Highly sensitive wastewater surveillance of SARS-CoV-2 variants by targeted next-generation amplicon sequencing provides early warning of incursion in Victoria, Australia.

The future of the COVID pandemic and its public health and societal impact will be determined by the profile and spread of emerging variants and the timely identification and response to them. Wastewater surveillance of SARS-CoV-2 has been widely adopted in many countries across the globe and has played an important role in tracking infection levels and providing useful epidemiological information that cannot be adequately captured by clinical testing alone. However, novel variants can emerge rapidly, spread globally, and markedly alter the trajectory of the pandemic, as exemplified by the Delta and Omicron variants. Most mutations linked to the emergence of new SARS-CoV-2 variants are found within variable regions of the SARS-CoV-2 Spike protein. We have developed a duplex hemi-nested PCR method that, coupled with short amplicon sequencing, allows simultaneous typing of two of the most highly variable and informative regions of the Spike gene: the N-terminal domain and the receptor binding motif. Using this method in an operationalized public health program, we identified the first known incursion of Omicron BA.1 into Victoria, Australia and demonstrated how sensitive amplicon sequencing methods can be combined with wastewater surveillance as a relatively low-cost solution for early warning of variant incursion and spread.IMPORTANCEThis study offers a rapid, cost-effective, and sensitive approach for monitoring SARS-CoV-2 variants in wastewater. The method's flexibility permits timely modifications, enabling the integration of emerging variants and adaptations to evolving SARS-CoV-2 genetics. Of particular significance for low- and middle-income regions with limited surveillance capabilities, this technique can potentially be utilized to study a range of pathogens or viruses that possess diverse genetic sequences, similar to influenza.

A Compact, Low-Cost, and Low-Power Turbidity Sensor for Continuous In Situ Stormwater Monitoring.

Turbidity stands as a crucial indicator for assessing water quality, and while turbidity sensors exist, their high cost prohibits their extensive use. In this paper, we introduce an innovative turbidity sensor, and it is the first low-cost turbidity sensor that is designed specifically for long-term stormwater in-field monitoring. Its low cost (USD 23.50) enables the implementation of high spatial resolution monitoring schemes. The sensor design is available under open hardware and open-source licences, and the 3D-printed sensor housing is free to modify based on different monitoring purposes and ambient conditions. The sensor was tested both in the laboratory and in the field. By testing the sensor in the lab with standard turbidity solutions, the proposed low-cost turbidity sensor demonstrated a strong linear correlation between a low-cost sensor and a commercial hand-held turbidimeter. In the field, the low-cost sensor measurements were statistically significantly correlated to a standard high-cost commercial turbidity sensor. Biofouling and drifting issues were also analysed after the sensors were deployed in the field for more than 6 months, showing that both biofouling and drift occur during monitoring. Nonetheless, in terms of maintenance requirements, the low-cost sensor exhibited similar needs compared to the GreenSpan sensor.

A Low-Cost Radar-Based IoT Sensor for Noncontact Measurements of Water Surface Velocity and Depth.

We designed an out-of-water radar water velocity and depth sensor, which is unique due to its low cost and low power consumption. The sensor is a first at a cost of less than USD 50, which is well suited to previously cost-prohibited high-resolution monitoring schemes. This use case is further supported by its out-of-water operation, which provides low-effort installations and longer maintenance-free intervals when compared with in-water sensors. The inclusion of both velocity and depth measurement capabilities allows the sensor to also be used as an all-in-one solution for flowrate measurement. We discuss the design of the sensor, which has been made freely available under open-hardware and open-source licenses. The design uses commonly available electronic components, and a 3D-printed casing makes the design easy to replicate and modify. Not before seen on a hydrology sensor, we include a 3D-printed radar lens in the casing, which boosts radar sensitivity by 21 dB. The velocity and depth-sensing performance were characterised in laboratory and in-field tests. The depth is accurate to within ±6% and ±7 mm and the uncertainty in the velocity measurements ranges from less than 30% to 36% in both laboratory and field conditions. Our sensor is demonstrated to be a feasible low-cost design which nears the uncertainty of current, yet more expensive, velocity sensors, especially when field performance is considered.

A comparative study between low- and high-tech methods for the detection and mitigation of illicit connections in stormwater systems.

Illicit connections of wastewater to stormwater systems are the main drawback of separate sewer systems, as they lead to a direct discharge of untreated wastewater to the aquatic environment. Consequently, several inspection methods have been developed for detecting illicit connections. This study simultaneously applied several low- and high-tech methods for the detection of illicit connections in the same catchment (De Heuvel, the Netherlands). The methods included mesh wire screens for capturing coarse contamination, measurements of electroconductivity and temperature, sampling and quantification of Escherichia coli and extended-spectrum ß-lactamase-producing E. coli (ESBL-EC), DNA analysis via quantitative polymerase chain reaction for human-, dog-, and bird-specific fecal indicators, and distributed temperature sensing. Significant illicit connections could be identified using all methods. Nonetheless, hydraulic conditions and, predominantly, the sewage volume determine whether a misconnection can be detected by especially the low-tech methods. Using these results, the identified misconnections were repaired and biological and DNA analyses were repeated. Our results demonstrate that there were no changes in E. coli or ESBL-EC before and after mitigation, suggesting that these common markers of fecal contamination are not specific enough to evaluate the performance of mitigation efforts. However, a marked decrease in human wastewater markers (HF183) was observed.

Passive sampling, a practical method for wastewater-based surveillance of SARS-CoV-2.

In search of practical and affordable tools for wastewater-based surveillance of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), three independent field experiments were conducted using three passive sampler sorbents (electronegative membrane, cotton bud, and gauze) in Guelph, Ontario, Canada. Total daily cases during this study ranged from 2 to 17/100,000 people and 43/54 traditionally collected wastewater samples were positive for SARS-CoV-2 with mean detectable concentrations ranging from 8.4 to 1780 copies/ml. Viral levels on the passive samplers were assessed after 4, 8, 24, 48, 72, and 96 hrs of deployment in the wastewater and 43/54 membrane, 42/54 gauze, and 27/54 cotton bud samples were positive. A linear accumulation rate of SARS-CoV-2 on the membranes was observed up to 48 hours, suggesting the passive sampler could adequately reflect wastewater levels for up to two days of deployment. Due the variability in accumulation observed for the cotton buds and gauzes, and the pre-processing steps required for the gauzes, we recommend membrane filters as a simple cost-effective option for wastewater-based surveillance of SARS-CoV-2.

Development of muscle mass and body fat reference curves for white male UK firefighters.

OBJECTIVE: This study describes the development of the world's first suite of firefighter body composition centile reference curves which can be used as both academic research tools and clinical references, to plot and track individual firefighter skeletal muscle mass (SMM) and fat mass (FM) measurements against the representative reference sample. METHODS: The body composition of 497 white male London (England) firefighters was measured by anthropometry and bioelectrical impedance analysis. Smoothed centile curves were then generated for skeletal muscle mass index (SMMI), fat mass index (FMI), body fat percentage (BF%) and waist-to-height ratio (WHtR). RESULTS: Between 48 and 62 years, firefighter SMMI is greater than the UK white male age-matched general population by a mean of 0.35 units, although SMMI declines 0.006 units/years faster in firefighters between these ages. This is estimated to translate to a mean decline of approximately 0.6% of absolute SMM per year. Between 40 and 49 years, firefighter FMI is 0.1 units greater than the UK white male age-matched general population, which becomes identical (7 units) between 50 and 54 years. At the 50th centile, WHtR exceeds 0.5 by 39 years reaching 0.55 at 62 years. This contrasts with FMI which remains stable from 47 years. CONCLUSION: Firefighters in this study possess greater FM and SMM compared with the UK general population. SMM appears to decline rapidly within older age ranges. These references offer a novel improvement upon the limitations of BMI and BF% for the benefit of an occupational group at elevated risk of cardiovascular disease.

Giant, symptomatic mixed vascular malformation containing a cavernoma, developmental venous anomaly, and capillary telangiectasia in a 19-month-old infant.

Intracranial mixed vascular malformations (MVMs) are defined as any combination of a developmental venous anomaly (DVA), cerebral cavernous malformation (CCM), capillary telangiectasia (CTG), or arteriovenous malformation (AVM) within a single, contiguous lesion. However, most MVMs described in the literature contain only 2 pathologically discrete malformations; juxtaposition of 3 or more abnormalities in a single lesion remains exceedingly rare. We present the case of a 19-month-old female with new onset focal seizures and a 4-cm right basal ganglia lesion initially believed to be an embryonal neoplasm. She subsequently underwent gross total resection (GTR) of the lesion via a transsylvian-transinsular approach. Intraoperatively, the lesion appeared to be heterogenous and highly vascular, with areas of purplish-gray friable tissue. Pathology confirmed the lesion to be a MVM containing a CCM, CTG, and a DVA. This appears to be the first reported case of such a lesion confirmed on pathology in the literature.

A Low-Cost, Low-Power Water Velocity Sensor Utilizing Acoustic Doppler Measurement.

Current commercial sensors to monitor water flow velocities are expensive, bulky, and require significant effort to install. Low-cost sensors open the possibility of monitoring storm and waste water systems at a much greater spatial and temporal resolution without prohibitive costs and resource investment. To aid in this, this work developed a low-cost, low-power velocity sensor based on acoustic Doppler velocimetry. The sensor, costing less than 50 USD is open-source, open-hardware, compact, and easily interfaceable to a wide range of data-logging systems. A freely available sensor design at this price point does not currently exist, and its novelty is in enabling high-resolution real-time monitoring schemes. The design is capable of measuring water velocities up to 1200 mm/s. The sensor is characterised and then verified in an in-field long-term test. Finally, the data from this test are then used to evaluate the performance of the sensor in a real-world scenario. The analysis concludes that the sensor is capable of effectively measuring water velocity.

Performance analysis of a stormwater green infrastructure model for flow and water quality predictions.

Nature-based solutions or Green infrastructure (GI) used for managing stormwater pollution are growing in popularity across the globe. Stormwater GI models are important tools to inform the planning of these systems (type, design, size), in the most efficient and cost-effective manner. MUSIC, an example of such a tool, uses regression and first order decay models. Studies validating MUSIC model performance are, however, scarce, hindering future model development and transferability of the model for systems operating under different design and climatic conditions. To close this gap, this paper evaluates MUSIC for a field scale bioretention system, stormwater wetland and vegetated swale operating under Singapore tropical climate. The treatment modules were able to simulate outflows and effluent pollutant concentrations reasonably well for cumulative event volumes (mostly within ±25%) and cumulative TP and TN loads (within ±30%). Outflow TSS loads were significantly under-estimated as a result of greater variability in measured TSS concentrations across events. The findings indicate that simple empirical models such as MUSIC can be transferred to different regions provided that management decisions are based on long-term modelling efforts. The modules generally simulated the outflow hydrographs and pollutographs of the different inflow and drying/wetting conditions relatively poorly.

Passive Sampling of SARS-CoV-2 for Wastewater Surveillance.

The shedding of pathogens by infected humans enables the use of sewage monitoring to conduct wastewater-based epidemiology (WBE). Although most WBE studies use data from large sewage treatment plants, timely data from smaller catchments are needed for targeted public health action. Traditional sampling methods, like autosamplers or grab sampling, are not conducive to quick ad hoc deployments and high-resolution monitoring at these smaller scales. This study develops and validates a cheap and easily deployable passive sampler unit, made from readily available consumables, with relevance to the COVID-19 pandemic but with broader use for WBE. We provide the first evidence that passive samplers can be used to detect SARS-CoV-2 in wastewater from populations with low prevalence of active COVID-19 infections (0.034 to 0.34 per 10,000), demonstrating their ability for early detection of infections at three different scales (lot, suburb, and city). A side by side evaluation of passive samplers (n = 245) and traditionally collected wastewater samples (n = 183) verified that the passive samplers were sensitive at detecting SARS-CoV-2 in wastewater. On all 33 days where we directly compared traditional and passive sampling techniques, at least one passive sampler was positive when the average SARS-CoV-2 concentration in the wastewater equaled or exceeded the quantification limit of 1.8 gene copies per mL (n = 7). Moreover, on 13 occasions where wastewater SARS-CoV-2 concentrations were less than 1.8 gene copies per mL, one or more passive samplers were positive. Finally, there was a statistically significant (p < 0.001) positive relationship between the concentrations of SARS-CoV-2 in wastewater and the levels found on the passive samplers, indicating that with further evaluation, these devices could yield semi-quantitative results in the future. Passive samplers have the potential for wide use in WBE with attractive feasibility attributes of cost, ease of deployment at small-scale locations, and continuous sampling of the wastewater. Further research will focus on the optimization of laboratory methods including elution and extraction and continued parallel deployment and evaluations in a variety of settings to inform optimal use in wastewater surveillance.

Repetitive Transcranial Magnetic Stimulation for Treating Chronic Neuropathic Pain: a Systematic Review.

Given pharmacological interventions' limited efficacy and abundance of its adverse effects, the repetitive transcranial magnetic stimulation (rTMS) is considered a viable non-invasive option for managing chronic neuropathic pain of different origins with promising outcomes. PURPOSE OF REVIEW: The provision of a systematic review of current literature on rTMS for managing chronic neuropathic pain of different origins, and assess its efficacy and outcomes, highlighting the need for standard protocols for utilizing rTMS. RECENT FINDINGS: Variable stimulation modalities were trialed targeting the M1, DLPFC, and somatosensory cortices S1 and S2. The M1 yielded the best results in 11 of the studies. Frequency of stimulation was variable; however, optimal outcome was with higher frequencies ranging 10-20 Hz rather than low-frequency 1 Hz. Repetitive TMS can produce significant relief from chronic neuropathic pain. The lack of standard methods for rTMS, stimulatory parameters, and target stimulation site precludes concluding the optimal modality for stimulation. The practical algorithm by Lefaucheur and Nguyen (Neurophysiol Clin. 49(4):301-7, 2019) can guide setting standardized algorithms for rTMS. Defining optimal stimulation sites, frequencies, and pulses to maximize patient's pain relief and minimize required rTMS sessions requires further research.

A Low-Cost Water Depth and Electrical Conductivity Sensor for Detecting Inputs into Urban Stormwater Networks.

High-resolution data collection of the urban stormwater network is crucial for future asset management and illicit discharge detection, but often too expensive as sensors and ongoing frequent maintenance works are not affordable. We developed an integrated water depth, electrical conductivity (EC), and temperature sensor that is inexpensive (USD 25), low power, and easily implemented in urban drainage networks. Our low-cost sensor reliably measures the rate-of-change of water level without any re-calibration by comparing with industry-standard instruments such as HACH and HORIBA's probes. To overcome the observed drift of level sensors, we developed an automated re-calibration approach, which significantly improved its accuracy. For applications like monitoring stormwater drains, such an approach will make higher-resolution sensing feasible from the budget control considerations, since the regular sensor re-calibration will no longer be required. For other applications like monitoring wetlands or wastewater networks, a manual re-calibration every two weeks is required to limit the sensor's inaccuracies to ±10 mm. Apart from only being used as a calibrator for the level sensor, the conductivity sensor in this study adequately monitored EC between 0 and 10 mS/cm with a 17% relative uncertainty, which is sufficient for stormwater monitoring, especially for real-time detection of poor stormwater quality inputs. Overall, our proposed sensor can be rapidly and densely deployed in the urban drainage network for revolutionised high-density monitoring that cannot be achieved before with high-end loggers and sensors.

Hospital teaching status associated with reduced inpatient mortality and perioperative complications in surgical neuro-oncology.

PURPOSE: Studies have demonstrated that higher surgical volumes correlate with improved neurosurgical outcomes yet none exist evaluating the effects of hospital teaching status on the surgical neuro-oncology patient. We present the first analysis comparing brain tumor surgery perioperative outcomes at academic and non-teaching centers. METHODS: Brain tumor surgeries in the Nationwide Inpatient Sample (NIS) from 1998 to 2014 were identified. A teaching hospital, defined by the NIS, must have ≥ 1 Accreditation Council of Graduate Medical Education (ACGME) approved residency programs, Council of Teaching Hospitals membership, or have a ratio ≥ 0.25 of full-time residents to hospital beds. Annual treatment trends were stratified by hospital teaching status, assessing yearly caseload with linear regression. Multivariable logistic regression determined predictors of inpatient mortality/complications. Hospitals were further divided into quartiles by case volume and teaching status was compared in each. RESULTS: Teaching hospitals (THs) exhibited an average annual increase in brain tumor surgeries (+ 1057/year, p < 0.0001). In multivariable analysis, teaching status was associated with decreased risk of mortality (OR 0.82, p = 0.0003) and increased likelihood of discharge home (OR 1.21, p < 0.0001). In subgroup analysis, within the highest hospital quartile by caseload, higher mortality rates and lower routine discharges were again seen at non-teaching hospitals (NTHs) (p = 0.0002 and p = 0.0016, respectively). CONCLUSION: THs are performing more brain tumor surgeries over time with lower rates of inpatient mortality and perioperative complications even after controlling for hospital case volume. These results suggest a shift in neuro-oncology practice patterns favoring THs to optimize patient outcomes especially at the highest volume centers.

Salmonella from a Microtidal Estuary Are Capable of Invading Human Intestinal Cell Lines.

Faecal contamination poses health risks for the recreational users of urban estuaries. However, our understanding of the potential pathogenicity of faecal microbes in these environments is limited. To this end, a study was conducted to understand the spatial and seasonal distribution of Salmonella in water and sediments of the Yarra River estuary, Melbourne, Australia. Among 210 samples in total, culturable Salmonella were recovered from 27%, 17%, and 19% of water, bank, and bed sediment samples, respectively. The combined detection increased from 15% in winter to 32% in summer (p < 0.05) indicating seasonal variation as potential part of public health risk assessments. Further, pathogenic potential of the Salmonella isolates was characterised via the quantification of attachment and invasion capacity using human epithelial colorectal cell line Caco-2 on a subset of isolates (n = 62). While all of these isolates could attach and invade Caco-2 cells, 52% and 13% of these showed greater attachment and invasiveness, respectively, than the corresponding mean values for S. Typhimurium ATCC14028 control. Isolates from winter were on average more invasive (seven out of eight isolates with the highest invasiveness recovered from the colder sampling period) than the isolates from summer, and Salmonella collected during summer showed lower invasion (p < 0.05) compared with the control. Similar low invasion compared with the same control was observed for isolates recovered from bank sediment (p < 0.05). While the higher prevalence in summer may imply higher risks during these peak recreational periods, it is essential that this information is used in combination with quantitative microbial risk assessments to fully understand the health risks posed by Salmonella in microtidal estuaries.

Endoscopic third ventriculostomy inpatient failure rates compared with shunting in post-hemorrhagic hydrocephalus of prematurity.

PURPOSE: Endoscopic third ventriculostomy (ETV) has gained traction as a method for treating post-hemorrhagic hydrocephalus of prematurity (PHHP) in an effort to obviate lifelong shunt dependence in neonates. However, data remains limited regarding inpatient failures. METHODS: A retrospective analysis of the NIS between 1998 and 2014 was performed. Discharges with age < 1 year and ICD-9-CM codes indicating intraventricular hemorrhage of prematurity (772.1x) and ETV/shunt (02.22 and 02.3x) were included. Patients with ICD-9-CM codes for ventricular drain/reservoir (02.21) were excluded to prevent confounding. Time trend series plots were created. Yearly trends were quantified using logarithmic regression analysis. Kaplan-Meier curves were utilized to analyze time to treatment failure. Time to failure for each treatment was compared using log-rank. RESULTS: A total of 11,017 discharges were identified. ETV was more likely to be utilized at < 29 weeks gestational age (p = 0.0039) and birth weight < 1000 g (p = 0.0039). Shunts were less likely to fail in older and heavier newborns (OR 0.836 p = 0.00456, OR 0.828 p = 0.0001, respectively). Those initially shunted had lower failure rates compared with ETV (OR 0.44, p < 0.0001) but time to failure was longer with ETV (p = 0.04562). 79.5% of ETVs that failed were shunted after the first failure. Shunts were much less likely to undergo ETV if they failed (OR 0.21, p < 0.0001). Higher grade IVH was predictive of shunt failure but not ETV (OR 2.36, p = 0.0129). CONCLUSIONS: Although ETV can be effective in PHHP, it has a much higher initial failure rate than shunting and should thus be chosen based on a multifactorial approach.

Hair-sparing technique using absorbable intradermal barbed suture versus traditional closure methods in supratentorial craniotomies for tumor.

BACKGROUND: Hair-sparing techniques in cranial neurosurgery have gained traction in recent years and previous studies have shown no difference in infection rates, yet limited data exists evaluating the specific closure techniques utilized during hair-sparing craniotomies. Therefore, it was the intention of this study to evaluate the rate of surgical site infections (SSIs) and perioperative complications associated with using an absorbable intradermal barbed suture for skin closure in hair-sparing supratentorial craniotomies for tumor in order to prove non-inferiority to traditional methods. METHODS: A retrospective review of supratentorial craniotomies for tumor by a single surgeon from 2011 to 2017 was performed. All perioperative adverse events and wound complications, defined as a postoperative infection, wound dehiscence, or CSF leak, were compared between three different groups: (1) hair shaving craniotomies + transdermal polypropylene suture/staples for scalp closure, (2) hair-sparing craniotomies + transdermal polypropylene suture/staples for scalp closure, and (3) hair-sparing craniotomies + absorbable intradermal barbed suture for scalp closure. RESULTS: Two hundred sixty-three patients underwent hair shaving + transdermal polypropylene suture/staples, 83 underwent hair sparing + transdermal polypropylene suture/staples, and 100 underwent hair sparing + absorbable intradermal barbed suture. Overall, 2.9% of patients experienced a perioperative complication and 4.3% developed a wound complication. In multivariable analysis, the use of a barbed suture for scalp closure and hair-sparing techniques was not predictive of any complication or 30-day readmission. Furthermore, the absorbable intradermal barbed suture cohort had the lowest overall rate of wound complications (4%). CONCLUSIONS: Hair-sparing techniques using absorbable intradermal barbed suture for scalp closure are safe and do not result in higher rates of infection, readmission, or reoperation when compared with traditional methods.

Prolonged Heightened Blood Pressure Following Mechanical Thrombectomy for Acute Stroke is Associated with Worse Outcomes.

BACKGROUND: Most data evaluating the relationship of post-mechanical thrombectomy (MT) blood pressure (BP) management and outcomes of patients with large vessel occlusion (LVO) focus on early BP control within the first 24 h. We investigated the correlation of daily BP trends up to the third day following MT with patient outcomes. METHODS: We retrospectively reviewed our prospectively maintained database for LVO patients treated with MT from February 2015 to December 2017. Recorded BP values for 72 h post-reperfusion were reviewed. Daily peak systolic and diastolic blood pressures (SBP, DBP) were extracted for each day post-procedure. The association and importance between BP increments of 10 mmHg and mortality, hemorrhage, and functional independence (FI = mRS ≤ 2) was analyzed in a multivariable logistic regression and random forest (RF) analyses modeling. RESULTS: A total of 212 thrombectomies were included. An increase in peak 24-h SBP was independently associated with higher likelihood of symptomatic hemorrhage (OR 1.2, p = 0.048) and decreased functional independence (OR 0.85, p = 0.03). Higher day 2 and day 3 peak SBP was strongly correlated with decreased functional independence and higher mortality. Third day SBP < 140 was independently associated with higher likelihood of functional independence (OR 4.3, p = 0.0004). Post-MT patients with and without functional independence demonstrated a similar relative decrease in peak SBP between the first 2 days following thrombectomy (p = 0.26); however, those without functional independence experienced a significant rebound increase in peak SBP on the third day following MT (mean change from day 2 to 3: FI - 3.5 mmHg, non-FI + 3.9 mmHg; p = 0.005). CONCLUSION: High daily maximum SBP and a rebound SBP on the third day following MT is independently associated with increased likelihood of functional dependence.

Green wall height and design optimisation for effective greywater pollution treatment and reuse.

Green walls that effectively treat greywater have the potential to become a part of the solution for the issues of water scarcity and pollution control in our cities. To develop reliable and efficient designs of such systems, the following two research questions were addressed: what would be the optimal design of a green wall for greywater treatment, and how tall should the system be to assure adequate treatment. This paper reports on (i) a long-term pollutant removal comparison study of two typical green wall configurations: pot and block designs, and (ii) a short-term profile study exploring pollutant retention at different heights of a three-level green wall, across different plant species. Removal of suspended solids (TSS), nitrogen (TN), phosphorus (TP), chemical oxygen demand (COD) and Escherichia coli was tested, as well as various physical parameters. Pot and block designs were found to exhibit similar pollutant removal performance for standard and high inflow concentrations, while the block design was more resistant to drying. However, due to its multiple practical advantages, pot designs are favoured. The greatest removal was achieved within the top green wall level for all studied pollutants, while subsequent levels facilitated further removal of TSS, COD, and TN. Interestingly, colour, pH, and EC increased after each green wall level, which must be taken into account to determine the maximum height of these systems. The optimal size of the system was found to be dependent on plant species choice. The results were used to create practical recommendations for the effective design of greywater treatment green walls.

Myelomeningocele-associated hydrocephalus: nationwide analysis and systematic review.

OBJECTIVE: Myelomeningocele (MMC), the most severe form of spina bifida, is characterized by protrusion of the meninges and spinal cord through a defect in the vertebral arches. The management and prevention of MMC-associated hydrocephalus has evolved since its initial introduction with regard to treatment of MMC defect, MMC-associated hydrocephalus treatment modality, and timing of hydrocephalus treatment. METHODS: The Nationwide Inpatient Sample (NIS) database from the years 1998-2014 was reviewed and neonates with spina bifida and hydrocephalus status were identified. Timing of hydrocephalus treatment, delayed treatment (DT) versus simultaneous MMC repair with hydrocephalus treatment (ST), and treatment modality (ETV vs ventriculoperitoneal shunt [VPS]) were analyzed. Yearly trends were assessed with univariable logarithmic regression. Multivariable logistic regression identified correlates of inpatient shunt failure. A PRISMA systematic literature review was conducted that analyzed data from studies that investigated 1) MMC closure technique and hydrocephalus rate, 2) hydrocephalus treatment modality, and 3) timing of hydrocephalus treatment. RESULTS: A weighted total of 10,627 inpatient MMC repairs were documented in the NIS, 8233 (77.5%) of which had documented hydrocephalus: 5876 (71.4%) were treated with VPS, 331 (4.0%) were treated with ETV, and 2026 (24.6%) remained untreated on initial inpatient stay. Treatment modality rates were stable over time; however, hydrocephalic patients in later years were less likely to receive hydrocephalus treatment during initial inpatient stay (odds ratio [OR] 0.974, p = 0.0331). The inpatient hydrocephalus treatment failure rate was higher for patients who received ETV treatment (17.5% ETV failure rate vs 7.9% VPS failure rate; p = 0.0028). Delayed hydrocephalus treatment was more prevalent in the later time period (77.9% vs 69.5%, p = 0.0287). Predictors of inpatient shunt failure included length of stay, shunt infection, jaundice, and delayed treatment. A longer time between operations increased the likelihood of inpatient shunt failure (OR 1.10, p < 0.0001). However, a meta-analysis of hydrocephalus timing studies revealed no difference between ST and DT with respect to shunt failure or infection rates. CONCLUSIONS: From 1998 to 2014, hydrocephalus treatment has become more delayed and the number of hydrocephalic MMC patients not treated on initial inpatient stay has increased. Meta-analysis demonstrated that shunt malfunction and infection rates do not differ between delayed and simultaneous hydrocephalus treatment.

Endothelial dysfunction in cerebral aneurysms

Endothelial cell (EC) dysfunction is known to contribute to cerebral aneurysm (CA) pathogenesis. Evidence shows that damage or injury to the EC layer is the first event in CA formation. The mechanisms behind EC dysfunction in CA disease are interrelated and include hemodynamic stress, hazardous nitric oxide synthase (NOS) activity, oxidative stress, estrogen imbalance, and endothelial cell-to-cell junction compromise. Abnormal variations in hemodynamic stress incite pathological EC transformation and inflammatory zone formation, ultimately leading to destruction of the vascular wall and aneurysm dilation. Hemodynamic stress activates key molecular pathways that result in the upregulation of chemotactic cytokines and adhesion molecules, leading to inflammatory cell recruitment and infiltration. Concurrently, oxidative stress damages EC-to-EC junction proteins, resulting in interendothelial gap formation. This further promotes leukocyte traffic into the vessel wall and the release of matrix metalloproteinases, which propagates vascular remodeling and breakdown. Abnormal hemodynamic stress and inflammation also trigger adverse changes in NOS activity, altering proper EC mediation of vascular tone and the local inflammatory environment. Additionally, the vasoprotective hormone estrogen modulates gene expression that often suppresses these harmful processes. Crosstalk between these sophisticated pathways contributes to CA initiation, progression, and rupture. This review aims to outline the complex mechanisms of EC dysfunction in CA pathogenesis.