Sludge management paradigms: impact of priority substances and priority hazardous substances

As a by-product of treatment processes, municipal wastewater treatment plants (WWTP) generate large quantities of sludge, with sludge treatment focused on sterilisation, volume reduction and biogas production. Whilst the EU Sewage Sludge Directive sets limits on the concentrations of selected metals in sludge applied to agricultural land, the potential impact of many EU Water Framework Directive priority and priority hazardous substances (PS/PHS) on human or environmental health has yet to be fully addressed. Research presented here shows that treated sludge from five urban WWTPs experiencing differing local conditions contain a range of PS/PHS including substances whose use has been banned or heavily restricted. Concentrations reported in this study do not exceed the limit values set for the four PS/PHS currently included in the EU Sewage Sludge Directive. However, more stringent national limits are exceeded. The basis for developing and applying Predicted No Effect Concentration (PNEC) values for the application of sludge to agricultural land is still unclear. However, comparison between PS/PHS sludge concentrations and available PNEC soil values clearly indicate the need for further research. Implications and research priorities arising from these findings in terms of achieving compliance with EU Sewage Sludge and Water Framework Directives are discussed

Pulse oximetry and oxygen services for the care of children with pneumonia attending frontline health facilities in Lagos, Nigeria (INSPIRING-Lagos): study protocol for a mixed-methods evaluation

INTRODUCTION: The aim of this evaluation is to understand whether introducing stabilisation rooms equipped with pulse oximetry and oxygen systems to frontline health facilities in Ikorodu, Lagos State, alongside healthcare worker (HCW) training improves the quality of care for children with pneumonia aged 0-59 months. We will explore to what extent, how, for whom and in what contexts the intervention works. METHODS AND ANALYSIS: Quasi-experimental time-series impact evaluation with embedded mixed-methods process and economic evaluation. SETTING: seven government primary care facilities, seven private health facilities, two government secondary care facilities. TARGET POPULATION: children aged 0-59 months with clinically diagnosed pneumonia and/or suspected or confirmed COVID-19. INTERVENTION: 'stabilisation rooms' within participating primary care facilities in Ikorodu local government area, designed to allow for short-term oxygen delivery for children with hypoxaemia prior to transfer to hospital, alongside HCW training on integrated management of childhood illness, pulse oximetry and oxygen therapy, immunisation and nutrition. Secondary facilities will also receive training and equipment for oxygen and pulse oximetry to ensure minimum standard of care is available for referred children. PRIMARY OUTCOME: correct management of hypoxaemic pneumonia including administration of oxygen therapy, referral and presentation to hospital. SECONDARY OUTCOME: 14-day pneumonia case fatality rate. Evaluation period: August 2020 to September 2022. ETHICS AND DISSEMINATION: Ethical approval from University of Ibadan, Lagos State and University College London. Ongoing engagement with government and other key stakeholders during the project. Local dissemination events will be held with the State Ministry of Health at the end of the project (December 2022). We will publish the main impact results, process evaluation and economic evaluation results as open-access academic publications in international journals. TRIAL REGISTRATION NUMBER: ACTRN12621001071819; Registered on the Australian and New Zealand Clinical Trials Registry

Interventions for families affected by HIV

Family-based interventions are efficacious for human immunodeficiency virus (HIV) detection, prevention, and care, but they are not broadly diffused. Understanding intervention adaptation and translation processes can support evidence-based intervention (EBI) diffusion processes. This paper provides a narrative review of a series of EBI for families affected by HIV (FAH) that were adapted across five randomized controlled trials in the US, Thailand, and South Africa over 15 years. The FAH interventions targeted parents living with HIV and their children or caregiver supports. Parents with HIV were primarily mothers infected through sexual transmission. The EBIs for FAH are reviewed with attention to commonalities and variations in risk environments and intervention features. Frameworks for common and robust intervention functions, principles, practice elements, and delivery processes are utilized to highlight commonalities and adaptations for each location, time period, and intervention delivery settings. Health care, housing, food, and financial security vary dramatically in each risk environment. Yet, all FAH face common health, mental health, transmission, and relationship challenges. The EBIs efficaciously addressed these common challenges and were adapted across contexts with fidelity to robust intervention principles, processes, factors, and practices. Intervention adaptation teams have a series of structural decision points: mainstreaming HIV with other local health priorities or not; selecting an optimal delivery site (clinics, homes, community centers); and how to translate intervention protocols to local contexts and cultures. Replication of interventions with fidelity must occur at the level of standardized functions and robust principles, processes, and practices, not manualized protocols. Adopting a continuous quality improvement paradigm will enhance rapid and global diffusion of EBI for FAH

Status Update and Interim Results from the Asymptomatic Carotid Surgery Trial-2 (ACST-2)

Objectives: ACST-2 is currently the largest trial ever conducted to compare carotid artery stenting (CAS) with carotid endarterectomy (CEA) in patients with severe asymptomatic carotid stenosis requiring revascularization. Methods: Patients are entered into ACST-2 when revascularization is felt to be clearly indicated, when CEA and CAS are both possible, but where there is substantial uncertainty as to which is most appropriate. Trial surgeons and interventionalists are expected to use their usual techniques and CE-approved devices. We report baseline characteristics and blinded combined interim results for 30-day mortality and major morbidity for 986 patients in the ongoing trial up to September 2012. Results: A total of 986 patients (687 men, 299 women), mean age 68.7 years (SD ± 8.1) were randomized equally to CEA or CAS. Most (96%) had ipsilateral stenosis of 70-99% (median 80%) with contralateral stenoses of 50-99% in 30% and contralateral occlusion in 8%. Patients were on appropriate medical treatment. For 691 patients undergoing intervention with at least 1-month follow-up and Rankin scoring at 6 months for any stroke, the overall serious cardiovascular event rate of periprocedural (within 30 days) disabling stroke, fatal myocardial infarction, and death at 30 days was 1.0%. Conclusions: Early ACST-2 results suggest contemporary carotid intervention for asymptomatic stenosis has a low risk of serious morbidity and mortality, on par with other recent trials. The trial continues to recruit, to monitor periprocedural events and all types of stroke, aiming to randomize up to 5,000 patients to determine any differential outcomes between interventions. Clinical trial: ISRCTN21144362. © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved

Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding: UK Medical Research Council and Health Technology Assessment Programme

Endobridging of Iliac Artery Avulsion Complicating Endovascular Aortic Aneurysm Repair

: Introduction: Iliac avulsion is a potentially catastrophic complication of endovascular procedures, which requires immediate recognition and repair. This study describes an innovative approach to manage this serious complication. Report: An 81-year-old male presenting with a 113-mm infra-renal abdominal aortic aneurysm and bilateral iliofemoral atherosclerosis, including a complete left-sided occlusion, was referred for urgent endovascular aneurysm repair. Repair was approached using an aorto-uniliac endograft deployed through a right iliofemoral bypass conduit. The procedure was complicated by complete avulsion of the common iliac artery close to its origin. Haemostatic control was achieved by deploying an endo-balloon initially over the femoral wire, which was subsequently exchanged with an occlusion balloon from a brachial access point. A bridging iliac limb endograft was deployed across the defect and anchored to the native common iliac artery proximally and distally by interrupted sutures. The remainder of the procedure was completed as planned. Discussion: This case highlights a successful endovascular strategy to control a potentially lethal haemorrhage. Keywords: Endovascular aneurysm repair, Iliac avulsion, Aortic aneurys

Development of a database to support the assessment of potential source control and treatment options for priority pollutants.

Reducing the emissions of priority pollutants (PPs) from urban areas into receiving waters presents a challenge both to the regulating authorities and to industry. In order to support such practitioners in this task, the European ScorePP project aims to develop comprehensive source control strategies that can be used to reduce the emissions of 33 priority substances (with a special focus on the 11 priority hazardous substances) identified in the European Water Framework Directive (WFD; 2000/60/EC). The objectives of the ScorePP project are thus to identify the sources of PPs in urban areas, and to identify and assess appropriate strategies for limiting the releases of PPs from these urban sources and associated PP containing waste streams. The emission control approaches for targeting PPs within a range of wastewater types has been conducted at a variety of scales (e.g. close to the pollutant generating source, end-of-pipe or urban drainage system level) in relartion to a range of different characteristics (e.g. removal efficiency). This paper will focus on the development of a database and decision-support tool to support the transfer of knowledge on existing source control and treatment options withina GIS format