Strategic planning of the integrated urban wastewater system using adaptation pathways.

Emerging threats such as climate change and urbanisation pose an unprecedented challenge to the integrated management of urban wastewater systems, which are expected to function in a reliable, resilient and sustainable manner regardless of future conditions. Traditional long term planning is rather limited in developing no-regret strategies that avoid maladaptive lock-ins in the near term and allow for flexibility in the long term. In this study, a novel adaptation pathways approach for urban wastewater management is developed in order to explore the compliance and adaptability potential of intervention strategies in a long term operational period, accounting for different future scenarios and multiple performance objectives in terms of reliability, resilience and sustainability. This multi-criteria multi-scenario approach implements a regret-based method to assess the relative performance of two types of adaptation strategies: (I) standalone strategies (i.e. green or grey strategies only); and (II) hybrid strategies (i.e. combined green and grey strategies). A number of adaptation thresholds (i.e. the points at which the current strategy can no longer meet defined objectives) are defined to identify compliant domains (i.e. periods of time in a future scenario when the performance of a strategy can meet the targets). The results obtained from a case study illustrate the trade-off between adapting to short term pressures and addressing long term challenges. Green strategies show the highest performance in simultaneously meeting near and long term needs, while grey strategies are found less adaptable to changing circumstances. In contrast, hybrid strategies are effective in delivering both short term compliance and long term adaptability. It is also shown that the proposed adaption pathways method can contribute to the identification of adaptation strategies that are developed as future conditions unfold, allowing for more flexibility and avoiding long term commitment to strategies that may cause maladaptation. This provides insights into the near term and long term planning of ensuring the reliability, resilience and sustainability of integrated urban drainage systems.

Reliable, Resilient and Sustainable Urban Drainage Systems: An Analysis of Robustness under Deep Uncertainty.

Reliability, resilience and sustainability are key goals of any urban drainage system. However, only a few studies have recently focused on measuring, operationalizing and comparing such concepts in a world of deep uncertainty. In this study, these key concepts are defined and quantified for a number of gray, green and hybrid strategies, aimed at improving the capacity issues of an existing integrated urban wastewater system. These interventions are investigated by means of a regret-based approach, which evaluates the robustness (that is the ability to perform well under deep uncertainty conditions) of each strategy in terms of the three qualities through integration of multiple objectives (i.e., sewer flooding, river water quality, combined sewer overflows, river flooding, greenhouse gas emissions, cost and acceptability) across four different future scenarios. The results indicate that strategies found to be robust in terms of sustainability were typically also robust for resilience and reliability across future scenarios. However, strategies found to be robust in terms of their resilience and, in particular, for reliability did not guarantee robustness for sustainability. Conventional gray infrastructure strategies were found to lack robustness in terms of sustainability due to their unbalanced economic, environmental and social performance. Such limitations were overcome, however, by implementing hybrid solutions that combine green retrofits and gray rehabilitation solutions.

An Integrated Environmental Assessment of Green and Gray Infrastructure Strategies for Robust Decision Making.

The robustness of a range of watershed-scale "green" and "gray" drainage strategies in the future is explored through comprehensive modeling of a fully integrated urban wastewater system case. Four socio-economic future scenarios, defined by parameters affecting the environmental performance of the system, are proposed to account for the uncertain variability of conditions in the year 2050. A regret-based approach is applied to assess the relative performance of strategies in multiple impact categories (environmental, economic, and social) as well as to evaluate their robustness across future scenarios. The concept of regret proves useful in identifying performance trade-offs and recognizing states of the world most critical to decisions. The study highlights the robustness of green strategies (particularly rain gardens, resulting in half the regret of most options) over end-of-pipe gray alternatives (surface water separation or sewer and storage rehabilitation), which may be costly (on average, 25% of the total regret of these options) and tend to focus on sewer flooding and CSO alleviation while compromising on downstream system performance (this accounts for around 50% of their total regret). Trade-offs and scenario regrets observed in the analysis suggest that the combination of green and gray strategies may still offer further potential for robustness.

Appropriate revascularization in stable angina: lessons from the BARI 2D trial.

BACKGROUND: The 2012 Guidelines for Diagnosis and Management of Patients with Stable Ischemic Heart Disease recommend intensive antianginal and risk factor treatment (optimal medical management [OMT]) before considering revascularization to relieve symptoms. The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial randomized patients with ischemic heart disease and anatomy suitable to revascularization to (1) initial OMT with revascularization if needed or (2) initial revascularization plus OMT and found no difference in major cardiovascular events. Ultimately, however, 37.9% of the OMT group was revascularized during the 5-year follow-up period. METHODS: Data from the 1192 patients randomized to OMT were analyzed to identify subgroups in which the incidence of revascularization was so high that direct revascularization without a trial period could be justified. Multivariate logistic analysis, Cox regression models of baseline data, and a landmark analysis of participants who did not undergo revascularization at 6 months were constructed. RESULTS: The models that used only data available at the time of study entry had limited predictive value for revascularization by 6 months or by 5 years; however, the model incorporating severity of angina during the first 6 months could better predict revascularization (C statistic = 0.789). CONCLUSIONS: With the possible exception of patients with severe angina and proximal left anterior descending artery disease, this analysis supports the recommendation of the 2012 guidelines for a trial of OMT before revascularization. Patients could not be identified at the time of catheterization, but a short period of close follow-up during OMT identified the nearly 40% of patients who underwent revascularization.

Using Tic-Tac software to reduce anxiety-related behaviour in adults with autism and learning difficulties during waiting periods: a pilot study.

Deficits in the perception of time and processing of changes across time are commonly observed in individuals with autism. This pilot study evaluated the efficacy of the use of the software tool Tic-Tac, designed to make time visual, in three adults with autism and learning difficulties. This research focused on applying the tool in waiting situations where the participants exhibited anxiety-related behaviour. The intervention followed a baseline and intervention (AB) design, and a partial interval recording procedure was used to code the presence of stereotypes, nervous utterances, wandering or other examples of nervousness during the selected waiting situations. The results showed that the use of Tic-Tac resulted in lower levels of anxiety-related behaviour in all three participants, compared to the baseline, suggesting that this software may be an effective technology for helping people with autism with organisation and predictability during waiting periods. The results are discussed in terms of limitations and implications for further study.

The cost of post-operative shed blood salvage after total knee arthroplasty: an analysis of 1,093 consecutive procedures.

BACKGROUND: Requirements for allogeneic red cell transfusion after total knee arthroplasty are still high (20-50%), and salvage and reinfusion of unwashed, filtered post-operative shed blood is an established method for reducing transfusion requirements following this operation. We performed a cost analysis to ascertain whether this alternative is likely to be cost-effective. MATERIALS AND METHODS: Data from 1,093 consecutive primary total knee arthroplasties, managed with (reinfusion group, n=763) or without reinfusion of unwashed salvaged blood (control group, n=330), were retrospectively reviewed. The costs of low-vacuum drains, shed blood collection canisters (Bellovac ABT, Wellspect HealthCare and ConstaVac CBC II, Stryker), shed blood reinfusion, acquisition and transfusion of allogeneic red cell concentrate, haemoglobin measurements, and prolonged length of hospital stay were used for the blood management cost analysis. RESULTS: Patients in the reinfusion group received 152±64 mL of red blood cells from postoperatively salvaged blood, without clinically relevant incidents, and showed a lower allogeneic transfusion rate (24.5% vs. 8.5%, for the control and reinfusion groups, respectively; p =0.001). There were no differences in post-operative infection rates. Patients receiving allogeneic transfusions stayed in hospital longer (+1.9 days [95% CI: 1.2 to 2.6]). As reinfusion of unwashed salvaged blood reduced the allogeneic transfusion rate, both reinfusion systems may provide net savings in different cost scenarios (€ 4.6 to € 106/patient for Bellovac ABT, and € -51.9 to € 49.9/patient for ConstaVac CBCII). DISCUSSION: Return of unwashed salvaged blood after total knee arthroplasty seems to save costs in patients with pre-operative haemoglobin between 12 and 15 g/dL. It is not cost-saving in patients with a pre-operative haemoglobin >15 g/dL, whereas in those with a pre-operative haemoglobin <12 g/dL, although cost-saving, its efficacy could be increased by associating some other blood-saving method.

Blood donation and blood transfusion in Spain (1997 - 2007): the effects of demographic changes and universal leucoreduction.

BACKGROUND AND OBJECTIVE: As epidemiological information is useful in planning the provision and assessing the efficiency of product use, we reviewed Spanish data on population, blood donation and blood component transfusion from 1997 to 2007, and the possible effect of universal leucoreduction. METHODS: Data on the Spanish population were obtained from the National Institute of Statistics, whereas data on blood donation and blood component transfusion were acquired from the Spanish Ministry of Health. RESULTS: During the study period, the Spanish population increased by 5.6 million persons (14.4%), and blood donation by 28.1%, although the amount of red blood cells (RBC) obtained increased by only 21.5% whereas RBC transfusions increased by 28.3%. The RBC transfusion rate was significantly higher after the implementation of universal leucoreduction (2002 - 2006) than during the pre-leucoreduction period (1997 - 2001) (difference = 2.54 units/1,000 population/year; 95%CI 1.81 - 3.27; P<0.001). We also observed statistical ly, but not clinically, significant differences for platelet and plasma transfusions. CONCLUSION: The increase observed in the RBC transfusion index after implementation of universal leucoreduction may have been due to a reduction of the haemoglobin content in the RBC units. Our data on blood use do, therefore, seem to add to the case against universal leucoreduction, which has led to an incremental cost for unknown, but probably slight, benefits for patients.

[Usefulness of the administration of intravenous iron sucrose for the correction of preoperative anemia in major surgery patients]. / Utilidad de la administración de hierro sacarosa intravenoso para la corrección de la anemia preoperatoria en pacientes programados para cirugía mayor.

BACKGROUND AND OBJECTIVE: There is a high incidence of perioperative anemia among surgical patients (20%-70%). Preoperative anemia has been linked to an increased postoperative morbidity and mortality, as well as a decreased quality of life of surgical patients. In addition, a low preoperative hemoglobin constitutes an important predictive factor of allogeneic blood transfusion in major surgery. We evaluated the efficacy of intravenous iron sucrose (IVIS) administration for correction of anemia in these patient populations. PATIENTS AND METHOD: Data from 84 patients with anemia who were scheduled for major elective surgery (30 colon cancer resections, 33 abdominal hysterectomies, 21 lower limb arthroplasties) and who received preoperative IVIS during 3-5 weeks were propectively collected. RESULTS: Administration of IVIS -mean dose (standard deviation): 1000 (440)mg- caused a significant increase of hemoglobin levels -2.0 (1.6)g/dl (p<0.001)- and anemia was resolved in 58% of patients. No life-threatening adverse effect was witnessed. CONCLUSIONS: Because of the low incidence of side effects and the rapid increase of hemoglobin levels, IVIS emerges as a safe, effective drug for treating preoperative anemia in these patient populations.

[Incidence and mortality of massive transfusion in a university hospital: study of the period 2001-2005]. / Incidencia y mortalidad de la transfusión masiva en un hospital universitario: estudio del período 2001-2005.

BACKGROUND AND OBJECTIVE: There are few epidemiological studies on massive transfusion (MT), although they may be important to evaluate possible strategies to reduce the number of transfused units, as well as transfusion side-effects. We, therefore, retrospectively assessed the incidence of MT at our institution (a 700-bed university hospital) during a 5-year period. PATIENTS AND METHOD: Local blood bank records were searched for MT episodes occurred from January 2001 to December 2005. MT was defined as the transfusion of 8 or more packed red cell (PRC) units within 24 h. Patient's clinical data were exclusively gathered from the blood requesting form. RESULTS: Overall, 304 episodes of MT were identified in 288 patients (one episode per week), who received 4,845 PCR units (3,515 units within the first 24 h), because of ruptured aortic aneurism (n = 62), poly-trauma (n = 57), upper digestive bleeding (n = 51), cardiac surgery (n = 41), elective surgery (n = 36), emergency surgery (n = 30), and oncology surgery (n = 27). Mortality rate was 48%, and multivariate analysis identified age (odds ratio [OR] =1.023; 95% confidence interval [CI]. 1.006-1.040) and number of PRC transfused within the first 24 h (OR = 1.094; 95% CI, 1.0032-1.160) as weak but significant independent predictors of mortality, whereas poly-trauma diagnosis was a protective factor (OR = 0.325; 95% CI, 0.112 - 0,940). CONCLUSIONS: Overall, the mortality rate among patients receiving MT was very high, and was influenced by the number of transfused units, patient's age, and admitting diagnose. As the majority of the MT episodes occurred within the surgical or polytrauma context, possible strategies to reduce the volume of MT are discussed.

Impact of postoperative unwashed shed blood retrieved after total knee arthroplasty on endotoxin-stimulated tumor necrosis factor alpha release in vitro.

BACKGROUND: : Allogeneic or autologous blood seems to have an immunosuppressive effect that is largely attributable to storage-dependent factors. However, transfusion of postoperative unwashed shed blood (USB) after elective total knee replacement does not undergo storage. Therefore, the authors explored the effects of USB on the mitogen-driven cytokine synthesis by the patient's peripheral blood mononuclear cells. METHODS: : Perioperative blood samples were obtained from 12 total knee replacement patients with and 5 without reinfusion of leukoreduced USB, and from USB reinfusion line, before and after leukoreduction. Venous blood obtained at 4-6 postoperative hours was coincubated with USB. Endotoxin-stimulated release of tumor necrosis factor alpha and interleukin 10 was measured after 24 h of culture by solid-phase enzyme-labeled chemiluminescent immunometric assay. RESULTS: : Coincubation of postoperative venous blood with USB, USB cells, or USB plasma resulted in a significant depression of tumor necrosis factor-alpha synthesis, without significant effects on interleukin-10 synthesis. However, no differences were observed for endotoxin-stimulated cytokine release in perioperative blood samples from patients receiving or not receiving USB. CONCLUSION: : These data suggest that USB seemed to contain an antiinflammatory agent. However, at the actual retransfusion rate, USB does not seem to further enhance the immunosuppression that follows knee replacement surgery.

Benefits of postoperative shed blood reinfusion in patients undergoing unilateral total knee replacement.

INTRODUCTION: In patients undergoing total knee replacement (TKR), most of the measured blood loss occurs during the postoperative period, and 30-50% of these patients receive allogeneic blood transfusion (ABT). For this reason, the salvage and return of unwashed filtered shed blood (USB) from postoperative drainage may represent an alternative to ABT in these patients. We have, therefore, evaluated the clinical utility of USB return in TKR patients, with a special focus on patients with mild anaemia. MATERIALS AND METHODS: Data from 200 TKR patients (group 2) receiving USB within the first 6 postoperative hours (ConstaVac CBC II, Sryker) were prospectively collected. A retrospective series of 100 TRK patients served as the control group (group 1). RESULTS: USB return was possible in 162 patients who received a mean of 0.98+/-0.4 U/pte, without any clinically relevant incident. Return of USB decreased both the percentage of patients with ABT (48% vs 11%, for groups 1 and 2, respectively; p < 0.01) and the ABT units/patient index (1.31+/-1.27 vs 0.29+/-0.87 units/patient, respectively; p < 0.01). A transfusion protocol was not established, but there was no difference between groups with respect to either perioperative Hb levels or overall transfusion index, indicating that the transfusion criteria were uniform. However, for the subgroups of patients who needed ABT, the preoperative Hb level was 1 g/dL lower in those receiving USB (13.4+/-1.4 vs 12.4+/-1.2 g/dL; p < 0.05). There was no difference in the postoperative complication rate, and patients in group 2 recovered the ability to walk 1 day earlier, and their hospital stay was 3 days shorter than in group 1 (p < 0.01). CONCLUSIONS: Return of USB after TKR seems to shorten the hospital stay and effectively reduce postoperative requirements for ABT, especially in patients with preoperative Hb > or = 13 g/dL. For patients with preoperative Hb < 13 g/dL, although the return of USB also decreased the requirements for ABT, a further reduction will probably be obtained with the addition of another blood-saving method.

Bloqueo cardiaco completo por escleroderma: informe de un caso / Complete heart block due to scleroderma: report of a case

Se presenta el caso de una paciente del sexo femenino de 34 años de edad sin antecedentes familiares ni personales de cardiopatía, hipertensión arterial, tabaquismo o diabetes mellitus. Portadora de escleroderma por tres años, aparentemente estable y bien controlada con D-penicilamina, presentó como primera complicación cardiaca de su enfermedad un cuadro de síncope por bloqueo cardiaco completo con una respuesta ventricular de 30 latidos por minuto. La paciente se recuperó con la inserción de un marcapasos definitivo. Se discute la importancia de la valoración cardiológica en estos pacientes para evitar complicaciones como ésta que puede provocar muerte súbita.