Resilience of stormwater biofilters following the deposition of wildfire residues: Implication on downstream water quality management in wildfire-prone regions.

Stormwater treatment systems such as biofilters could intercept and remove pollutants from contaminated runoff in wildfire-affected areas, ensuring the protection of water quality downstream. However, the deposition of wildfire residues such as ash and black carbon onto biofilters could potentially impair their stormwater treatment functions. Yet, whether and how wildfire residue deposition could affect biofilter functions is unknown. This study examines the impact of wildfire residue deposition on biofilter infiltration and pollutant removal capacities. Exposure to wildfire residues decreased the infiltration capacity based on the amount of wildfire deposited. Wildfire residues accumulated at the top layer of the biofilter, forming a cake layer, but scraping this layer restored the infiltration capacity. While the deposition of wildfire residues slightly changed the pore water geochemistry, it did not significantly alter the removal of metals and E. coli. Although wildfire residues leached some metals into pore water within the simulated root zone, the leached metals were effectively removed by the compost present in the filter media. Collectively, these results indicate that biofilters downstream of wildfire-prone areas could remain resilient or functional and protect downstream water quality if deposited ash is periodically scraped to restore any loss of infiltration capacity following wildfire residue deposition.

University Stormwater Management within Urban Environmental Regulatory Regimes: Barriers to Progressivity or Opportunities to Innovate?

U.S. public university campuses are held directly responsible for compliance with many of the same federal- and state-level environmental regulations as cities, including stormwater management. While operating as 'cities within cities' in many respects, campuses face unique constraints in achieving stormwater regulatory compliance. To compare the abilities of campuses to comply with stormwater regulations to municipalities, we conduct mixed-methods research using primary data from five University of California (UC) campuses. Public universities constituted over 20% of California's "nontraditional" permittees under the municipal separate storm sewer system (MS4) regulation regime in 2013. We utilize semi-structured interviews with campus and regulatory officials, a survey of campus students and staff around support and willingness to pay for innovative stormwater management, and content analysis of campus stormwater management documents to examine challenges to public university stormwater compliance. We find that, despite their progressive environmental practices in other areas like energy and water conservation, even as compared to cities, stormwater management practices on the evaluated campuses are constrained by several factors: infrastructure financing limitations, lack of transparent and coordinated decision-making, a lack of campus resident involvement, and regulatory inflexibility. Our study provides new insights, both for understanding campuses as sustainable 'cities within cities' and more broadly for urban environmental compliance regimes globally.

Subsidized Households and Wildfire Hazards in California.

As deadly and destructive wildfires become increasingly common in the western United States due to climate change, low-income households face particular difficulties recovering from these disasters. Despite this threat, surprisingly little empirical evidence exists about the exposure and vulnerability to wildfire hazards of residents of subsidized housing. This study focuses on the subsidized housing population for several reasons: residents generally have less adaptive capacity to respond to wildfires; the locations of subsidized housing units reflect relatively stable locations of low-income households for decades; and policymakers can intervene to retrofit existing housing as well as shape future housing siting and design. The dataset created for this study includes all Census tracts in California with housing units by type, wildland-urban interface (WUI) coverage, and an index of social vulnerability. Using a combination of descriptive statistics and spatial regression models, the analysis focuses on the intersection of subsidized housing and wildfire hazards. Results show that subsidized housing is disproportionately located outside the WUI in California's metropolitan and nonmetropolitan areas. However, policy interventions are necessary because many vulnerable households-including those residing in the 140,000 subsidized units in the WUI-live in harm's way.

Sources of and solutions to mistrust of tap water originating between treatment and the tap: Lessons from Los Angeles County.

Tap water mistrust has adverse impacts on health and welfare. This study identifies, defines and motivates attention to cases of mistrust of tap water which originate between the treatment plant and the tap where people ultimately consume it. Between treatment and the tap, water quality contamination can be introduced within two segments of the built environment with two distinct responsible parties- community water system's distributional networks and property owner's premise plumbing. This contamination is considered secondary from a health perspective but elevates consumer concern. We use examples from Los Angeles County, an area with high resident tap water mistrust especially among disadvantaged communities, despite there being relatively few health-related water quality violations. We triangulate evidence from primary and secondary sources to illustrate how such water quality concerns occur. We identify potential solutions to address concerns using a series of case studies of communities with high levels of tap water mistrust, a stakeholder workshop and associated working group on premise plumbing concerns, and customer concern data from the city of Los Angeles' water system. Findings suggest that there are numerous instances where the distributional network, and secondarily premise plumbing, introduce water quality contamination which contributes to tap mistrust in urban communities by making water unclean, but not necessarily unsafe per existing regulation. In cases where water systems' distributional networks have introduced water quality contamination, responses to assuage concerns have largely rested upon pressure from the press and advocates. Premise plumbing issues have been harder to address. Our study suggests that an evidence-based path forward to comprehensively addressing these issues involves new requirements for systems to report quality contamination in distributional networks and incentives for property owners to upgrade premise plumbing. Moreover, this study reasserts that infrastructure neglect contributes to rational, but costly decision-making by disadvantaged urban communities to consume tap alternatives.

Toward a comprehensive explanatory model of reliance on alternatives to the tap: evidence from California's retail water stores.

Building on a recent increase in scholarly attention to the problem of tap water mistrust and resulting negative health impacts, we examine the relationship between neighborhood reliance on tap water alternatives and a range of explanatory factors. We model retail water store locations as a proxy for reliance on tap water alternatives in urbanized neighborhoods across California. Our study is unique in its inclusion of variables representing both compliance with primary and secondary water quality standards by publicly regulated drinking water systems serving particular neighborhoods, other water system attributes and the socioeconomic characteristics of neighborhoods. The location of retail water stores in urbanized neighborhoods does not appear strongly related to observed measures of water quality. Secondary contamination shows a weak relationship to tap alternative reliance, and primary contamination was not correlated with higher levels of tap alternative reliance. On the other hand, our research suggests that other socioeconomic factors, particularly country of birth, are associated with the prevalence of more water stores. Increasing reliance on tap water likely requires measuring and addressing secondary contamination found in distributional systems and premise plumbing, and more aggressive public education campaigns.

Adjuvant concurrent chemoradiation using intensity-modulated radiotherapy and simultaneous integrated boost for resected high-risk adenocarcinoma of the distal esophagus and gastro-esophageal junction.

PURPOSE: Multimodality therapy leads to improved outcomes for adenocarcinoma of the distal esophagus and gastroesophageal junction (GEJ) over surgery alone. At our institution, adjuvant chemoradiation (chemoRT) using IMRT and SIB is standard of care for resected high-risk disease. In this study, we review our experience with a recent cohort of patients treated in this manner. METHODS AND MATERIALS: We identified 18 patients with resected T3 and/or N1 adenocarcinoma of the distal esophagus and GEJ who received adjuvant chemoRT. A large elective volume (PTV1) and a smaller high-risk volume (PTV2) were irradiated simultaneously using IMRT and an SIB technique. All patients received concurrent chemotherapy. Relevant clinical outcomes are reported. RESULTS: The median dose to 95% of PTV1 was 3747cGy and to 95% of PTV2 was 4876cGy. All RT was given in a median of 28 daily fractions. Four patients did not complete chemotherapy. At a median follow up of 952 days from the start of RT, 7 of 18 patients were dead; of these, 3 had developed local recurrence only; 3 had developed both local and distant recurrence; 1 died of a late toxicity, without recurrence. OS was 88% at 1year, 76% at 2 years and 58% at 3 years. Freedom from local recurrence was 88% at 1 year, 82% at 2 years and 82% at 3 years. Freedom from distant recurrence was 72% at 1 year, 67% at 2 years and 56% at 3 years. Toxicity was acceptable. CONCLUSIONS: Adjuvant concurrent chemoRT with IMRT and SIB is feasible for resected high-risk adenocarcinoma of the distal esophagus and GEJ. Our results describe how modern treatment techniques can be employed as part of a treatment paradigm that is neither commonly used nor commonly described in the literature.

Case report: Complex internal mammary to pulmonary artery fistula as a cause of hemoptysis in tuberculosis: Diagnosis and endovascular management using ethylene vinyl alcohol copolymer (Onyx).

A complex right internal mammary to right pulmonary artery fistula resulting in hemoptysis was successfully treated by embolization with a liquid, nonadhesive, embolic agent - ethylene vinyl alcohol copolymer (Onyx). There were no procedural complications and no recurrence of symptoms has been seen after 2 years of follow-up.

Utility of the Amplatzer Vascular Plug in splenic artery embolization: a comparison study with conventional coil technique.

PURPOSE: To retrospectively evaluate the role of the Amplatzer Vascular Plug (AVP) in proximal splenic artery embolization (SAE) compared with coils. MATERIALS AND METHODS: Forty patients had proximal SAE performed with AVP(s) or coils as the primary embolic agent for splenic artery steal syndrome (n=23), trauma (n=5), portal hypertension (n=5), bleeding due to pancreatic pathology (n=4), and pre-splenectomy (n=3). Comparisons were made of occlusion and procedure time, cost, and radiation dose. RESULTS: Eighteen proximal SAE procedures were successfully performed with AVP. Twenty-two procedures were performed with coils, including one failed AVP attempt, which was completed with coils. Precise deployment without migration was achieved in all 18 AVP cases. Seven of 22 (31.8%) coil procedures had distal migration without consequence. There was no statistically significant difference in mean occlusion time (24.4 min for AVP vs. 31.5 min for coils, P=0.13), procedure time (43.7 min for AVP vs. 53.8 min for coils, P=0.16), or cost ($1474.13 for AVP vs. $1722.51 for coils, P=0.69). There was significant difference in radiation dose (842 mGy for AVP vs. 1,309 mGy for coils, P=0.04). Fourteen of the 18 (78%) AVP devices required additional embolic material. CONCLUSIONS: AVP with additional embolic agents is a useful alternative for proximal SAE because of precise deployment, resistance to migration, and radiation reduction. AVP use may be limited by vessel tortuosity. The occlusion time, procedure time, and cost were reduced but this was not statistically significant due to the need for additional embolic material.

Splenic injury during percutaneous nephrolithotomy.

BACKGROUND: Injury to the spleen is a recognized complication during percutaneous renal access due to the close anatomical relationship of the spleen and the left kidney. However, transsplenic renal access is a rare complication of percutaneous nephrolithotomy and can also result in considerable morbidity, often requiring emergent splenectomy. METHODS: We present our experience with splenic injury during percutaneous nephrolithotomy managed conservatively with the use of a collagen-thrombin hemostatic sealant (D-Stat; Vascular Solutions, Inc., Minneapolis, MN) after delayed removal of the nephrostomy tubes. RESULTS: The patient had an uneventful recovery and was discharged home on postoperative day 6. CONCLUSION: In select hemodynamically stable patients, nonoperative management with the adjunctive use of hemostatic sealants may be considered.

Effectiveness of coil embolization in angiographically detectable versus non-detectable sources of upper gastrointestinal hemorrhage.

PURPOSE: To determine whether the effectiveness of arterial embolization in patients with acute upper gastrointestinal hemorrhage is related to the visualization of contrast medium extravasation at angiography. MATERIALS AND METHODS: Transcatheter embolization was performed in 108 patients who experienced acute upper gastrointestinal hemorrhage during a 5-year period. Patient charts were retrospectively reviewed. Thirty-six patients who underwent embolization after angiography demonstrated active contrast medium extravasation from an involved artery. Seventy-two patients underwent embolization in the absence of contrast medium extravasation into a bowel lumen. Embolization technique, requirement for further blood products, need for further surgery, and 30-day mortality were recorded. RESULTS: The gastroduodenal artery (GDA) was embolized in 26 of the 36 patients (72%) with extravasation, and the left gastric artery was embolized in 10 (28%). The GDA was embolized in 64 of the 72 patients (89%) without extravasation, and the left gastric artery was embolized in 13 (18%). After embolization, 23 of the 36 patients (64%) with extravasation and 44 of the 72 (61%) without extravasation required additional blood product transfusions. Seven of the 36 patients (19%) with extravasation and 16 of the 72 (22%) without extravasation required subsequent surgery secondary to bleeding. Thirty-day hemorrhage-related mortality was 17% (six of 36 patients) in the positive extravasation group and 22% (16 of 72 patients) in the negative extravasation group. The treatment success rate was 44% (16 of 36 patients) in the positive extravasation group and 44% (32 of 72 patients) in the negative extravasation group. CONCLUSIONS: In patients with acute upper gastrointestinal hemorrhage, arterial embolization is equally effective in patients who demonstrate active contrast medium extravasation at angiography as in those who do not show contrast extravasation.

"Splenic artery steal syndrome" is a misnomer: the cause is portal hyperperfusion, not arterial siphon.

Splenic artery embolization (SAE) improves hepatic artery (HA) flow in liver transplant (OLT) recipients with so-called splenic artery steal syndrome. We propose that SAE actually improves HA flow by reducing the HA buffer response (HABR). Patient 1: On postoperative day (POD) 1, Doppler ultrasonography (US) showed patent vasculature with HA resistive index (RI) of 0.8. On POD 4, aminotransferases rose dramatically; his RI was 1.0 with no diastolic flow. Octreotide was begun, but on POD 5 US showed reverse diastolic HA flow with no signal in distal HA branches. After SAE, US showed markedly improved flow, RI was 0.6, diastolic flow in the main artery, and complete visualization of all distal branches. By POD 6, liver function had normalized. RI in the main HA is 0.76 at 2 months postsurgery. Patient 2: On POD 1, RI was 1.0. US showed worsening intrahepatic signal, with no signal in the intrahepatic branches and reversed diastolic flow despite good graft function. On POD 7, SAE improved the intrahepatic waveform and RI (from 1.0 to 0.72). Patient 3: Intraoperative reverse diastolic arterial flow persisted on PODs 1, 2, and 3, with progressive loss of US signal in peripheral HA branches. SAE on POD 4 improved the RI (0.86) and peripheral arterial branch signals. Patient 4: US on POD 1 showed good HA flow with a normal RI (0.7). A sudden waveform change on POD 2 with increasing RI (0.83) prompted SAE, after which the wave form normalized, with reconstitution of a normal diastolic flow (RI 0.68). In conclusion, these reports confirm the usefulness of SAE for poor HA flow but suggest that inflow steal was not the problem. Rather than producing an increase in arterial inflow, SAE worked by reducing portal flow and HABR, thereby reducing end-organ outflow resistance. Evidence of this effect is the marked reduction of the RI after the SAE to 0.6, 0.72, 0.86, and 0.68, in patients 1-4, respectively. SAE reduces excessive portal vein flow and thereby ameliorates an overactive HABR that can cause graft dysfunction and ultimately HA thrombosis.

Coping, distress, and marital adjustment in couples with cancer: an examination of the personal and social context.

We examined the links between coping and psychological outcomes in 53 patients who had undergone radiotherapy for cancer. Patients completed a coping survey and a measure of perceived support during a six-week course of radiation therapy and reported about their mental health and marital satisfaction one month following treatment. The prospective associations between coping and psychological distress and martial satisfaction depended upon the supportive context in which patients were coping. Seeking emotional support and using positive reappraisal were more effective (i.e., were significantly and positively correlated with marital satisfaction) for people low in spousal support than for people high in such support. Although men and women reported coping similarly with the cancer and had similar levels of adjustment, the association between coping and outcomes differed by gender; the associations for women were significantly stronger than they were for men. Results thus suggest that both individual and environmental characteristics moderate the associations between coping and outcomes in cancer survivors.

The endovascular management of visceral artery aneurysms and pseudoaneurysms.

OBJECTIVE: Visceral artery aneurysms may be treated by aneurysm exclusion, excision, revascularization, and endovascular techniques. The purpose of this study was to review the outcomes of the management of visceral artery aneurysms with catheter-based techniques. METHODS: Between 1997 and 2005, 90 patients were identified with a diagnosis of visceral artery aneurysm. This was inclusive of aneurysmal disease of the celiac axis, superior mesenteric artery (SMA), inferior mesenteric artery, and their branches. Surveillance without intervention occurred in 23 patients, and 19 patients underwent open aneurysm repair (4 ruptures). The endovascular treatment of 48 consecutive patients (mean age 58, 60% men) with 20 visceral artery aneurysms (VAA) and 28 visceral artery pseudoaneurysms (VAPA) was the basis for this study. Electronic and hardcopy medical records were reviewed for demographic data and clinical variables. Original computed tomography (CT) scans and fluoroscopic imaging were evaluated. RESULTS: The endovascular treatment of visceral artery aneurysms was technically successful in 98% of 48 procedures, consisting of 3 celiac axis repairs, 2 left gastric arteries, 1 SMA, 12 hepatic arteries, 20 splenic arteries, 7 gastroduodenal arteries, 1 middle colic artery, and 2 pancreaticoduodenal arteries. Of these, 29 (60%) were performed for symptomatic disease (5 ruptured aneurysms). Procedures were performed in the endovascular suite under local anesthesia with conscious sedation (94%). The femoral artery was used as the preferential access site (90%). Coil embolization was used for aneurysm exclusion in 96%. N-butyl-2-cyanoacrylate (glue) was used selectively (19%) using a triaxial system with a 3F microcatheter for persistent flow or multiple branches. The 30-day mortality was 8.3% (n = 4). One patient died from recurrent gastrointestinal bleeding after gastroduodenal embolization, and the remaining died of unrelated causes. All perioperative deaths occurred in patients requiring urgent or emergent intervention in the setting of hemodynamic instability. No patients undergoing elective intervention died in the periprocedural period. Postprocedural imaging was performed after 77% of interventions at a mean of 16 months. Complete exclusion of flow within the aneurysm sac occurred in 97% interventions with follow-up imaging, but coil and glue artifact complicated CT evaluation. Postembolization syndrome developed in three patients (6%) after splenic artery embolization. There was no evidence of hepatic insufficiency or bowel ischemia after either hepatic or mesenteric artery aneurysm treatment. Three patients required secondary interventions for persistent flow (n = 1) and recurrent bleeding from previously embolized aneurysms (n = 2). CONCLUSION: Visceral artery aneurysms and pseudoaneurysms can be successfully treated with endovascular means with low periprocedural morbidity; however, the urgent repair of these lesions is still associated with elevated mortality rates. Aneurysm exclusion can be accomplished with coil embolization and the selective use of N-butyl-2-cyanoacrylate. Current catheter-based techniques extend our ability to exclude visceral artery aneurysms, but imaging artifact hampers postoperative CT surveillance.

Basics of computed tomography angiography of the lower extremity vessels.

Complete noninvasive, angiographic evaluation of the abdominal aorta and lower extremity vessels using the latest generation of multidetector row computed tomography (CT) scanners can now be accomplished in a single scan lasting less than a minute. The high spatial resolution of these new scanners and their more efficient use of contrast permit accurate depiction of disease in the smaller tibial and pedal vessels, as well as the larger diameter iliac and femoral arteries; nevertheless, many challenges and obstacles remain to its more widespread acceptance. Foremost among these, is the difficulty in accurately reconstructing the smaller leg and pedal vessels from individual CT slices, a process that must to a very great extent be done manually, and the potential nephrotoxicity of iodinated contrast material. Future advances in imaging software that could more fully automate accurate three-dimensional reconstructions of the lower extremity vasculature, and detector technology to allow for even finer resolution of the vasculature will further enhance an already powerful and clinically useful tool.