Exploring transitions of sewer wastewater infrastructure towards decentralisation using the modular model TURN-Sewers.

We present a new modular model called TURN-Sewers for exploring different adaptations of centralised wastewater infrastructure towards more decentralised wastewater systems under different urban development scenarios. The modular model is flexible and computationally efficient in exploring transitions at the city scale, allowing for the comparison of different policies and management strategies for sanitary wastewater infrastructure. TURN-Sewers includes independent modules that simulate the generation, dimensioning, deterioration, management, and calculation of performance indicators for different wastewater systems. This model can use readily available spatial information to support infrastructure planners and other stakeholders in exploring different transition pathways from centralised to decentralised wastewater infrastructure. An illustrative example demonstrates how TURN-Sewers can generate multiple future alternatives, define different infrastructure management strategies regarding system expansion, rehabilitation and transition, and assess the economic, hydraulic and structural impacts.

The Impact of the COVID-19 Pandemic on Esophageal and Gastric Cancer Surgery in Germany: A Four-Year Retrospective Single-Center Study of 287 Patients.

Background: Disruptions to surgical care for cancer patients during the COVID-19 pandemic remain an ongoing debate. This study assesses the effects of the COVID-19 pandemic on perioperative outcomes in a continuous series of surgically treated esophageal and gastric carcinoma patients at a large university hospital in Europe over 48 months. Methods: We conducted a retrospective single-center cohort study at a tertiary referral center. All patients who underwent oncologic esophageal or gastric resection between March 2018 and February 2022 were included in the analysis. The sample was split into a 24 months COVID-19 and an equivalent pre-COVID-19 control period. Outcome variables included caseload, in-hospital mortality, morbidity, treatment course, and disease stage at presentation. Results: Surgeons performed 287 operations, with around two-thirds (62%) of the cohort undergoing esophagectomy and one-third (38%) gastrectomy. The in-hospital mortality was 1% for the COVID-19 and the control periods. Patients did not present at a later disease stage nor did they wait longer for treatment. There was no decrease in caseload, and patients did not suffer from more perioperative complications during COVID-19. Conclusions: Esophageal and gastric carcinoma patients received safe and timely surgical care during the pandemic. Future pandemic protocols may streamline oncologic care towards tertiary referral centers.

When does infrastructure hybridisation outperform centralised infrastructure paradigms? - Exploring economic and hydraulic impacts of decentralised urban wastewater system expansion.

We explore the dynamics of centralised and decentralised wastewater infrastructure across various scenarios and introduce novel insights into their performance regarding structural vulnerability, hydraulic capacity, and costs. This study determines circumstances under which infrastructure hybridisation outperforms traditional centralised infrastructure paradigms. We combined system analysis to map out the modelling problem with the model-based exploration of the transition space using the novel TURN-Sewers model. System diagramming was used to identify the parameters or combinations of parameters that significantly influence the performance indicators being assessed. This allowed the creation of relevant simulation scenarios to identify circumstances where a decentralised sewer system could outperform a centralised one. TURN-Sewers was applied to model the infrastructure maintenance and generation of new infrastructure over 20 years for a municipality on the Swiss Plateau, considering a population growth rate of 0.03 a-1. Results show that decentralisation in expansion areas with higher densification can outperform the hydraulic performance and structural vulnerability of expanding centralised sanitary wastewater infrastructure. Decentralised systems can also offer economic advantages when capital expenditure costs for small-scale wastewater treatment plants are significantly reduced compared to current costs, particularly at higher discount rates, e.g. reaping effects of economies of scale. The findings of this study emphasise the potential of transition pathways towards decentralisation in urban water infrastructures and the value of models that allow the exploration of this transition space.

Use and accuracy of decision support systems using artificial intelligence for tumor diseases: a systematic review and meta-analysis.

Background: For therapy planning in cancer patients multidisciplinary team meetings (MDM) are mandatory. Due to the high number of cases being discussed and significant workload of clinicians, Clinical Decision Support System (CDSS) may improve the clinical workflow. Methods: This review and meta-analysis aims to provide an overview of the systems utilized and evaluate the correlation between a CDSS and MDM. Results: A total of 31 studies were identified for final analysis. Analysis of different cancers shows a concordance rate (CR) of 72.7% for stage I-II and 73.4% for III-IV. For breast carcinoma, CR for stage I-II was 72.8% and for III-IV 84.1%, P≤ 0.00001. CR for colorectal carcinoma is 63% for stage I-II and 67% for III-IV, for gastric carcinoma 55% and 45%, and for lung carcinoma 85% and 83% respectively, all P>0.05. Analysis of SCLC and NSCLC yields a CR of 94,3% and 82,7%, P=0.004 and for adenocarcinoma and squamous cell carcinoma in lung cancer a CR of 90% and 86%, P=0.02. Conclusion: CDSS has already been implemented in clinical practice, and while the findings suggest that its use is feasible for some cancers, further research is needed to fully evaluate its effectiveness.

Concordance of a decision algorithm and multidisciplinary team meetings for patients with liver cancer-a study protocol for a randomized controlled trial.

INTRODUCTION: Multidisciplinary team meetings (MDMs), also known as tumor conferences, are a cornerstone of cancer treatments. However, barriers such as incomplete patient information or logistical challenges can postpone tumor board decisions and delay patient treatment, potentially affecting clinical outcomes. Therapeutic Assistance and Decision algorithms for hepatobiliary tumor Boards (ADBoard) aims to reduce this delay by providing automated data extraction and high-quality, evidence-based treatment recommendations. METHODS AND ANALYSIS: With the help of natural language processing, relevant patient information will be automatically extracted from electronic medical records and used to complete a classic tumor conference protocol. A machine learning model is trained on retrospective MDM data and clinical guidelines to recommend treatment options for patients in our inclusion criteria. Study participants will be randomized to either MDM with ADBoard (Arm A: MDM-AB) or conventional MDM (Arm B: MDM-C). The concordance of recommendations of both groups will be compared using interrater reliability. We hypothesize that the therapy recommendations of ADBoard would be in high agreement with those of the MDM-C, with a Cohen's kappa value of ≥ 0.75. Furthermore, our secondary hypotheses state that the completeness of patient information presented in MDM is higher when using ADBoard than without, and the explainability of tumor board protocols in MDM-AB is higher compared to MDM-C as measured by the System Causability Scale. DISCUSSION: The implementation of ADBoard aims to improve the quality and completeness of the data required for MDM decision-making and to propose therapeutic recommendations that consider current medical evidence and guidelines in a transparent and reproducible manner. ETHICS AND DISSEMINATION: The project was approved by the Ethics Committee of the Charité - Universitätsmedizin Berlin. REGISTRATION DETAILS: The study was registered on ClinicalTrials.gov (trial identifying number: NCT05681949; https://clinicaltrials.gov/study/NCT05681949 ) on 12 January 2023.

Textbook Outcome after Gastrectomy for Gastric Cancer Is Associated with Improved Overall and Disease-Free Survival.

(1) Background: The complexity of the perioperative outcome for patients with gastric cancer is not well reflected by single quality metrics. To study the effect of the surgical outcome on survival, we have evaluated the relationship between textbook outcome (TO)-a new composite parameter-and oncological outcome. (2) Methods: All patients undergoing total gastrectomy or trans-hiatal extended gastrectomy for gastric cancer with curative intent between 2017 and 2021 at our institution were included. TO was defined by negative resection margins (R0); collection of ≥25 lymph nodes; the absence of major perioperative complications (Clavien-Dindo ≥ 3); the absence of any reintervention; absence of unplanned ICU re-admission; length of hospital stay < 21 days; absence of 30-day readmission and 30-day mortality. We evaluated factors affecting TO by multivariate logistic regression. The correlation between TO and long-term survival was assessed using a multivariate cox proportional-hazards model. (3) Results: Of the patients included in this study, 52 (52.5 %) achieved all TO metrics. Open surgery (p = 0.010; OR 3.715, CI 1.334-10.351) and incomplete neoadjuvant chemotherapy (p = 0.020, OR 4.278, CI 1.176-15.553) were associated with failure to achieve TO on multivariate analysis. The achievement of TO significantly affected overall survival (p = 0.015). TO (p = 0.037, OD 0.448, CI 0.211-0.954) and CCI > 4 (p = 0.034, OR 2.844, CI 1.079-7.493) were significant factors affecting DFS upon univariate analysis. In multivariate analysis, CCI > 4 (p = 0.035, OR 2.605, CI 0.983-6.905) was significantly associated with DFS. (4) Conclusions: We identified patient- and procedure-related factors influencing TO. Importantly, achieving TO is strongly associated with improved long-term survival in gastric cancer patients and merits further focus on surgical quality improvement efforts.

Supporting the planning of urban blue-green infrastructure for biodiversity: A multi-scale prioritisation framework.

Primary considerations for urban blue-green infrastructure (BGI) encompass sustainable stormwater/urban heat management while biodiversity conservation is often considered an inherent benefit rather than a core planning requirement. However, ecological function of BGI as 'stepping stones' or linear corridors for otherwise fragmented habitats is undisputed. While quantitative approaches for modelling ecological connectivity in conservation planning are well established, mismatches in scope and scale with models that support the planning of BGI makes their adoption and integration difficult across disciplines. Technical complexities have led to ambiguity around circuit and network-based approaches, focal node placement, spatial extents, and resolution. Furthermore, these approaches are often computationally intensive, and considerable gaps remain in their use for identifying local-scale critical "pinch-points" that urban planners may respond to with the integration of BGI interventions that address biodiversity enhancement among other ecosystem services. Here, we present a framework that simplifies and integrates the merits of regional connectivity assessments with a focus on urban areas to prioritise BGI planning interventions while reducing computational demands. Our framework facilitates: (1) modelling potential ecological corridors at a coarse regional scale, (2) prioritising local-scale BGI interventions based on the relative contribution of individual nodes in this regional network, and (3) inferring connectivity hot- and cold-spots for local-scale BGI interventions. We illustrate this in the Swiss lowlands, demonstrating how, compared to previous work, we are able to identify and rank different priority locations across the region for BGI interventions in support of biodiversity enhancement and how their local-scale functional design may be benefited by addressing specific environmental variables.

Several Small or Single Large? Quantifying the Catchment-Wide Performance of On-Site Wastewater Treatment Plants with Inaccurate Sensors.

On-site wastewater treatment plants (OSTs) often lack monitoring, resulting in unreliable treatment performance. They thus appear to be a stopgap solution despite their potential contribution to circular water management. Low-maintenance but inaccurate soft sensors are emerging that address this concern. However, how their inaccuracy impacts the catchment-wide treatment performance of a system of many OSTs has not been quantified. We develop a stochastic model to estimate catchment-wide OST performances with a Monte Carlo simulation. In our study, soft sensors with a 70% accuracy improved the treatment performance from 66% of the time functional to 98%. Soft sensors optimized for specificity, indicating the true negative rate, improve the system performance, while sensors optimized for sensitivity, indicating the true positive rate, quantify the treatment performance more accurately. This new insight leads us to suggest programming two soft sensors in practical settings with the same hardware sensor data as input: one soft sensor geared to high specificity for maintenance scheduling and one geared to high sensitivity for performance quantification. Our findings suggest that a maintenance strategy combining inaccurate sensors with appropriate alarm management can vastly improve the mean catchment-wide treatment performance of a system of OSTs.

Robotic-Assisted Ivor Lewis Esophagectomy Is Safe and Cost Equivalent Compared to Minimally Invasive Esophagectomy in a Tertiary Referral Center.

In recent decades, robotic-assisted minimally invasive esophagectomy (RAMIE) has been increasingly adopted for patients with esophageal cancer (EC) or cancer of the gastroesophageal junction (GEJ). However, concerns regarding its costs compared to conventional minimally invasive esophagectomy (MIE) have emerged. This study examined outcomes and costs of RAMIE versus total MIE in 128 patients who underwent Ivor Lewis esophagectomy for EC/GEJ at our department between 2017 and 2021. Surgical costs were higher for RAMIE (EUR 12,370 vs. EUR 10,059, p < 0.001). Yet, median daily (EUR 2023 vs. EUR 1818, p = 0.246) and total costs (EUR 30,510 vs. EUR 29,180, p = 0.460) were comparable. RAMIE showed a lower incidence of postoperative pneumonia (8% vs. 25%, p = 0.029) and a trend towards shorter hospital stays (15 vs. 17 days, p = 0.205), which may have equalized total costs. Factors independently associated with higher costs included readmission to the intensive care unit (hazard ratio [HR] = 7.0), length of stay (HR = 13.5), anastomotic leak (HR = 17.0), and postoperative pneumonia (HR = 5.4). In conclusion, RAMIE does not impose an additional financial burden. This suggests that RAMIE may be considered as a valid alternative approach for esophagectomy. Attention to typical cost factors can enhance postoperative care across surgical methods.

The Learning Curve for Hand-Assisted Laparoscopic Total Gastrectomy in Gastric Cancer Patients.

(1) Background: Hand-assisted laparoscopic total gastrectomy (LTG) for patients with gastric cancer (GC) has been established as the standard surgical treatment at our center. This study aims to quantify the learning curve for surgeons performing minimally invasive total gastrectomy at a high-volume single center. (2) Methods: One hundred and eighteen consecutive patients who underwent minimally invasive total gastrectomy between January 2014 and December 2020 at a single high-volume center were included and reviewed retrospectively. Risk-adjusted cumulative sum analysis (RA-CUSUM) was used to monitor the surgical outcomes for patients with different risks of postoperative mortality using varying-coefficient logistic regression models. Patients were ordered by the sequential number of the procedure performed and divided into two groups according to the degree of surgeon proficiency as determined by RA-CUSUM analysis (group A: 45; group B: 73 patients). Age, gender, body mass index (BMI), tumor location, pathology, and comorbidities were compared while primary endpoints comprised surgical parameters, postoperative course, and survival outcomes. (3) Results: Forty-four cases were required for the completion of the learning curve. During this time, the mean operating time decreased. Hand-assisted laparoscopic total gastrectomy performed after a learning curve was associated with a shorter median operating time (OT) (360 min vs. 289 min, <0.001), and a reduced length of stay (A = 18.0 vs. B = 14.0 days) (p = 0.154), while there was a trend toward less major complications (Clavien−Dindo (CD) 3−5 within 90 days (12 (26.67%) vs. 10 (13.70%) p = 0.079). Our results showed no difference in anastomotic leakage between the two groups (group A vs. group B, 3 (6.67%) vs. 4 (5.48%) p = 0.99). Similarly, 30-day (0 (0%) vs. 1 (1.7%), p = 0.365) and 90-day mortality (1 (2.08%) vs. 2 (3.39%), p = 0.684) were comparable. Following multivariate analysis, the level of surgical proficiency was not a significant prognostic factor for overall survival. (4) Conclusions: A minimum of 44 cases are required for experienced laparoscopic surgeons to achieve technical competence for performing LTG. While operation time decreased after completion of the learning curve, quality criteria such as achievement of R0 resection, anastomotic leakage, and perioperative mortality remained unaltered. Of note, the level of surgical training showed no significant impact on the 2 year OS or DFS.

The Association between Neoadjuvant Radio-Chemotherapy and Prolonged Healing of Anastomotic Leakage after Esophageal Resection Treated with EndoVAC Therapy.

(1) Background: Endoscopic vacuum therapy (EVT) has become the mainstay in the treatment of early anastomotic leakage (AL) after esophageal resection. The effect of nRCT on the efficacy of EVT is currently unknown. (2) Methods: Data of 427 consecutive patients undergoing minimally invasive esophagectomy between 2013 and 2022 were analyzed. A total of 26 patients received EVT for AL after esophagectomy between 2010 and 2021. We compared a cohort of 13 patients after treatment with EVT for anastomotic leakage after neoadjuvant radiochemotherapy (nRCT) with a control group of 13 patients after neoadjuvant chemotherapy (nCT) using inverse propensity score weighting to adjust for baseline characteristics between the groups. EVT therapy was assessed regarding patient survival, treatment failure as defined by a change in treatment to stent/operation, duration of treatment, and secondary complications. Statistical analysis was performed using linear regression analysis. (3) Results: Time to EVT after initial tumor resection did not vary between the groups. The duration of EVT was longer in patients after nRCT (14.69 days vs. 20.85 days, p = 0.002) with significantly more interventions (4.38 vs. 6.85, p = 0.001). The success rate of EVT did not differ between the two groups (nCT n = 8 (61.54%) vs. nCT n = 5 (38.46%), p = 0.628). The rate of operative revision did not vary between the groups. Importantly, no mortality was reported within 30 days and 90 days in both groups. (4) Conclusions: EVT is a valuable tool for the management of AL after esophageal resection in patients after nRCT. While the success rates were comparable, EVT was associated with a significantly longer treatment duration. Anastomotic leakages after nRCT often require prolonged and multimodal treatment strategies while innovative strategies such as prophylactic endoVAC placement or use of a VAC-Stent may be considered.

Reconciling cities with nature: Identifying local Blue-Green Infrastructure interventions for regional biodiversity enhancement.

Increasing urbanization degrades quantity, quality, and the functionality of spatial cohesion of natural areas essential to biodiversity and ecosystem functioning worldwide. The uncontrolled pace of building activity and the erosion of blue (i.e., aquatic) and green (i.e., terrestrial) landscape elements threaten existing habitat ranges and movability of wildlife. Local scale measures, such as nature-inspired engineered Blue-Green Infrastructure (BGI) are emerging mitigation solutions. Originally planned to promote sustainable stormwater management, adaptation to climate change and improved human livability in cities, such instruments offer interesting synergies for biodiversity in support of existing ecological infrastructure. BGI are especially appealing for globally declining amphibians, a rich and diverse vertebrate assemblage sensitive to urbanization. We integrated biological and highly resolved urban-rural land-cover data, ensemble models of habitat suitability, and connectivity models based on circuit theory to improve multi-scale and multi-species protection of core habitats and ecological corridors in the Swiss lowlands. Considering a broad spectrum of amphibian biodiversity, we identified distributions of amphibian biodiversity hotspots and four landscape elements essential to amphibian movability at the regional scale, namely i) forest edges, ii) wet-forest habitats, iii) soils with variable moisture and iv) riparian zones. Our work shows that cities can make a substantial contribution (e.g., up to 15% of urban space in the study area) to wider landscape habitat connectivity. We highlight the importance of planning BGI locally in strategic locations across urban and peri-urban areas to promote the permeability and availability of 'stepping stone' habitats in densely populated landscapes, essential to the maintenance of regional habitat connectivity and thereby enhancing biodiversity and ecosystem functioning.

Robotic versus open pancreatic surgery: a propensity score-matched cost-effectiveness analysis.

BACKGROUND: Robotic pancreatic surgery (RPS) is associated with high intraoperative costs compared to open pancreatic surgery (OPS). However, it remains unclear whether several advantages of RPS such as reduced surgical trauma and a shorter postoperative recovery time could lead to a reduction in total costs outweighing the intraoperative costs. The study aimed to compare patients undergoing OPS and RPS with regards to cost-effectiveness in a propensity score-matched (PSM) analysis. METHODS: Patients undergoing OPS and RPS between 2017 and 2019 were included in this monocentric, retrospective analysis. The controlling department provided financial data (costs and revenues, net loss/profit). A propensity score-matched analysis was performed or OPS and RPS (matching criteria: age, American society of anesthesiologists (ASA) score, gender, body mass index (BMI), and type of pancreatic resection) with a caliper 0.2. RESULTS: In total, 272 eligible OPS cases were identified, of which 252 met all inclusion criteria and were thus included in the further analysis. The RPS group contained 92 patients. The matched cohorts contained 41 patients in each group. Length of hospital stay (LOS) was significantly shorter in the RPS group (12 vs. 19 days, p = 0.003). Major postoperative morbidity (Dindo/Clavien ≥ 3a) and 90-day mortality did not differ significantly between OPS and RPS (p > 0.05). Intraoperative costs were significantly higher in the RPS group than in the OPS group (7334€ vs. 5115€, p < 0.001). This was, however, balanced by other financial categories. The overall cost-effectiveness tended to be better when comparing RPS to OPS (net profit-RPS: 57€ vs. OPS: - 2894€, p = 0.328). Binary logistic regression analysis revealed major postoperative complications, longer hospital stay, and ASA scores < 3 were linked to the risk of net loss (i.e., costs > revenue). CONCLUSIONS: Surgical outcomes of RPS were similar to those of OPS. Higher intraoperative costs of RPS are outweighed by advantages in other categories of cost-effectiveness such as decreased lengths of hospital stay.

Reducing the Pill Burden: Immunosuppressant Adherence and Safety after Conversion from a Twice-Daily (IR-Tac) to a Novel Once-Daily (LCP-Tac) Tacrolimus Formulation in 161 Liver Transplant Patients.

Non-adherence to immunosuppressant therapy reduces long-term graft and patient survival after solid organ transplantation. The objective of this 24-month prospective study was to determine adherence, efficacy and safety after conversion of stable liver transplant (LT) recipients from a standard twice-daily immediate release Tacrolimus (IR-Tac) to a novel once-daily life cycle pharma Tacrolimus (LCP-Tac) formulation. We converted a total of 161 LT patients at baseline, collecting Tacrolimus trough levels, laboratories, physical examination data and the BAASIS© questionnaire for self-reported adherence to immunosuppression at regular intervals. With 134 participants completing the study period (17% dropouts), the overall adherence to the BAASIS© increased by 57% until month 24 compared to baseline (51% vs. 80%). Patients who required only a morning dose of their concomitant medications reported the largest improvement in adherence after conversion. The intra-patient variability (IPV) of consecutive Tacrolimus trough levels after conversion did not change significantly compared to pre-conversion levels. Despite reducing the daily dose by 30% at baseline as recommended by the manufacturer, Tac-trough levels remained stable, reflected by an increase in the concentration-dose (C/D) ratio. No episodes of graft rejection or loss occurred. Our data suggest that the use of LCP-Tac in liver transplant patients is safe and can increase adherence to immunosuppression compared to conventional IR-Tac.

A Simplified Sanitary Sewer System Generator for Exploratory Modelling at City-Scale.

Future climatic, demographic, technological, urban and socio-economic challenges call for more flexible and sustainable wastewater infrastructure systems. Exploratory modelling can help to investigate the consequences of these developments on the infrastructure. In order to explore large numbers of adaptation strategies, we need to re-balance the degree of realism of sewer network and ability to reflect key performance characteristics against the model's parsimony and computational efficiency. We present a spatially explicit algorithm for creating sanitary sewer networks that realistically represent key characteristics of a real system. Basic topographic, demographic and urban characteristics are abstracted into a squared grid of 'Blocks' which are the foundation for the sewer network's topology delineation. We compare three different pipe dimensioning approaches and found a good balance between detail and computational efficiency. With a basic hydraulic performance assessment, we demonstrate that we attain a computationally efficient and high-fidelity wastewater sewer network with adequate hydraulic performance. A spatial resolution of 250 m Block size in combination with a sequential Pipe-by-Pipe (PBP) design algorithm provides a sound trade-off between computational time and fidelity of relevant structural and hydraulic properties for exploratory modelling. We can generate a simplified sewer network (both topology and hydraulic design) in 18 s using PBP, versus 36 min using a highly detailed model or 1 s using a highly abstract model. Moreover, this simplification can cut up to 1/10th to 1/50th the computational time for the hydraulic simulations depending on the routing method implemented. We anticipate our model to be a starting point for sophisticated exploratory modelling into possible infrastructure adaptation measures of topological and loading changes of sewer systems for long-term planning.

Perioperative Risk Assessment in Pancreatic Surgery Using Machine Learning.

Pancreatic surgery is associated with a high risk for postoperative complications and death of patients. Complications occur in a variable interval after the procedure. Often, a patient has already left the ICU and is not properly monitored anymore when the complication occurs. Risk stratification models can assist in identifying patients at risk in order to keep these patients in ICU for longer. This, in turn, helps to identify complications earlier and increase survival rates. We trained multiple machine learning models on pre-, intra- and short term postoperative data from patients who underwent pancreatic resection at the Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin. The presented models achieve an area under the precision-recall curve (AUPRC) of up to 0.51 for predicting patient death and 0.53 for predicting a specific major complication. Overall, we found that a classical logistic regression model performs best for the investigated classification tasks. As more patient data becomes available throughout the perioperative stay, the performance of the risk stratification model improves and should therefore repeatedly be computed.

Intrahepatic De Novo Tumors in Liver Recipients are Highly Associated With Recurrent Viral Hepatitis.

BACKGROUND/AIMS: Long-term survival of liver transplant recipients is endangered by tumorigenesis at different sites. Little is known about primary de novo tumors developing in the graft. METHODS: We analyzed the follow-up data of 2731 liver recipients that were transplanted between 1988 and 2019 at our institution (Charité - Universitätsmedizin Berlin, Department of Surgery). All cases with new intrahepatic tumors during follow-up were identified. RESULTS: A total of nine patients were diagnosed at a median of 16 years (range, 2-24 years) after surgery. Eight patients presented with hepatocellular carcinoma (HCC), and one patient presented with epithelioid hemangioendothelioma (EHE). All eight HCC patients had a recurrence of the initial disease that had caused liver failure before transplantation. This was associated with viral reinfection with either HCV or HBV in seven cases. Of the nine patients, three underwent surgical resection and only one patient was alive at data abstraction. CONCLUSION: Intrahepatic de novo neoplasms in the liver graft need to be considered in the long-term follow-up of liver recipients and were strongly associated with recurrent viral hepatitis in our study. Although prognosis of this rare complication is generally poor, patients may benefit from surgical resection of localized disease.

Not all SuDS are created equal: Impact of different approaches on combined sewer overflows.

Sustainable urban drainage systems (SuDS) help in stormwater management by reducing runoff volume, increasing runoff concentration time and thereby improving the drainage system capacity. This study investigated the potential and cost-effectiveness of SuDS in reducing combined sewer overflows (CSOs). We simulated the performance of four SuDS techniques (bioretention cell, permeable pavement, rain barrel and green roof) at incremental levels of spatial coverage for a small urban catchment with a combined sewer system. We also used an Analytic Hierarchy Process (AHP) considering end-point CSO, land use, imperviousness, slope and elevation criteria to identify priority areas for SuDS deployment. Results showed that CSO volume attenuation ranged a maximum of 50-99% for the catchment, depending on the deployment strategy and underlying mechanisms of each technology. We also found that deployment of SuDS in AHP-selected sub-catchments improved CSO reduction only for rain barrels and green roofs, but not for bioretention cells and permeable pavements. SuDS were also a cost-effective retrofit option: for a 40% volume reduction, the SuDS cost, at most, 25% of the equivalent cost required for a large CSO tank. Outcomes of this study demonstrate the efficacy of SuDS in controlling CSOs, adding yet another tangible benefit to their increasingly recognised multi-functionality.

Ex-ante quantification of nutrient, total solids, and water flows in sanitation systems.

To prioritise sustainable sanitation systems in strategic sanitation planning, indicators such as local appropriateness or resource recovery have to be known at the pre-planning phase. The quantification of resource recovery remains a challenge because existing substance flow models require large amounts of input data and can therefore only be applied for a few options at a time for which implementation examples exist. This paper aims to answer two questions: How can we predict resource recovery and losses of sanitation systems ex-ante at the pre-planning phase? And how can we do this efficiently to consider the entire sanitation system option space? The approach builds on an existing model to create all valid sanitation systems from a set of conventional and emerging technologies and to evaluate their appropriateness for a given application case. It complements the previous model with a Substance Flow Model (SFM) and with transfer coefficients from a technology library to quantify nutrients (phosphorus and nitrogen), total solids (as an indicator for energy and organics), and water flows in sanitation systems ex ante. The transfer coefficients are based on literature data and expert judgement. Uncertainties resulting from the variability of literature data or ignorance of experts are explicitly considered, allowing to assess the robustness of the model output. Any (future) technologies or additional products can easily be added to the library. The model is illustrated with a small didactic example showing how 12 valid system configurations are generated from a few technologies, and how substance flows, recovery ratios, and losses to soil, air, and water are quantified considering uncertainties. The recovery ratios vary between 0 and 28% for phosphorus, 0-10% for nitrogen, 0-26% for total solids, and 0-12% for water. The uncertainties reflect the high variability of the literature data but are comparable to those obtained in studies using a conventional post-ante material flow analysis (generally about 30% variability at the scale of a an urban area). Because the model is fully automated and based on literature data, it can be applied ex-ante to a large and diverse set of possible sanitation systems as shown with a real application case. From the 41 technologies available in the library, 101,548 systems are generated and substance flows are modelled. The resulting recovery ratios range from nothing to almost 100%. The two examples also show that recovery depend on technology interactions and has therefore to be assessed for all possible system configurations and not at the single technology level only. The examples also show that there exist trade-offs among different types of reuse (e.g. energy versus nutrients) or different sustainability indicators (e.g. local appropriateness versus resource recovery). These results show that there is a need for such an automated and generic approach that provides recovery data for all system configurations already at the pre-planning phase. The approach presented enables to integrate transparently the best available knowledge for a growing number of sanitation technologies into a planning process. The resulting resource recovery and loss ratios can be used to prioritise resource efficient systems in sanitation planning, either for the pre-selection or the detailed evaluation of options using e.g. MCDA. The results can also be used to guide future development of technology and system innovations. As resource recovery becomes more relevant and novel sanitation technologies and system options emerge, the approach presents itself as a useful tool for strategic sanitation planning in line with the Sustainable Development Goals (SDGs).

Comparative analysis of sanitation systems for resource recovery: Influence of configurations and single technology components.

Resource recovery and emissions from sanitation systems are critical sustainability indicators for strategic urban sanitation planning. In this context, sanitation systems are the most often structured using technology-driven templates rather than performance-based sustainability indicators. In this work, we answer two questions: Firstly, can we estimate generic resource recovery and loss potentials and their uncertainties for a diverse and large set of sanitation systems? And secondly, can we identify technological aspects of sanitation systems that indicate a better overall resource recovery performance? The aim is to obtain information that can be used as an input into any strategic planning process and to help shape technology development and system design for resource recovery in the future. Starting from 41 technologies, which include novel and conventional options, we build 101,548 valid sanitation system configurations. For each system configuration we quantify phosphorus, nitrogen, total solids, and water flows and use that to calculate recovery potentials and losses to the environment, i.e. the soil, air, or surface water. The four substances cover different properties and serve as a proxy for nutrient, organics, energy, and water resources. For modelling the flows ex-ante, we use a novel approach to consider a large range of international literature and expert data considering uncertainties. Thus all results are generic and can therefore be used as input into any strategic planning process or to help guide future technology development. A detailed analysis of the results allows us to identify factors that influence recovery and losses. These factors include the type of source, the length of systems, and the level of containment in storage and treatment. The factors influencing recovery are related to interactions of different technologies in a system which shows the relevance of a modelling approach that allows to look at all possible system configurations systematically. Based on our analysis, we developed five recommendations for the optimization of resource recovery: (i) prioritize short systems that close the loop at the lowest possible level; (ii) separate waste streams as much as possible, because this allows for higher recovery potentials; (iii) use storage and treatment technologies that contain the products as much as possible, avoid leaching technologies (e.g. single pits) and technologies with high risk of volatilization (e.g. drying beds); (iv) design sinks to optimise recovery and avoid disposal sinks; and (v) combine various reuse options for different side streams (e.g. urine diversion systems that combine reuse of urine and production of biofuel from faeces).