Purpose Management of empyema has been debated in the literature for decades. Although both primary video-assisted thoracoscopic surgery (VATS) and tube thoracostomy with pleural instillation of fibrinolytics have been shown to result in early resolution when compared to tube thoracostomy alone, there is a lack of comparative data between these modes of management. Therefore, we conducted a prospective, randomized trial comparing VATS to fibrinolytic therapy in children with empyema. Methods After Institutional Review Board approval, children defined as having empyema by either loculation on imaging or more than 10,000 white blood cells/μL were treated with VATS or fibrinolysis. Based on our retrospective data using length of postoperative hospitalization as the primary end point, a sample size of 36 patients was calculated for an α of .5 and a power of 0.8. Fibrinolysis consisted of inserting a 12F chest tube followed by infusion of 4 mg tissue plasminogen activator mixed with 40 mL of normal saline at the time of tube placement followed by 2 subsequent doses 24 hours apart. Results At diagnosis, there were no differences between groups in age, weight, degree of oxygen support, white blood cell count, or days of symptoms. The outcome data showed no difference in days of hospitalization after intervention, days of oxygen requirement, days until afebrile, or analgesic requirements. Video-assisted thoracoscopic surgery was associated with significantly higher charges. Three patients (16.6%) in the fibrinolysis group subsequently required VATS for definitive therapy. Two patients in the VATS group required ventilator support after therapy, one of whom required temporary dialysis. No patient in the fibrinolysis group clinically worsened after initiation of therapy. Conclusions There are no therapeutic or recovery advantages between VATS and fibrinolysis for the treatment of empyema; however, VATS resulted in significantly greater charges. Fibrinolysis may pose less risk of acute clinical deterioration and should be the first-line therapy for children with empyema.

In the 21st century, even with the advent of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), the existing built environment still fails the neighborhood accessibility needs of people with disability. People with disabilities' human right to the neighborhood is, at face value, enshrined in legislation and 'much' built environment accessibility legislation is in place. But, built environment accessibility practice has been, and continues to be, shaped by a hidden discourse based on theoretical underpinnings little understood by built environment practitioners. Similarly, built environment practitioners have little understanding of either the diversity of the human condition or the accessibility needs of people with disability. In Australia, the operationalization of built environment accessibility rights is, via opaque legislation, not necessarily reflective of the lived experience of people with disability, and weak in terms of built environment spatial coverage. Empirically, little is known about the extent of built environment inaccessibility, particularly neighborhood inaccessibility. Therefore, the question explored in this paper is: How might an understanding of models of disability and human rights inform the improvement of built environment accessibility, for people with disability, at a neighborhood scale? Literature related to disability and human rights theory, built environment accessibility legislation primarily using Australia as an example, and built environment accessibility assessment is drawn together. This paper argues that built environment practitioners must recognize the disabling potency of current built environment practice, that built environment practitioners need to engage directly with people with disability to improve understanding of accessibility needs, and that improved measure, at neighborhood scale, of the extent of existing built environment inaccessibility is required.

PurposeThe COVID-19 pandemic has engendered changes in previously unimaginable timeframes, leading to new ways of working, which can quickly become the “ordinary” way of working. Many traditional workplace and educational practices and environments, however, are disadvantageous to people with disability and consequently are under-represented in the workforce and higher education.Design/methodology/approachContributing factors include exclusionary societal and employer attitudes and inaccessible built environments including lack of attention to paths of travel, amenities, acoustics, lighting and temperature. Social exclusion resulting from lack of access to meaningful work is also problematic. COVID-19 has accelerated the incidence of working and studying from home, but the home environment of many people with disability may not be suitable in terms of space, privacy, technology access and connection to the wider community.FindingsHowever, remote and flexible working arrangements may hold opportunities for enhancing work participation of people with disabilities. Instigating systemic conditions that will empower people with disability to take full advantage of ordinary working trajectories is key. As the current global experiment in modified work and study practices has shown, structural, organisational and design norms need to change. The future of work and study is almost certainly more work and study from home. An expanded understanding of people with disabilities lived experience of the built environment encompassing opportunities for work, study and socialisation from home and the neighbourhood would more closely align with the UNCRPD's emphasis on full citizenship.Originality/valueThis paper examines what is currently missing in the development of a distributed work and study place continuum that includes traditional workplaces and campuses, local neighbourhood hubs and homes.

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