Cervical disc arthroplasty versus anterior cervical discectomy and fusion: an analysis of the Michigan Spine Surgery Improvement Collaborative Database.

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are established surgical options for the treatment of cervical radiculopathy, myelopathy, and cervical degenerative disc disease. However, current literature does not demonstrate a clear superiority between ACDF and CDA. PURPOSE: To investigate procedural and patient-reported outcomes of ACDF and CDA among patients included in the Michigan Spine Surgery Improvement Collaborative (MSSIC) database. DESIGN: Retrospective study of prospectively collected outcomes registry data. PATIENT SAMPLE: Individuals within the MSSIC database presenting with radiculopathy, myelopathy, or cervical spondylosis refractory to typical conservative care undergoing primary ACDF or CDA from January 4, 2016, to November 5, 2021. OUTCOME MEASURES: Perioperative measures (including surgery length, length of stay, return to OR, any complications), patient-reported functional outcomes at 2-year follow-up (including return to work, patient satisfaction, PROMIS, EQ-5D, mJOA). METHODS: Patients undergoing ACDF were matched 4:1 with those undergoing CDA; propensity analysis performed on operative levels (1- and 2- level procedures), presenting condition, demographics, and comorbidities. Initial comparisons performed with univariate testing and multivariate analysis performed with Poisson generalized estimating equation models clustering on hospital. RESULTS: A total of 2,208 patients with ACDF and 552 patients with CDA were included. Baseline demographics were similar, with younger patients undergoing CDA (45.6 vs 48.6 years; p<.001). Myelopathy was more frequent in ACDF patients (30% vs 25%; p=.015). CDA was more frequently planned as an outpatient procedure. Length of stay was increased in ACDF (1.3 vs 1.0 days; p<.001). Functional outcomes were similar, with comparable proportions of patients meeting minimal clinically important difference thresholds in neck pain, arm pain, PROMIS, EQ-5D, and mJOA score. After multivariate regression, no significant differences were seen in surgical or functional outcomes. CONCLUSIONS: This study demonstrates similar outcomes for those undergoing ACDF and CDA at 2 years. Previous meta-analyses of CDA clinical trial data adhere to strict inclusion and exclusion criteria required by clinical studies; this registry data provides "real world" clinical outcomes reflecting current practices for ACDF and CDA patient selection.

Bone Grafting Options for Single-Level TLIF: So Many Options, What Is the Evidence?

BACKGROUND: This review seeks to investigate the clinically relevant bone graft materials in single-level transforaminal lumbar interbody fusion (TLIF) procedures as defined by (1) primary outcomes (ie, fusion rates and complication rates) and (2) patient-reported outcomes (ie, visual analog scale [VAS] and Oswestry disability index [ODI]). Because of the advantages in stimulating bone growth, autologous bone grafts such as the iliac crest bone graft (ICBG) have been the gold standard. Numerous alternatives to ICBG have been introduced. Understanding the risks and benefits of bone graft options is vital to optimizing patient care. METHODS: A PubMed search was performed for all clinical studies published between January 2008 and March 2023 that referenced the single-level TLIF procedure as well as one of the following grafts: autograft, allograft, bone morphogenetic protein (BMP), demineralized bone matrix, or mesenchymal stem cells (MSCs). Case studies and reports were excluded. RESULTS: Twenty-eight studies met the inclusion criteria. Studies from the PubMed search demonstrated similarly high fusion rates across nearly all graft materials, the lone exception being MSCs, which showed lower fusion rates. ICBG grafts experienced higher rates of postoperative graft site pain. The BMP graft material had high rates of radiculitis, heterogeneous ossification, and vertebral osteolysis. Patients saw an overall improvement in VAS and ODI scores with all graft materials. CONCLUSION: Local autografts and ICBG have been the most studied. Fusion rates during single-level TLIF were similar across all graft materials except MSCs. Patient-reported pain levels improved after TLIF surgery regardless of the type of grafts used. While BMP implants have shown promising benefits, they have introduced a new array of complications not normally seen in ICBG implants. The study is limited by the lack of evidence of certain graft materials as well as nonuniformity in metrics evaluating the efficacy of graft materials.

The Effect of Preoperative Symptom Duration on Patient-Reported Outcomes After Anterior Cervical Discectomy and Fusion in Nonmyelopathic Patients: Analyses From the Michigan Spine Surgery Improvement Collaborative (MSSIC).

BACKGROUND: The effect of preoperative symptom duration (PSD) on patient-reported outcomes (PROs) in anterior cervical discectomy and fusion (ACDF) for radiculopathy is unclear. OBJECTIVE: To determine whether PSD is a predictor for PRO after ACDF for radiculopathy. METHODS: The Michigan Spine Surgery Improvement Collaborative registry was queried between March, 2014, and July, 2019, for patients who underwent ACDF without myelopathy and PROs (baseline, 90 days, 1 year, 2 years). PROs were measured by numerical rating scales for neck/arm pain, Patient-Reported Outcomes Measurement Information System Short Form-Physical Function (PROMIS-PF), EuroQol-5D (EQ5D), and North American Spine Society satisfaction. Univariate analyses were used to evaluate the proportion of patients reaching minimal clinically important differences (MCID). PSD was <3 months, 3 month-1 year, or >1 years. Multiple logistic regression models were used to estimate the association between PSD and PRO reaching MCID. The discriminative ability of the model was evaluated by receiver operating characteristic curve. RESULTS: We included 2233 patients who underwent ACDF with PSD <3 months (278, 12.4%), 3 month-1 year (669, 30%), and >1 years (1286, 57.6%). Univariate analyses demonstrated a greater proportion of patients achieving MCID in <3-month cohort for arm numerical rating scales, PROMIS-PF, EQ5D, and North American Spine Society Satisfaction. Multivariable analyses demonstrated using <3 months PSD as a reference, PSD >1 years was associated with decreased odds of achieving MCID for EQ5D (odds ratio 0.5, CI 0.32-0.80, P = .004). Private insurance and increased baseline PRO were associated with significantly higher odds for achieving PROMIS-PF MCID and EQ5D-MCID. CONCLUSION: Preoperative symptom duration greater than 1 year in patients who underwent ACDF for radiculopathy was associated with worse odds of achieving MCID for multiple PROs.

Characteristics and outcomes of patients undergoing lumbar spine surgery for axial back pain in the Michigan Spine Surgery Improvement Collaborative.

BACKGROUND CONTEXT: The indications for surgical intervention of axial back pain without leg pain for degenerative lumbar disorders have been limited in the literature, as most study designs allow some degree of leg symptoms in the inclusion criteria. PURPOSE: To determine the outcome of surgery (decompression only vs. fusion) for pure axial back pain without leg pain. STUDY DESIGN/SETTING: Prospectively collected data in the Michigan Spine Surgery Improvement Collaborative (MSSIC). PATIENT SAMPLE: Patients with pure axial back pain without leg pain underwent lumbar spine surgery for primary diagnoses of lumbar disc herniation, lumbar stenosis, and isthmic or degenerative spondylolisthesis ≤ grade II. OUTCOME MEASURES: Minimally clinically important difference (MCID) for back pain, Numeric Rating Scale of back pain, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), MCID of PROMIS-PF, and patient satisfaction on the North American Spine Surgery Patient Satisfaction Index were collected at 90 days, 1 year, and 2 years after surgery. METHODS: Log-Poisson generalized estimating equation models were constructed with patient-reported outcomes as the independent variable, reporting adjusted risk ratios (RRadj). RESULTS: Of the 388 patients at 90 days, multi-level versus single level lumbar surgery decreased the likelihood of obtaining a MCID in back pain by 15% (RRadj=0.85, p=.038). For every one-unit increase in preoperative back pain, the likelihood for a favorable outcome increased by 8% (RRadj=1.08, p<.001). Of the 326 patients at 1 year, symptom duration > 1 year decreased the likelihood of a MCID in back pain by 16% (RRadj=0.84, p=.041). The probability of obtaining a MCID in back pain increased by 9% (RRadj=1.09, p<.001) for every 1-unit increase in baseline back pain score and by 14% for fusions versus decompression alone (RRadj=1.14, p=.0362). Of the 283 patients at 2 years, the likelihood of obtaining MCID in back pain decreased by 30% for patients with depression (RRadj=0.70, p<.001) and increased by 8% with every one-unit increase in baseline back pain score (RRadj=1.08, p<.001). CONCLUSIONS: Only the severity of preoperative back pain was associated with improvement in MCID in back pain at all time points, suggesting that surgery should be considered for selected patients with severe axial pain without leg pain. Fusion surgery versus decompression alone was associated with improved patient-reported outcomes at 1 year only, but not at the other time points.

Assessment of Surgical Procedural Time, Pedicle Screw Accuracy, and Clinician Radiation Exposure of a Novel Robotic Navigation System Compared With Conventional Open and Percutaneous Freehand Techniques: A Cadaveric Investigation.

STUDY DESIGN: Cadaveric study. OBJECTIVE: To evaluate accuracy, radiation exposure, and surgical time of a new robotic-assisted navigation (RAN) platform compared with freehand techniques in conventional open and percutaneous procedures. METHODS: Ten board-certified surgeons inserted 16 pedicle screws at T10-L5 (n = 40 per technique) in 10 human cadaveric torsos. Pedicle screws were inserted with (1) conventional MIS technique (L2-L5, patient left pedicles), (2) MIS RAN (L2-L5, patient right pedicles), (3) conventional open technique (T10-L1, patient left pedicles), and (4) open RAN (T10-L1, patient right pedicles). Output included (1) operative time, (2) number of fluoroscopic images, and (3) screw accuracy. RESULTS: In the MIS group, compared with the freehand technique, RAN allowed for use of larger screws (diameter: 6.6 ± 0.6 mm vs 6.3 ± 0.5 mm; length: 50.3 ± 4.1 mm vs 46.9 ± 3.5 mm), decreased the number of breaches >2 mm (0 vs 7), fewer fluoroscopic images (0 ± 0 vs 108.3 ± 30.9), and surgical procedure time per screw (3.6 ± 0.4 minutes vs 7.6 ± 2.0 minutes) (all P < .05). Similarly, in the open group, RAN allowed for use of longer screws (46.1 ± 4.1 mm vs 44.0 ± 3.8 mm), decreased the number of breaches >2 mm (0 vs 13), fewer fluoroscopic images (0 ± 0 vs 24.1 ± 25.8) (all P < .05), but increased total surgical procedure time (41.4 ± 8.8 minutes vs 24.7 ± 7.0 minutes, P = .000) while maintaining screw insertion time (3.31.4 minutes vs 3.1 ± 1.0 minutes, P = .650). CONCLUSION: RAN significantly improved accuracy and decreased radiation exposure in comparison to freehand techniques in both conventional open and percutaneous surgical procedures in cadavers. RAN significantly increased setup time compared with both conventional procedures.

A comprehensive performance evaluation of heterogeneous Bi2Fe4O9/peroxymonosulfate system for sulfamethoxazole degradation.

In this study, a Bi2Fe4O9 catalyst with nanoplate morphology was fabricated using a facile hydrothermal method. It was used as a catalyst to activate peroxymonosulfate (PMS) for aqueous sulfamethoxazole (SMX) removal. A comprehensive performance evaluation of the Bi2Fe4O9/PMS system was conducted by investigating the effects of pH, PMS dosage, catalyst loading, SMX concentration, temperature, and halides (Cl- and Br-) on the degradation of SMX. The Bi2Fe4O9/PMS system demonstrated a remarkable catalytic activity with >95% SMX removal within 30 min (conditions: pH 3.8, [Bi2Fe4O9] = 0.1 g L-1, [SMX]:[PMS] mol ratio =1:20). It was found that both Cl- and Br- can lead to the formation of PMS-induced reactive halide species (i.e. HClO, HBrO, and Br2) which can also react with SMX forming halogenated SMX byproducts. Based on the detected degradation byproducts, the major SMX degradation pathway in the Bi2Fe4O9/PMS system is proposed. The SMX degradation by Bi2Fe4O9/PMS system in the wastewater secondary effluent (SE) was also investigated. The results showed that SMX degradation rate in the SE was relatively slower than in the deionized water due to (i) reactive radical scavenging by water matrix species found in SE (e.g.: dissolved organic matters (DOCs), etc.), and (ii) partial deactivation of the catalyst by DOCs. Nevertheless, the selectivity of the SO4•- towards SMX degradation was evidenced from the rapid SMX degradation despite the high background DOCs in the SE. At least four times the dosage of PMS is required for SMX degradation in the SE to achieve a similar SMX removal efficiency to that of the deionized water matrix.

Risk Factors Associated With 90-Day Readmissions After Degenerative Lumbar Fusion: An Examination of the Michigan Spine Surgery Improvement Collaborative (MSSIC) Registry.

BACKGROUND: Most studies have evaluated 30-d readmissions after lumbar fusion surgery. Evaluation of the 90-d period, however, allows a more comprehensive assessment of factors associated with readmission. OBJECTIVE: To assess the reasons and risk factors for 90-d readmissions after lumbar fusion surgery. METHODS: The Michigan Spine Surgery Improvement Collaborative (MSSIC) registry is a prospective, multicenter, and spine-specific database of patients surgically treated for degenerative disease. MSSIC data were retrospectively analyzed for causes of readmission, and independent risk factors impacting readmission were found by multivariate logistic regression. RESULTS: Of 10 204 patients who underwent lumbar fusion, 915 (9.0%) were readmitted within 90 d, most commonly for pain (17%), surgical site infection (16%), and radicular symptoms (10%). Risk factors associated with increased likelihood of readmission were other race (odds ratio [OR] 1.81, confidence interval [CI] 1.22-2.69), coronary artery disease (OR 1.57, CI 1.25-1.96), ≥4 fused levels (OR 1.41, CI 1.06-1.88), diabetes (OR 1.34, CI 1.10-1.63), and surgery length (OR 1.09, CI 1.03-1.16). Factors associated with decreased risk were discharge to home (OR 0.63, CI 0.51-0.78), private insurance (OR 0.79, CI 0.65-0.97), ambulation same day of surgery (OR 0.81, CI 0.67-0.97), and spondylolisthesis diagnosis (OR 0.82, CI 0.68-0.97). Of those readmitted, 385 (42.1%) patients underwent another surgery. CONCLUSION: Ninety-day readmission occurred in 9.0% of patients, mainly for pain, wound infection, and radicular symptoms. Increased focus on postoperative pain may decrease readmissions. Among factors impacting the likelihood of 90-d readmission, early postoperative ambulation may be most easily modifiable. Optimization of preexisting medical conditions could also potentially decrease readmission risk.

Regulation, formation, exposure, and treatment of disinfection by-products (DBPs) in swimming pool waters: A critical review.

The microbial safety of swimming pool waters (SPWs) becomes increasingly important with the popularity of swimming activities. Disinfection aiming at killing microbes in SPWs produces disinfection by-products (DBPs), which has attracted considerable public attentions due to their high frequency of occurrence, considerable concentrations and potent toxicity. We reviewed the latest research progress within the last four decades on the regulation, formation, exposure, and treatment of DBPs in the context of SPWs. This paper specifically discussed DBP regulations in different regions, formation mechanisms related with disinfectants, precursors and other various conditions, human exposure assessment reflected by biomarkers or epidemiological evidence, and the control and treatment of DBPs. Compared to drinking water with natural organic matter as the main organic precursor of DBPs, the additional human inputs (i.e., body fluids and personal care products) to SPWs make the water matrix more complicated and lead to the formation of more types and greater concentrations of DBPs. Dermal absorption and inhalation are two main exposure pathways for trihalomethanes while ingestion for haloacetic acids, reflected by DBP occurrence in human matrices including exhaled air, urine, blood, and plasma. Studies show that membrane filtration, advanced oxidation processes, biodegradation, thermal degradation, chemical reduction, and some hybrid processes are the potential DBP treatment technologies. The removal efficiency, possible mechanisms and future challenges of these DBP treatment methods are summarized in this review, which may facilitate their full-scale applications and provide potential directions for further research extension.

Determination of urine-derived odorous compounds in a source separation sanitation system.

Source separation sanitation systems have attracted more and more attention recently. However, separate urine collection and treatment could induce odor issues, especially in large scale application. In order to avoid such issues, it is necessary to monitor the odor related compounds that might be generated during urine storage. This study investigated the odorous compounds that emitted from source-separated human urine under different hydrolysis conditions. Batch experiments were conducted to investigate the effect of temperature, stale/fresh urine ratio and urine dilution on odor emissions. It was found that ammonia, dimethyl disulfide, allyl methyl sulfide and 4-heptanone were the main odorous compounds generated from human urine, with headspace concentrations hundreds of times higher than their respective odor thresholds. Furthermore, the high temperature accelerated urine hydrolysis and liquid-gas mass transfer, resulting a remarkable increase of odor emissions from the urine solution. The addition of stale urine enhanced urine hydrolysis and expedited odor emissions. On the contrary, diluted urine emitted less odorous compounds ascribed to reduced concentrations of odorant precursors. In addition, this study quantified the odor emissions and revealed the constraints of urine source separation in real-world applications. To address the odor issue, several control strategies are recommended for odor mitigation or elimination from an engineering perspective.

Removal of haloacetic acids from swimming pool water by reverse osmosis and nanofiltration.

Recent studies report high concentrations of haloacetic acids (HAAs), a prevalent class of toxic disinfection by-products, in swimming pool water (SPW). We investigated the removal of 9 HAAs by four commercial reverse osmosis (RO) and nanofiltration (NF) membranes. Under typical SPW conditions (pH 7.5 and 50 mM ionic strength), HAA rejections were >60% for NF270 with molecular weight cut-off (MWCO) equal to 266 Da and equal or higher than 90% for XLE, NF90 and SB50 with MWCOs of 96, 118 and 152 Da, respectively, as a result of the combined effects of size exclusion and charge repulsion. We further included 7 neutral hydrophilic surrogates as molecular probes to resolve the rejection mechanisms. In the absence of strong electrostatic interaction (e.g., pH 3.5), the rejection data of HAAs and surrogates by various membranes fall onto an identical size-exclusion (SE) curve when plotted against the relative-size parameter, i.e., the ratio of molecular radius over membrane pore radius. The independence of this SE curve on molecular structures and membrane properties reveals that the relative-size parameter is a more fundamental SE descriptor compared to molecular weight. An effective molecular size with the Stokes radius accounting for size exclusion and the Debye length accounting for electrostatic interaction was further used to evaluate the rejection. The current study provides valuable insights on the rejection of trace contaminants by RO/NF membranes.

Role of calcium ions on the removal of haloacetic acids from swimming pool water by nanofiltration: mechanisms and implications.

We investigated the removal of haloacetic acids (HAAs) from swimming pool waters (SPWs) by two nanofiltration membranes NF270 and NF90. The strong matrix effect (particularly by Ca2+) on membrane rejection prompts us to systematically investigate the mechanistic role of Ca2+ in HAA rejection. At typical SPW pH of 7.5, NF90 maintained consistently high rejection of HAAs (>95%) with little influence by Ca2+, thanks to the dominance of size exclusion effect for this tight membrane (pore radius âˆ¼ 0.31 nm). In contrast, the rejections of both inorganic ions (e.g., Na+ and Cl-) and HAA anions were decreased at higher Ca2+ concentration for NF270 (pore radius âˆ¼ 0.40 nm). Further tests show that the rejection of neutral hydrophilic molecular probes and the membrane pore size were not affected by Ca2+. Although Ca2+ is unable to form strong complex with HAAs, we observed the binding of Ca2+ to NF270 together with a reduction in its surface charge. Therefore, the formation of membrane-Ca2+ complex, which weakens charge interaction effect, was responsible for the reduced HAA rejection. The current study reveals important mechanistic insights of the matrix effect on trace contaminant rejection, which is critical for a better understanding of their fate and removal in membrane-based treatment.

Multiple geophysical surveys for old landfill monitoring in Singapore.

One-dimensional boring presents limitations on mapping the refuse profile in old landfills owning to waste heterogeneity. Electrical imaging (EI) and multiple-analysis of surface wave (MASW) were hereby deployed at an old dumping ground in Singapore to explore the subsurface in relation to geotechnical analysis. MASW estimated the refuse boundary with a higher precision as compared to EI, due to its endurance for moisture variation. EI and MASW transection profiles suggested spots of interest, e.g., refuse pockets and leachate mounds. 3D inversion of EI and MASW data further illustrated the transformation dynamics derived by natural attenuation, for instance the preferential infiltration pathway. Comparison of geophysical surveys at different years uncovered the subterranean landfill conditions, indicating strong impacts induced by aging, precipitation, and settlement. This study may shed light on a characterization framework of old landfills via combined geophysical models, thriving landfill knowledge with a higher creditability.

Direct and indirect photodegradation pathways of cytostatic drugs under UV germicidal irradiation: Process kinetics and influences of water matrix species and oxidant dosing.

The ever-increasing consumption of various cytostatic drugs (CSDs) has attracted growing public concern in recent years. The photodegradation of 8 CSDs was investigated using a low-pressure UV-254Hg lamp, resulting in fluence-based first-order kinetic rate constants in the range of (0.20-6.97)×10-4cm2mJ-1. The influence of water matrix components, including natural dissolved organic matter (DOM), bicarbonate (HCO3-), nitrate (NO3-), chloride (Cl-), and sulfate (SO42-), was investigated. The degradation rates of CSDs decrease in the presence of DOM due to the competition for the UV light, but increase with addition of NO3- due to an indirect production of HO. Further investigation was carried out to evaluate the viability of UV treatment performances using two real water samples, namely treated water from a water treatment plant and secondary effluent from a wastewater treatment plant. The primary photodegradation byproducts of CSDs were identified using LC/MS/MS to investigate the mechanism of direct UV photolysis and indirect NO3--induced and DOM-induced photolysis. The degradation rates of CSDs increase significantly with the addition of H2O2 or S2O82- under UV irradiation, due to the generation of non-selective HO or selective SO4-. As an electrophilic radical, SO4- mainly reacts via electron transfer and selectively attacks certain electron-donating functional groups of CSDs.

An insight of disinfection by-product (DBP) formation by alternative disinfectants for swimming pool disinfection under tropical conditions.

Sodium hypochlorite (NaClO) is the most commonly used disinfectant in pool treatment system. Outdoor pools usually suffer from the strong sunlight irradiation which degrades the free chlorine rapidly. In addition, more pools start to adopt the recirculation of swimming pool water, which intensifies the disinfection by-product (DBP) accumulation issue. Given these potential drawbacks of using NaClO in the tropical environment, two alternative organic-based disinfectants, trichloroisocyanuric acid (TCCA, C3Cl3N3O3) and bromochlorodimethylhydantoin (BCDMH, C5H6BrClN2O2), were investigated and compared to NaClO in terms of their self-degradation and the formation of DBPs, including trihalomethanes (THMs) and haloacetic acids (HAAs), under simulated tropical climate conditions. The result reveals that halogen stabilizer, TCCA, had the advantages of slower free chlorine degradation and lower DBP concentration compared to NaClO, which makes it a good alternative disinfectant. BCDMH was not recommended mainly due to the highly reactive disinfecting ingredient, hypobromous acid (HBrO), which fails to sustain the continuous disinfection requirement. Total disinfectant dosage was the main factor that affects residual chlorine/bromine and THM/HAA formation regardless of different disinfectant dosing methods, e.g. shock dosing (one-time spiking) in the beginning, and continuous dosing during the whole experimental period. Two-stage second-order-kinetic-based models demonstrate a good correlation between the measured and predicted data for chlorine decay (R(2) ≥ 0.95), THM (R(2) ≥ 0.99) and HAA (R(2) ≥ 0.83) formation. Higher temperature was found to enhance the DBP formation due to the temperature dependence of reaction rates. Thus, temperature control of pools, especially for those preferring higher temperatures (e.g. hydrotherapy and spa), should take both bather comfort and DBP formation potential into consideration. It is also observed that chlorine competition existed between different precursors from natural organic matters (NOM) in filling water and body fluid analogue (BFA). Among the composition of BFA, uric acid, citric acid and hippuric acid were found to be the main precursors for HAA formation.

Indoor and outdoor particulate matter in primary school classrooms with fan-assisted natural ventilation in Singapore.

We conducted multiday continuous monitoring of indoor and outdoor particulate matter (PM) in classrooms with fan-assisted natural ventilation (NV) at five primary schools in Singapore. We monitored size-resolved number concentration of PM with diameter 0.3-10 µm at all schools and alveolar deposited surface area concentrations of PM with diameter 0.01-1.0 µm (SA0.01-1.0) at two schools. Results show that, during the monitoring period, schools closer to expressways and in the downtown area had 2-3 times higher outdoor PM0.3-1.0 number concentrations than schools located in suburban areas. Average indoor SA0.01-1.0 was 115-118 µm(2) cm(-3) during periods of occupancy and 72-87 µm(2) cm(-3) during unoccupied periods. There were close indoor and outdoor correlations for fine PM during both occupied and unoccupied periods (Pearson's r = 0.84-1.0) while the correlations for coarse PM were weak during the occupied periods (r = 0.13-0.74). Across all the schools, the size-resolved indoor/outdoor PM ratios (I/O ratios) were 0.81 to 1.58 and 0.61 to 0.95 during occupied and unoccupied periods, respectively, and average infiltration factors were 0.64 to 0.94. Average PM net emission rates, calculated during periods of occupancy in the classrooms, were lower than or in the lower range of emission rates reported in the literature. This study also reveals that indoor fine and submicron PM predominantly come from outdoor sources, while indoor sources associated with occupancy may be important for coarse PM even when the classrooms have high air exchange rates.

A cohort study of the morbidity of combined anterior-posterior cervical spinal fusions: incidence and predictors of postoperative dysphagia.

PURPOSE: To identify risk factors that may lead to the development of dysphagia after combined anterior and posterior (360°) cervical fusion surgery. METHODS: A single center, retrospective analysis of patients who had same-day, 360° fusion at Henry Ford Hospital between 2008 and 2012 was performed. Variables analyzed included demographics, medical co-morbidities, levels fused, and degree of dysphagia. RESULTS: The overall dysphagia rate was 37.7 %. Patients with dysphagia had a longer mean length of stay (p < 0.001), longer mean operative time (p < 0.001), greater intraoperative blood loss (p = 0.002), and fusion above the fourth cervical vertebra, C4, (p = 0.007). There were no differences in the rates of dysphagia when comparing patients undergoing primary or revision surgery (p = 0.554). CONCLUSION: Prolonged surgery and fusion above C4 lead to higher rates of dysphagia after 360° fusions. Prior anterior cervical fusion does not increase the risk of dysphagia development.

Oxidative toxicity of perfluorinated chemicals in green mussel and bioaccumulation factor dependent quantitative structure-activity relationship.

Concerns regarding perfluorinated chemicals (PFCs) have risen in recent years because of their ubiquitous presence and high persistency. However, data on the environmental impacts of PFCs on marine organisms are very limited. Oxidative toxicity has been suggested to be one of the major toxic pathways for PFCs to induce adverse effects on organisms. To investigate PFC-induced oxidative stress and oxidative toxicity, a series of antioxidant enzyme activities and oxidative damage biomarkers were examined to assess the adverse effects of the following 4 commonly detected compounds: perfluoro-octanesulfonate, perfluoro-ocanoic acid, perfluorononanoic acid, and perfluorodecanoic acid, on green mussel (Perna viridis). Quantitative structure-activity relationship (QSAR) models were also established. The results showed that all the tested PFCs are able to induce antioxidant response and oxidative damage on green mussels in a dose-dependent manner. At low exposure levels (0 µg/L-100 µg/L), activation of antioxidant enzymes (catalase [CAT] and superoxide dismutase [SOD]) was observed, which is an adaptive response to the excessive reactive oxygen species induced by PFCs, while at high exposure levels (100 µg/L-10 000 µg/L), PFCs were found to inhibit some enzyme activity (glutathione S-transferase and SOD) where the organism's ability to respond in an adaptive manner was compromised. The oxidative stress under high PFC exposure concentration also led to lipid and DNA damage. PFC-induced oxidative toxicity was found to be correlated with the bioaccumulation potential of PFCs. Based on this relationship, QSAR models were established using the bioaccumulation factor (BAF) as the molecular descriptor for the first time. Compared with previous octanol-water partition coefficient-dependent QSAR models, the BAF-dependent QSAR model is more suitable for the impact assessment of PFCs and thus provides a more accurate description of the toxic behavior of these compounds.

Life Cycle Assessment for desalination: a review on methodology feasibility and reliability.

As concerns of natural resource depletion and environmental degradation caused by desalination increase, research studies of the environmental sustainability of desalination are growing in importance. Life Cycle Assessment (LCA) is an ISO standardized method and is widely applied to evaluate the environmental performance of desalination. This study reviews more than 30 desalination LCA studies since 2000s and identifies two major issues in need of improvement. The first is feasibility, covering three elements that support the implementation of the LCA to desalination, including accounting methods, supporting databases, and life cycle impact assessment approaches. The second is reliability, addressing three essential aspects that drive uncertainty in results, including the incompleteness of the system boundary, the unrepresentativeness of the database, and the omission of uncertainty analysis. This work can serve as a preliminary LCA reference for desalination specialists, but will also strengthen LCA as an effective method to evaluate the environment footprint of desalination alternatives.

Genotoxicity of perfluorinated chemicals (PFCs) to the green mussel (Perna viridis).

Concerns regarding perfluorinated chemicals (PFCs) have grown significantly in recent years. However, regulations and guidelines regarding the emission and treatment of PFCs are still missing in most parts of the world, mostly due to the lack of PFC toxicity data. In the current study, the genotoxic effects of four common PFCs, named perfluorooctanesulfonate (PFOS), perfluoroocanoic acid (PFOA), perfluorononanoic acid (PFNA) and perfluorodecanoic acid (PFDA) were investigated on marine mussels. The effects of exposure time and concentration on the toxic behavior of the compounds were also examined. Genotoxicity of PFCs was assessed in biomarker assays, showing that exposure to the target compounds could damage the organism's genetic material to varying extents, including DNA strand breaks and fragmentation, chromosomal breaks and apoptosis. The adverse effects increased with both exposure concentration and time and were related with the organism burden of PFCs. The integrated biomarker response analysis demonstrated that PFOS exhibited a higher genotoxicity than the other tested compounds. The EC50 values and confidence intervals based on integrative genotoxicity were 33 (29-37), 594 (341-1036), 195 (144-265) and 78 (73-84) µg/L for PFOS, PFOA, PFNA and PFDA respectively, classifying PFOS as a highly genotoxic compound. Although primary DNA damage was shown to be recoverable after exposure ceased, permanent genetic damage caused by elevated PFC concentrations was not restored. This is the first ecotoxicity study of PFCs that focuses on the genotoxic effects of the compounds, clearly indicating the genotoxicity of the tested PFCs and demonstrating that functional groups have a major impact on the compounds' genotoxic behavior.