Thymopoiesis following HSCT; a retrospective review comparing interventions for aGVHD in a pediatric cohort.

Acute graft-versus-host disease (aGVHD) complicates allogeneic hematopoietic stem cell transplantation (HSCT), and is treated with topical and/or systemic corticosteroids. Systemic corticosteroids and aGVHD damage thymic tissue. We compared thymopoietic effect of topical steroid therapy, corticosteroids and extracorporeal photopheresis (ECP) in 102 pediatric allogeneic HSCT patients. We categorized patients into 4 groups: - no aGVHD, aGVHD treated with topical or systemic steroid, or ECP. Naïve CD4+CD45RA+CD27+ T-lymphocyte values at 3, 6, 9, 12months post-HSCT were recorded: for ECP patients, values were recorded at 3, 6, 9, 12months during ECP. Differences were compared using the Kruskal-Wallis test. 41 patients had no aGVHD, 23 had aGVHD treated topically or systemically (25), 13 received ECP. Rate of thymopoiesis was significantly different between all groups at all time-points post-transplant (p=0.002, p<0.001, p<0.001, p=0.001 respectively). Even mild aGVHD impairs thymopoiesis. Worst recovery was in ECP patients. Earlier institution of ECP may speed thymic recovery.

Cost-effectiveness of Coblation compared with cold steel tonsillectomies in the UK.

OBJECTIVE: This study aimed to estimate the cost-effectiveness of Coblation compared with cold steel tonsillectomy in adult and paediatric patients in the UK. METHOD: Decision analysis was undertaken by combining published clinical outcomes with resource utilisation estimates derived from a panel of clinicians. RESULTS: Using a cold steel procedure instead of Coblation is expected to generate an incremental cost of more than £2000 for each additional avoided haemorrhage, and the probability of cold steel being cost-effective was approximately 0.50. Therefore, the cost-effectiveness of the two techniques was comparable. When the published clinical outcomes were replaced with clinicians' estimates of current practice, Coblation was found to improve outcome for less cost, and the probability of Coblation being cost-effective was at least 0.70. CONCLUSION: A best-case scenario suggests Coblation affords the National Health Service a cost-effective intervention for tonsillectomy in adult and paediatric patients compared with cold steel procedures. A worst-case scenario suggests Coblation affords the National Health Service an equivalent cost-effective intervention for adult and paediatric patients.

The health economic burden that acute and chronic wounds impose on an average clinical commissioning group/health board in the UK.

OBJECTIVE: To estimate the patterns of care and related resource use attributable to managing acute and chronic wounds among a catchment population of a typical clinical commissioning group (CCG)/health board and corresponding National Health Service (NHS) costs in the UK. METHOD: This was a sub-analysis of a retrospective cohort analysis of the records of 2000 patients in The Health Improvement Network (THIN) database. Patients' characteristics, wound-related health outcomes and health-care resource use were quantified for an average CCG/health board with a catchment population of 250,000 adults ≥18 years of age, and the corresponding NHS cost of patient management was estimated at 2013/2014 prices. RESULTS: An average CCG/health board was estimated to be managing 11,200 wounds in 2012/2013. Of these, 40% were considered to be acute wounds, 48% chronic and 12% lacking any specific diagnosis. The prevalence of acute, chronic and unspecified wounds was estimated to be growing at the rate of 9%, 12% and 13% per annum respectively. Our analysis indicated that the current rate of wound healing must increase by an average of at least 1% per annum across all wound types in order to slow down the increasing prevalence. Otherwise, an average CCG/health board is predicted to manage ~23,200 wounds per annum by 2019/2020 and is predicted to spend a discounted (the process of determining the present value of a payment that is to be received in the future) £50 million on managing these wounds and associated comorbidities. CONCLUSION: Real-world evidence highlights the substantial burden that acute and chronic wounds impose on an average CCG/health board. Strategies are required to improve the accuracy of diagnosis and healing rates.

Clinical outcomes and cost-effectiveness of three different compression systems in newly-diagnosed venous leg ulcers in the UK.

OBJECTIVE: To assess clinical outcomes and cost-effectiveness of using a two-layer cohesive compression bandage (TLCCB; Coban 2) compared with a two-layer compression system (TLCS; KTwo) and a four-layer compression system (FLCS; Profore) in treating newly-diagnosed venous leg ulcers (VLUs) in clinical practice in the UK, from the perspective of the NHS. METHOD: This was a retrospective cohort analysis of the case records of patients with newly-diagnosed VLUs randomly extracted from The Health Improvement Network (THIN) database (a nationally representative database of clinical practice among patients registered with general practitioners in the UK) who were treated with either TLCCB (n=200), TLCS (n=200) or FLCS (n=200). The clinical outcomes and cost-effectiveness of the alternative compression systems were estimated over six months after starting treatment. RESULTS: Patients' mean age was 72 years and 58% were female. Time from wound onset to the start of compression was a mean of two months, and when starting compression the wound size was a mean of 45 cm2. The distribution of healing was significantly different between the three groups; 76% of wounds in the TLCCB group healed by six months compared with 70% and 64% in the TLCS and FLCS groups, respectively (p=0.006). Time to healing was significantly less in the TLCCB group compared with the two other groups (p=0.003). Patients in the TLCCB group experienced better health-related quality of life over six months (0.413 quality-adjusted life years (QALYs) per patient), compared with the TLCS and FLCS groups (0.404 and 0.396 QALYs per patient, respectively). The mean six-month NHS management cost was £3045, £3842 and £4480 per patient in the TLCCB, TLCS and FLCS groups, respectively. CONCLUSION: Real-world evidence demonstrates that treating newly-diagnosed VLUs with TLCCB, compared with the other two compression systems, affords a more cost-effective use of NHS-funded resources in clinical practice since it resulted in an increased healing rate, better health-related quality of life and a reduction in NHS management cost.

Influence of solids residence time and carbon storage on nitrogen and phosphorus recovery by microalgae across diel cycles.

Microalgal treatment systems could advance nutrient recovery from wastewater by achieving effluent nitrogen (N) and phosphorus (P) levels below the current limit of technology, but their successful implementation requires an understanding of how design decisions influence nutrient uptake over daily (i.e., diel) cycles. This work demonstrates the ability to influence microalgal N:P recovery ratio via solids residence time (SRT) while maintaining complete nutrient removal across day/night cycles through carbon storage and mobilization. Experiments were conducted with two microalgal species, Scenedesmus obliquus and Chlamydomonas reinhardtii, in photobioreactors (PBRs) operated as cyclostats (chemostats subjected to simulated natural light cycles) with retention times of 6-22 days (S. obliquus) and 7-13 days (C. reinhardtii). Nutrient loading and all other factors were fixed across all experiments. Elevated SRTs (>8 days) achieved limiting nutrient concentrations (either N or P) below the detection limit throughout the diel cycle. N:P mass ratio in algal biomass was linearly correlated with SRT, varying from 9.9:1 to 5.0:1 (S. obliquus) and 4.7:1 to 4.3:1 (C. reinhardtii). Carbohydrate content of biomass increased in high irradiance and decreased in low irradiance and darkness across all experiments, whereas lipid dynamics were minimal over 24-h cycles. Across all nutrient-limited cultures, specific (i.e., protein-normalized) dynamic carbohydrate generally decreased with increasing SRT. Nighttime consumption of stored carbohydrate fueled uptake of nutrients, enabling complete nutrient limitation throughout the night. Dynamic carbohydrate consumption for nutrient assimilation was consistent with dark protein synthesis but less than that of heterotrophic growth, underscoring the need for algal process models to decouple growth from nutrient uptake in periods of low/no light. The ability to tailor microalgal N:P uptake ratio and target an optimal energy storage metabolism with traditional engineering process controls (such as SRT) may enable advanced nutrient recovery facilities to target continuous and reliable dual limitation of nitrogen and phosphorus.

Cost-effectiveness of using adjunctive porcine small intestine submucosa tri-layer matrix compared with standard care in managing diabetic foot ulcers in the US.

OBJECTIVE: To estimate the cost-effectiveness of using tri-layer porcine small intestine submucosa (SIS; Oasis Ultra) as an adjunct to standard care compared with standard care alone in managing diabetic foot ulcers (DFUs) in the US, from the perspective of Medicare. METHOD: A Markov model was constructed to simulate the management of diabetic neuropathic lower extremity ulcers over a period of one year in the US. The model was used to estimate the cost-effectiveness of initially using adjunctive SIS compared with standard care alone to treat a DFU in the US at 2016 prices. RESULTS: At 12 months after the start of treatment, the use of adjunctive SIS instead of standard care alone is expected to lead to a 42 % increase in the number of ulcer-free months, 32 % increase in the probability of healing, a 3 % decrease in the probability of developing complicated ulcers and a 1 % decrease in the probability of undergoing an amputation. Health-care resource use is expected to be reduced by 11-14 % among patients who are initially managed with adjunctive SIS compared with those initially managed with standard care alone, with the exception of debridement, which is expected to be reduced by 35 %. Hence, the total health-care cost of starting treatment with adjunctive SIS instead of standard care alone was estimated to reduce payer costs by 1% (i.e. $105 per patient) over 12 months following the start of treatment. CONCLUSION: Within the study's limitations, the use of adjunctive SIS instead of standard care alone improves outcome for less cost and thereby affords a cost-effective use of Medicare-funded resources in the management of neuropathic foot ulcers among adult patients with type 1 or 2 diabetes mellitus in the US.

27 years of benthic and coral community dynamics on turbid, highly urbanised reefs off Singapore.

Coral cover on reefs is declining globally due to coastal development, overfishing and climate change. Reefs isolated from direct human influence can recover from natural acute disturbances, but little is known about long term recovery of reefs experiencing chronic human disturbances. Here we investigate responses to acute bleaching disturbances on turbid reefs off Singapore, at two depths over a period of 27 years. Coral cover declined and there were marked changes in coral and benthic community structure during the first decade of monitoring at both depths. At shallower reef crest sites (3-4 m), benthic community structure recovered towards pre-disturbance states within a decade. In contrast, there was a net decline in coral cover and continuing shifts in community structure at deeper reef slope sites (6-7 m). There was no evidence of phase shifts to macroalgal dominance but coral habitats at deeper sites were replaced by unstable substrata such as fine sediments and rubble. The persistence of coral dominance at chronically disturbed shallow sites is likely due to an abundance of coral taxa which are tolerant to environmental stress. In addition, high turbidity may interact antagonistically with other disturbances to reduce the impact of thermal stress and limit macroalgal growth rates.

Carotenoids and Neurobiological Health.

The consumption of carotenoid phytonutrients, largely as part of plant tissue, has been associated with a number of health benefits. Epidemiological and other studies support a link between higher dietary intake and tissue concentrations of carotenoids and lower risk of chronic diseases such as heart disease, diabetes, and some cancers. Evidence also suggests that increased levels of carotenoids can help maintain healthy cognitive function, especially into older age. Carotenoids mediate their beneficial effects via several mechanisms including cell growth regulation and modulation of gene expression and immune activity. However their primary protective mechanism is thought to be due to their potent antioxidant properties that effectively scavenge free radicals and reduce the risk of oxidative damage. This chapter discusses the impact of carotenoids on neurological health by first reviewing their chemical characteristics, dietary sources, and general mechanisms of action before examining in some detail the available evidence for a protective role for various carotenoids in neurodegenerative disease.

Role of Omega-3 PUFAs in Neurobiological Health.

The importance of the essential, dietary-derived, polyunsaturated fatty acids (PUFAs) omega-6 and omega-3 to human health was first reported over 85 years ago. Subsequent research has revealed many beneficial effects of the omega-3 PUFAs in particular. This has been linked to their involvement in multiple biochemical functions, including synthesis of inflammatory mediators, cell membrane fluidity, intracellular signalling and gene expression. Through these pathways, the omega-3 PUFAs help modulate aspects of inflammation and immunity, cell growth and tissue repair. While a detailed understanding of the mechanisms involved in the role of omega-3 PUFAs to health in the central nervous system (CNS) is still to be elucidated, a role for both inflammatory modulation and a direct impact on neuronal membrane fluidity and receptor function is apparent. At least partially through these mechanisms, low omega-3 levels have been associated with CNS-linked disorders such as poor cognition, depression, anxiety disorders, poor anger control, attention deficit hyperactivity disorder (ADHD) and accelerated neurodegeneration in the elderly.Following a brief introduction to the history and chemistry of the omega-3 family of PUFAs, this chapter will provide an overview of the omega-3 fatty acids and how various members of this PUFA family influence central nervous system function leading towards either health or disease.

Coral community response to bleaching on a highly disturbed reef.

While many studies of coral bleaching report on broad, regional scale responses, fewer examine variation in susceptibility among coral taxa and changes in community structure, before, during and after bleaching on individual reefs. Here we report in detail on the response to bleaching by a coral community on a highly disturbed reef site south of mainland Singapore before, during and after a major thermal anomaly in 2010. To estimate the capacity for resistance to thermal stress, we report on: a) overall bleaching severity during and after the event, b) differences in bleaching susceptibility among taxa during the event, and c) changes in coral community structure one year before and after bleaching. Approximately two thirds of colonies bleached, however, post-bleaching recovery was quite rapid and, importantly, coral taxa that are usually highly susceptible were relatively unaffected. Although total coral cover declined, there was no significant change in coral taxonomic community structure before and after bleaching. Several factors may have contributed to the overall high resistance of corals at this site including Symbiodinium affiliation, turbidity and heterotrophy. Our results suggest that, despite experiencing chronic anthropogenic disturbances, turbid shallow reef communities may be remarkably resilient to acute thermal stress.

Environmental factors in the development of autism spectrum disorders.

Autism spectrum disorders (ASD) are highly heterogeneous developmental conditions characterized by deficits in social interaction, verbal and nonverbal communication, and obsessive/stereotyped patterns of behavior and repetitive movements. Social interaction impairments are the most characteristic deficits in ASD. There is also evidence of impoverished language and empathy, a profound inability to use standard nonverbal behaviors (eye contact, affective expression) to regulate social interactions with others, difficulties in showing empathy, failure to share enjoyment, interests and achievements with others, and a lack of social and emotional reciprocity. In developed countries, it is now reported that 1%-1.5% of children have ASD, and in the US 2015 CDC reports that approximately one in 45 children suffer from ASD. Despite the intense research focus on ASD in the last decade, the underlying etiology remains unknown. Genetic research involving twins and family studies strongly supports a significant contribution of environmental factors in addition to genetic factors in ASD etiology. A comprehensive literature search has implicated several environmental factors associated with the development of ASD. These include pesticides, phthalates, polychlorinated biphenyls, solvents, air pollutants, fragrances, glyphosate and heavy metals, especially aluminum used in vaccines as adjuvant. Importantly, the majority of these toxicants are some of the most common ingredients in cosmetics and herbicides to which almost all of us are regularly exposed to in the form of fragrances, face makeup, cologne, air fresheners, food flavors, detergents, insecticides and herbicides. In this review we describe various scientific data to show the role of environmental factors in ASD.

Clinical outcomes and cost-effectiveness of an externally applied electroceutical device in managing venous leg ulcers in clinical practice in the UK.

OBJECTIVE: To estimate the cost-effectiveness of treating patients with a venous leg ulcer (VLU) with an externally applied electroceutical (EAE) device, plus dressings and compression bandaging or continuing with their previous care plan, from the perspective of the National Health Service (NHS) in the UK. METHOD: This was a prospective, single-arm, non-blinded, clinical and economic evaluation of EAE therapy performed in 2013/14. Patients' VLUs were treated with six active units of EAE therapy (each unit for two days) plus dressings and compression bandaging over a period of 12 days. Afterwards, patients were managed with a combination of dressings and bandages. Each patient acted as their own control so that clinical outcomes, resource use and costs associated with the wound over 12 months before the start of EAE therapy were retrospectively compared with the first 12 months after the start of treatment. The relative cost-effectiveness of EAE therapy was estimated at 2013/14 prices. RESULTS: Within 12 months of starting EAE therapy 77% of all wounds healed and the other 23% improved. This difference in effectiveness between the 12-months period before and after EAE therapy was estimated to yield a 12% improvement in health gain of 0.09 QALYs (p<0.01), a 34% reduction in the requirement for nurse visits (from a mean 50.7 to 33.3 visits per patient) and a 26% reduction in the number of dressings. This resulted in an 11% reduction in the NHS cost of VLU management over 12 months after the start of treatment when compared with the previous 12 months (from £1,981 to £1,754 per patient). Hence, use of EAE therapy was found to be a dominant treatment (i.e. improved outcome for less cost). CONCLUSION: Within the study's limitations, use of the EAE device potentially affords the NHS a cost-effective treatment for managing VLUs when compared with patients remaining on their previous care plan.

Navigating environmental, economic, and technological trade-offs in the design and operation of submerged anaerobic membrane bioreactors (AnMBRs).

Anaerobic membrane bioreactors (AnMBRs) enable energy recovery from wastewater while simultaneously achieving high levels of treatment. The objective of this study was to elucidate how detailed design and operational decisions of submerged AnMBRs influence the technological, environmental, and economic sustainability of the system across its life cycle. Specific design and operational decisions evaluated included: solids retention time (SRT), mixed liquor suspended solids (MLSS) concentration, sludge recycling ratio (r), flux (J), and specific gas demand per membrane area (SGD). The possibility of methane recovery (both as biogas and as soluble methane in reactor effluent) and bioenergy production, nutrient recovery, and final destination of the sludge (land application, landfill, or incineration) were also evaluated. The implications of these design and operational decisions were characterized by leveraging a quantitative sustainable design (QSD) framework which integrated steady-state performance modeling across seasonal temperatures (using pilot-scale experimental data and the simulating software DESASS), life cycle cost (LCC) analysis, and life cycle assessment (LCA). Sensitivity and uncertainty analyses were used to characterize the relative importance of individual design decisions, and to navigate trade-offs across environmental, economic, and technological criteria. Based on this analysis, there are design and operational conditions under which submerged AnMBRs could be net energy positive and contribute to the pursuit of carbon negative wastewater treatment.

Clinical outcomes and cost-effectiveness of three alternative compression systems used in the management of venous leg ulcers.

OBJECTIVE: To assess clinical outcomes and cost-effectiveness of using a two-layer cohesive compression bandage (TLCCB; Coban 2) compared with a two-layer compression system (TLCS; Ktwo) and a four-layer compression system (FLCS; Profore) in treating venous leg ulcers (VLUs) in clinical practice in the UK, from the perspective of the National Health Service (NHS). METHOD: This was a retrospective analysis of the case records of VLU patients, randomly extracted from The Health Improvement Network (THIN) database (a nationally representative database of clinical practice among patients registered with general practitioners in the UK), who were treated with either TLCCB (n=250), TLCS (n=250) or FLCS (n=175). Clinical outcomes and health-care resource use (and costs) over six months after starting treatment with each compression system were estimated. Differences in outcomes and resource use between treatments were adjusted for differences in baseline covariates. RESULTS: Patients' mean age was 75 years old and 57% were female. The mean time with a VLU was 6-7 months and the mean initial wound size was 77-85 cm2. The overall VLU healing rate, irrespective of bandage type, was 44% over the six months' study period. In the TLCCB group, 51% of wounds had healed by six months compared with 40% (p=0.03) and 28% (p=0.001) in the TLCS and FLCS groups, respectively. The mean time to healing was 2.5 months. Patients in the TLCCB group experienced better health-related quality of life (HRQoL) over six months (0.374 quality-adjusted life years (QALYs) per patient), compared with the TLCS (0.368 QALYs per patient) and FLCS (0.353 QALYs per patient). The mean six-monthly NHS management cost was £2,413, £2,707 and £2,648 per patient in the TLCCB, TLCS and FLCS groups, respectively. CONCLUSION: Despite the systems studied reporting similar compression levels when tested in controlled studies, real-world evidence demonstrates that initiating treatment with TLCCB, compared with the other two compression systems, affords a more cost-effective use of NHS-funded resources in clinical practice, since it resulted in an increased healing rate, better HRQoL and a reduction in NHS management cost. The evidence also highlighted the lack of continuity between clinicians managing a wound, the inconsistent nature of the administered treatments and the lack of specialist involvement, all of which may impact on healing. DECLARATION OF INTEREST: This study was supported by an unrestricted research grant from 3M Health Care, UK. 3M Health Care had no influence on the study design, the collection, analysis, and interpretation of data, or on the writing of, and decision to submit for publication, the manuscript.

Challenges for defining minimal clinically important difference (MCID) after spinal cord injury.

STUDY DESIGN: This is a review article. OBJECTIVES: This study discusses the following: (1) concepts and constraints for the determination of minimal clinically important difference (MCID), (2) the contrasts between MCID and minimal detectable difference (MDD), (3) MCID within the different domains of International Classification of Functioning, disability and health, (4) the roles of clinical investigators and clinical participants in defining MCID and (5) the implementation of MCID in acute versus chronic spinal cord injury (SCI) studies. METHODS: The methods include narrative reviews of SCI outcomes, a 2-day meeting of the authors and statistical methods of analysis representing MDD. RESULTS: The data from SCI study outcomes are dependent on many elements, including the following: the level and severity of SCI, the heterogeneity within each study cohort, the therapeutic target, the nature of the therapy, any confounding influences or comorbidities, the assessment times relative to the date of injury, the outcome measurement instrument and the clinical end-point threshold used to determine a treatment effect. Even if statistically significant differences can be established, this finding does not guarantee that the experimental therapeutic provides a person living with SCI an improved capacity for functional independence and/or an increased quality of life. The MDD statistical concept describes the smallest real change in the specified outcome, beyond measurement error, and it should not be confused with the minimum threshold for demonstrating a clinical benefit or MCID. Unfortunately, MCID and MDD are not uncomplicated estimations; nevertheless, any MCID should exceed the expected MDD plus any probable spontaneous recovery. CONCLUSION: Estimation of an MCID for SCI remains elusive. In the interim, if the target of a therapeutic is the injured spinal cord, it is most desirable that any improvement in neurological status be correlated with a functional (meaningful) benefit.

Comparison of colorectal cancer screening and diagnoses in HIV-positive and HIV-negative veterans.

Non-AIDS defining malignancies, including colorectal cancer (CRC), are emerging as significant problems in HIV-infected people. Some data suggest that HIV-positive patients have higher incidence of CRC at younger ages than those who are HIV-negative. This investigation examined CRC rates and screening types and trends between 943 HIV-infected cases and their age, race, and gender matched HIV-negative controls (n = 943) from 1 January 2005 to 31 December 2008 at the Atlanta VA Medical Center. The most common screening type among these patients was fecal occult blood testing (FOBT), but colonoscopies were more common in the controls (16.4% for cases, 27.5% for controls; p < 0.0001). Almost half of all patients included in this analysis did not have any screening for CRC during the four years of follow-up even though average age was 55 years. Fifty-one percent of cases had at least one screening test during follow-up compared to 48% of the controls; 7.6% of the cases had a screening each of the four years compared to only 2.4% of the controls (p < 0.0001). Ten HIV-positive patients were diagnosed with CRC during the study period compared to no CRC diagnoses among controls (p = 0.0015), though there was no difference in the diagnosis of colon polyps (4.6% vs. 5.1%, p = 0.5911). These data also suggest a discrepancy in CRC incidence between race and age groups: 80% of HIV-positive cases diagnosed with CRC during the study were black and two were less than 50 years of age. Future studies will need to address whether different recommendations are needed for screening based on HIV status, younger age, or race.

Energy positive domestic wastewater treatment: the roles of anaerobic and phototrophic technologies.

The negative energy balance of wastewater treatment could be reversed if anaerobic technologies were implemented for organic carbon oxidation and phototrophic technologies were utilized for nutrient recovery. To characterize the potential for energy positive wastewater treatment by anaerobic and phototrophic biotechnologies we performed a comprehensive literature review and analysis, focusing on energy production (as kJ per capita per day and as kJ m(-3) of wastewater treated), energy consumption, and treatment efficacy. Anaerobic technologies included in this review were the anaerobic baffled reactor (ABR), anaerobic membrane bioreactor (AnMBR), anaerobic fluidized bed reactor (AFB), upflow anaerobic sludge blanket (UASB), anaerobic sequencing batch reactor (ASBR), microbial electrolysis cell (MEC), and microbial fuel cell (MFC). Phototrophic technologies included were the high rate algal pond (HRAP), photobioreactor (PBR), stirred tank reactor, waste stabilization pond (WSP), and algal turf scrubber (ATS). Average energy recovery efficiencies for anaerobic technologies ranged from 1.6% (MFC) to 47.5% (ABR). When including typical percent chemical oxygen demand (COD) removals by each technology, this range would equate to roughly 40-1200 kJ per capita per day or 110-3300 kJ m(-3) of treated wastewater. The average bioenergy feedstock production by phototrophic technologies ranged from 1200-4700 kJ per capita per day or 3400-13 000 kJ m(-3) (exceeding anaerobic technologies and, at times, the energetic content of the influent organic carbon), with usable energy production dependent upon downstream conversion to fuels. Energy consumption analysis showed that energy positive anaerobic wastewater treatment by emerging technologies would require significant reductions of parasitic losses from mechanical mixing and gas sparging. Technology targets and critical barriers for energy-producing technologies are identified, and the role of integrated anaerobic and phototrophic bioprocesses in energy positive wastewater management is discussed.

Is it time to re-appraise the role of compression in non-healing venous leg ulcers?

OBJECTIVE: To evaluate the role of compression in non-healing venous leg ulcers (VLUs) of > 3 months' duration. METHOD: Patients' records from three independent data sets of non-healing VLUs of > 3 months'duration were re-analysed.Two data sets were separate audits of clinical practice and the third comprised patients' records from a randomised controlled trial. Some patients in each data set were never treated with compression. The effect of compression on healing at 6 months was tested with logistic regression. RESULTS: In each data set, patients in the compression and no-compression groups were matched according to ulcer size and duration; there were no differences in comorbidities. Comparing the no-compression with the compression groups, the healing rate at 6 months was 68% vs 48% in study 1, 12% vs 6% in study 2, and 26% vs 11% in study 3. Use of compression was found to be an independent predictor of not healing with an odds ratio of 0.422, 0.456 and 0.408 in studies 1, 2 and 3 respectively. CONCLUSION: The healing rate of non-healing VLUs of > 3 months' duration in the no-compression groups was double that of VLUs in the compression groups. These findings have the potential for treatment modification if confirmed in a prospective trial. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflicts of interest that are directly relevant to the content of this manuscript, which remains their sole responsibility.

Life cycle assessment applied to wastewater treatment: state of the art.

Life cycle assessment (LCA) is a technique to quantify the impacts associated with a product, service or process from cradle-to-grave perspective. Within the field of wastewater treatment (WWT) LCA was first applied in the 1990s. In the pursuit of more environmentally sustainable WWT, it is clear that LCA is a valuable tool to elucidate the broader environmental impacts of design and operation decisions. With growing interest from utilities, practitioners, and researchers in the use of LCA in WWT systems, it is important to make a review of what has been achieved and describe the challenges for the forthcoming years. This work presents a comprehensive review of 45 papers dealing with WWT and LCA. The analysis of the papers showed that within the constraints of the ISO standards, there is variability in the definition of the functional unit and the system boundaries, the selection of the impact assessment methodology and the procedure followed for interpreting the results. The need for stricter adherence to ISO methodological standards to ensure quality and transparency is made clear and emerging challenges for LCA applications in WWT are discussed, including: a paradigm shift from pollutant removal to resource recovery, the adaptation of LCA methodologies to new target compounds, the development of regional factors, the improvement of the data quality and the reduction of uncertainty. Finally, the need for better integration and communication with decision-makers is highlighted.