the programme, which provided support, from first hospital antenatal visit to one year postnatal. Planned frequency of contact was two-weekly (telephone or home visit) but was tailored to individuals' needs.</p> <p>Results</p> <p>Despite lay-workers living in the same locality, they experienced difficulty initiating contact with women and this affected their morale adversely. Despite researchers' attempts to ensure that the role of the mentor was understood clearly it appeared that this was not achieved for all participants. Mentors attempted to develop peer-mentor relationships by offering friendship and sharing personal experiences, which was appreciated by women. Mentors reported difficulties developing relationships with those who lacked interest in the programme. External influences, including family and friends, could prevent or facilitate mentoring. Time constraints in reconciling flexible mentoring arrangements with demands of other commitments posed major personal difficulties for lay-workers.</p> <p>Conclusion</p> <p>Difficulties in initiating contact, developing peer-mentor relationships and time constraints pose challenges to delivering lay-worker peer support. In developing such programmes, awareness of potential difficulties and of how professional support may help resolve these should improve uptake and optimise evaluation of their effectiveness.</p> <p>Trial Registration Number: ISRCTN55055030</p

Process evaluation for complex interventions in primary care: understanding trials using the normalization process model

Background: the Normalization Process Model is a conceptual tool intended to assist in understanding the factors that affect implementation processes in clinical trials and other evaluations of complex interventions. It focuses on the ways that the implementation of complex interventions is shaped by problems of workability and integration.Method: in this paper the model is applied to two different complex trials: (i) the delivery of problem solving therapies for psychosocial distress, and (ii) the delivery of nurse-led clinics for heart failure treatment in primary care.Results: application of the model shows how process evaluations need to focus on more than the immediate contexts in which trial outcomes are generated. Problems relating to intervention workability and integration also need to be understood. The model may be used effectively to explain the implementation process in trials of complex interventions.Conclusion: the model invites evaluators to attend equally to considering how a complex intervention interacts with existing patterns of service organization, professional practice, and professional-patient interaction. The justification for this may be found in the abundance of reports of clinical effectiveness for interventions that have little hope of being implemented in real healthcare setting

Loss of ELK1 has differential effects on age-dependent organ fibrosis and integrin expression

ETS domain-containing protein-1 (ELK1) is a transcription factor important in regulating αvβ6 integrin expression. αvβ6 integrins activate the profibrotic cytokine Transforming Growth Factor β1 (TGFβ1) and are increased in the alveolar epithelium in idiopathic pulmonary fibrosis (IPF). IPF is a disease associated with aging and therefore we hypothesised that aged animals lacking Elk1 globally would develop spontaneous fibrosis in organs where αvβ6 mediated TGFβ activation has been implicated. Here we identify that Elk1-knockout (Elk1−/0) mice aged to one year developed spontaneous fibrosis in the absence of injury in both the lung and the liver but not in the heart or kidneys. The lungs of Elk1−/0 aged mice demonstrated increased collagen deposition, in particular collagen 3α1, located in small fibrotic foci and thickened alveolar walls. Despite the liver having relatively low global levels of ELK1 expression, Elk1−/0 animals developed hepatosteatosis and fibrosis. The loss of Elk1 also had differential effects on Itgb1, Itgb5 and Itgb6 expression in the four organs potentially explaining the phenotypic differences in these organs. To understand the potential causes of reduced ELK1 in human disease we exposed human lung epithelial cells and murine lung slices to cigarette smoke extract, which lead to reduced ELK1 expression andmay explain the loss of ELK1 in human disease. These data support a fundamental role for ELK1 in protecting against the development of progressive fibrosis via transcriptional regulation of beta integrin subunit genes, and demonstrate that loss of ELK1 can be caused by cigarette smoke