Medicine and the Law.

Congenital high airway obstruction syndrome (CHAOS) is a rare condition that can be diagnosed antenatally by ultrasound. It is usually lethal without immediate intervention at delivery. A 24-year-old woman was diagnosed with fetal CHAOS at 27 weeks' gestation. The couple declined termination of pregnancy. A multidisciplinary team including obstetricians, geneticists, paediatric surgeons, neonatologists and anaesthetists was constituted to plan an ex utero intrapartum treatment (EXIT) procedure. After several simulations, a caesarean section was performed at 38 weeks' gestation under deep inhalational anaesthesia. The fetus was fully delivered with placenta remaining in utero to maintain perfusion. A surgical airway was established via tracheostomy in approximately 5 minutes. The operation was then completed with no maternal complications. The child remains well at 3 years of age. To our knowledge, this is the first EXIT procedure performed for CHAOS in the public sector. This procedure can be lifesaving and is possible with proper planning.

Poor cervical proprioception as a risk factor for concussion in professional male rugby union players.

BACKGROUND: Concussion is one of the most common injuries in male professional Rugby Union ('rugby') and accounts for significant time loss from training and competition. Despite the most recent Concussion in Sport Group consensus statement recommending a focus on the identification of modifiable risk factors, limited evidence for their existence is available. OBJECTIVE: To investigate the association between cervical proprioception and concussion incidence in a group of professional male rugby players over the course of a full season. METHODS: 165 players were assessed at pre-, mid- and end of season time points using the Cervical Joint Position Error Test (CJPET). Associations with diagnosed concussion injuries are presented as incidence rate ratios with 95% confidence intervals. We present the Incidence Rate Ratios (IRR) for a 10% increase in each variable and compared results against concussion using match minutes to account for risk exposure. RESULTS: During the study period, 45 concussions were incurred by 44 players [or 19.7 concussions per 1000 player-match hours]. There was a significant association between right rotation repositioning error and concussion, with a 5% increase in concussion rate for each 10% increase in gross right rotation error (P = 0.021). CONCLUSION: Poor gross right rotation repositioning error is a modifiable intrinsic risk factor for concussion in professional male rugby players. Interventions to improve proprioceptive function may act as an effective method for reducing concussion incidence in this population.

Influence of operational conditions and wastewater properties on the removal of organic micropollutants through ozonation.

The objective of this study was to evaluate the influence of operational conditions and wastewater properties on the removal of pharmaceuticals, contrast media and antibiotics through ozonation, in order to facilitate the optimization of treatment and its implementation on a full scale. Pilot-scale ozone oxidation trials were performed on treated wastewater, before and after post-precipitation, over a seven-month period, including summer and winter months. Hydraulic retention times as short as 7 min were found to be sufficient for organic micropollutant removal. A short hydraulic retention time reduces both investment costs and land use. Neither the choice of ozone dispersion method, a static mixer or a Venturi injector, nor the wastewater temperature had any significant effect on the removal efficiency of organic micropollutants, however, higher removal was achieved after on-site post-precipitation with aluminum chloride.

Biodegradation of third-generation organic antifouling biocides and their hydrolysis products in marine model systems.

The environmental fate for some selected antifouling biocides, dichlofluanid, tolylfluanid, tralopyril, and medetomidine, is relatively poorly understood with nearly all data derived from the assessment reports. Water/sediment systems and biofilms were used to determine biodegradation of the antifouling biocides. Dichlofluanid and tolylfluanid are known to hydrolyze to form DMSA (N,N-dimethyl-N'-phenylsulfamide) and DMST (N,N-Dimethyl-N'-(4-methylphenyl)sulfamide), respectively. DMSA did not show biodegradation, but it was shown to transform abiotically into N,N-dimethylsulfamide (N,N-DMS). In contrast, the structurally similar DMST did show biodegradation with a half-life of 5.78 days. The resulting transformation product of the biodegradation of DMST is also N,N-DMS. N,N-DMS accounted for the majority of the mass balance after 27 days in the water/sediment systems. Moreover, the biofilm systems also degraded both DMSA and DMST to N,N-DMS. The hydrolysis product of tralopyril, called BCCPCA (3-bromo-5-(4-chlorophenyl)-4-cyano-1 H-pyrrole-3-carboxylic acid), was not metabolized in the experiments and remained persistent. For this compound, a new log Kow of 2.47 was determined since the previously reported Kow value seemed to overestimate sediment partitioning. Medetomidine was removed from the water/sediment system, though, not significantly more than the control. However, a transformation product (medetomidine-acid) was detected in the incubation but not in the control, pointing to limited biodegradation. These results show that tolylfluanid can be rapidly removed by biodegradation in the marine environment, while dichlofluanid, tralopyril, and medetomidine remained in the system for a longer period of time. The prolonged stability of these biocides could mean that there is potential for accumulation in the environment. This potential is also there for the DMSA (dichlofluanid) and DMST (tolylfluanid) derived transformation product N,N-DMS, which was recalcitrant.

Tracheoesophageal fistula following button battery ingestion in an infant : Airway management considerations.

A 13-month-old infant was admitted to hospital approximately 3 weeks after ingestion of a button battery, which was lodged in the esophagus and had caused a tracheoesophageal fistula requiring mechanical ventilation. Since the battery had partially penetrated into the tracheal lumen just above the carina and also was in direct contact with the pulmonary artery, extensive considerations regarding airway and circulatory management were required preoperatively, which are presented and discussed in this case report.

Is dissolved COD a suitable design parameter for ozone oxidation of organic micropollutants in wastewater?

Ozone oxidation of organic micropollutants in biologically treated wastewater was investigated in pilot-scale after a high- and a low loaded activated sludge process. Higher ozone doses were required to remove organic micropollutants in the effluent wastewater from the high loaded activated sludge process. Further comparison of the micropollutant removal was based on normalized ozone doses, expressed as g O3/g DOC and g O3/g soluble COD (sCOD). A clear difference was noted for the two effluents when the micropollutant removal was normalized by DOC. This difference disappeared almost completely when the removal was linked to ozone doses normalized by sCOD. The dose-response curves for the organic micropollutants were practically linear in the removal range up to 95%. A linear prediction model was developed and compared with literature values to test the transferability of the obtained results. Results from this comparison indicated that the slope of the dose-response functions could be used to predict the removal efficiency of organic micropollutants at a third plant with an average uncertainty of 10%. The modeled ozone requirements were then set in relation to the COD concentrations in the discharged water from approximately 90 Swedish activated sludge treatment plants with and without nitrogen removal. This comparison highlighted the need for a well-functioning biological treatment for an effective ozone oxidation of organic micropollutants. The results in this study suggest that soluble COD should be further explored for design and modeling of ozone oxidation of organic micropollutants in biologically treated wastewater.

Sono-activated persulfate oxidation of diclofenac: Degradation, kinetics, pathway and contribution of the different radicals involved.

Degradation of a diclofenac aqueous solution was performed using persulfate anions activated by ultrasound. The objective of this study was to analyze different parameters affecting the diclofenac (DCF) removal reaction by the ultrasonic persulfate (US/PS) process and to evaluate the role played by various intermediate oxidative species such as hydroxyl- and sulfate radicals, superoxide radical anion or singlet oxygen in the removal process as well as to determine a possible reaction pathway. The effects of pH, initial persulfate anion concentration, ultrasonic amplitude and temperature on DCF degradation were examined. Sulfate and hydroxyl radicals were involved in the main reaction pathway of diclofenac. Diclofenac amide and three hydroxy-diclofenac isomers (3´-hydroxy diclofenac, 4´-hydroxy diclofenac and 5-hydroxy diclofenac) were identified as reaction intermediates.

Cross-reactivity between methylisothiazolinone, octylisothiazolinone and benzisothiazolinone using a modified local lymph node assay.

BACKGROUND: In the light of the exceptionally high rates of contact allergy to the preservative methylisothiazolinone (MI), information about cross-reactivity between MI, octylisothiazolinone (OIT) and benzisothiazolinone (BIT) is needed. OBJECTIVES: To study cross-reactivity between MI and OIT, and between MI and BIT. METHODS: Immune responses to MI, OIT and BIT were studied in vehicle and MI-sensitized female CBA mice by a modified local lymph node assay. The inflammatory response was measured by ear thickness, cell proliferation of CD4+ and CD8+ T cells, and CD19+ B cells in the auricular draining lymph nodes. RESULTS: MI induced significant, strong, concentration-dependent immune responses in the draining lymph nodes following a sensitization phase of three consecutive days. Groups of MI-sensitized mice were challenged on day 23 with 0·4% MI, 0·7% OIT and 1·9% BIT - concentrations corresponding to their individual EC3 values. No statistically significant difference in proliferation of CD4+ and CD8+ T cells was observed between mice challenged with MI compared with mice challenged with BIT and OIT. CONCLUSIONS: The data indicate cross-reactivity between MI, OIT and BIT, when the potency of the chemical was taken into account in choice of challenge concentration. This means that MI-sensitized individuals may react to OIT and BIT if exposed to sufficient concentrations.

A review of the peri-operative management of paediatric burns: Identifying adverse events.

BACKGROUND: Burn injuries are common in poverty-stricken countries. The majority of patients with large and complex burns are referred to burn centres. Of the children who qualify for admission, according to burn admission criteria, about half require some kind of surgical procedure to obtain skin cover. These range from massive full-thickness fire burns to skin grafts for small, residual unhealed wounds. Burn anaesthetic procedures are of the most difficult to perform and are known for high complication rates. Reasons include peri-operative sepsis, bleeding, issues around thermoregulation, the hypermetabolic state, nutritional and electrolyte issues, inhalation injuries and the amount of movement during procedures to wash patients, change drapes and access different anatomical sites. The appropriate execution of surgery is therefore of the utmost importance for both minor and major procedures. OBJECTIVE: To review the peri-operative management and standard of surgical care of burnt children. METHODS: This was a retrospective review and analysis of standard peri-operative care of burnt children at Red Cross War Memorial Children's Hospital, Cape Town, South Africa. A total of 558 children were operated on and supervised by the first author. Factors that could adversely affect surgical and anaesthetic outcomes were identified. RESULTS: There were 257 males and 301 females in this study, with an average age of 50.1 months and average weight of 19.5 kg. The total body surface area involved was 1 - 80%, with an average of 23.5%. Inhalational injury was present in 11.3%, pneumonia in 13.1%, wound sepsis in 20.8%, and septicaemia in 9.7%, and organ dysfunction in more than one organ was seen in 6.1%. The average theatre temperature during surgery was 30.0°C. Core temperatures recorded at the start, halfway through and at completion of surgery were 36.9°C, 36.8°C and 36.5°C, respectively. The average preoperative and postoperative haemoglobin levels were 11.28 g/dL and 9.64 g/dL, respectively. Blood loss was reduced by the use of clysis from 1.5 mL/kg/% burn to 1.4 mL/kg/% burn. Adverse intraoperative events were seen in 17.6% of children. CONCLUSION: Burn surgery is a high-risk procedure and comorbidities are common. Anaesthesia and surgery must be well planned and executed with special reference to temperature control, rapid blood loss, preceding respiratory illnesses and measures to reduce blood loss.

Temporal variations and trends in loads of commonly used pharmaceuticals to large wastewater treatment plants in Sweden, a case study (Ryaverket).

Loads of individual commonly used analgesics (ibuprofen, diclofenac), antibiotics (sulfamethoxazole, trimethoprim), ß-blockers (atenolol, metoprolol, sotalol, propranolol) and neuroleptics (carbamazepine, citalopram) to a large-scale operating wastewater treatment plant (WWTP) in Sweden (Ryaverket) were studied by monitoring concentrations and flows during a 9-year period (2006-2015). Variations in loads due to sampling and possible errors in chemical analyses were estimated to be below 40%. The variations in loads were analyzed and discussed in terms of the design of collecting wastewater system as an integrated part of the water treatment at the WWTP as well as the prescription and use of individual pharmaceuticals. Trend analysis in daily loads of individual pharmaceuticals indicated an increase for diclofenac, no significant changes for ibuprofen and metoprolol and a decrease for the other pharmaceuticals. The latter was ascribed to a decrease in their prescription and use. The increase in loads of diclofenac was ascribed to its growing topical use not requiring prescription. In view of future regulations by the EU, growing loads of diclofenac to WWTPs and its low removal rates in WWTPs may require an upgrade of WWTPs to achieve quality standards for diclofenac in receiving waters.

A Review of the Peri-Operative Management of Paediatric Burns: Identifying Adverse Events

Background. Burn injuries are common in poverty-stricken countries. The majority of patients with large and complex burns are referred to burn centres. Of the children who qualify for admission; according to burn admission criteria; about half require some kind of surgical procedure to obtain skin cover. These range from massive full-thickness fire burns to skin grafts for small; residual unhealed wounds. Burn anaesthetic procedures are of the most difficult to perform and are known for high complication rates. Reasons include peri-operative sepsis; bleeding; issues around thermoregulation; the hypermetabolic state; nutritional and electrolyte issues; inhalation injuries and the amount of movement during procedures to wash patients; change drapes and access different anatomical sites. The appropriate execution of surgery is therefore of the utmost importance for both minor and major procedures.Objective. To review the peri-operative management and standard of surgical care of burnt children.Methods. This was a retrospective review and analysis of standard peri-operative care of burnt children at Red Cross War Memorial Children's Hospital; Cape Town; South Africa. A total of 558 children were operated on and supervised by the first author. Factors that could adversely affect surgical and anaesthetic outcomes were identified.Results. There were 257 males and 301 females in this study; with an average age of 50.1 months and average weight of 19.5 kg. The total body surface area involved was 1 - 80%; with an average of 23.5%. Inhalational injury was present in 11.3%; pneumonia in 13.1%; wound sepsis in 20.8%; and septicaemia in 9.7%; and organ dysfunction in more than one organ was seen in 6.1%. The average theatre temperature during surgery was 30.0oC. Core temperatures recorded at the start; halfway through and at completion of surgery were 36.9oC; 36.8oC and 36.5oC; respectively. The average preoperative and postoperative haemoglobin levels were 11.28 g/dL and 9.64 g/dL; respectively. Blood loss was reduced by the use of clysis from 1.5 mL/kg/% burn to 1.4 mL/kg/% burn. Adverse intraoperative events were seen in 17.6% of children.Conclusion. Burn surgery is a high-risk procedure and comorbidities are common. Anaesthesia and surgery must be well planned and executed with special reference to temperature control; rapid blood loss; preceding respiratory illnesses and measures to reduce blood loss

Chemical and toxicological evaluation of transformation products during advanced oxidation processes.

The entry of pharmaceuticals into the water cycle from sewage treatment plants is of growing concern because environmental effects are evident at trace levels. Ozonation, UV- and UV/H(2)O(2)-treatment were tested as an additional step in waste water treatment because they have been proven to be effective in eliminating aqueous organic contaminants. The pharmaceuticals carbamazepine, ciprofloxacin, diclofenac, metoprolol and sulfamethoxazole as well as the personal care products galaxolide and tonalide were investigated in terms of degradation efficiency and by-product formation in consideration of toxic effects. The substances were largely removed from treatment plant effluent by ozonation, UV- and UV/H(2)O(2)-treatment. Transformation products were detected in all tested treatment processes. Accompanying analysis showed no genotoxic, cytotoxic or estrogenic potential for the investigated compounds after oxidative treatment of real waste waters. The results indicate that by-product formation from ozonation and advanced oxidation processes does not have any negative environmental impact.

Leaching of biocides from façades under natural weather conditions.

Biocides are included in organic building façade coatings as protection against biological attack by algae and fungi but have the potential to enter the environment via leaching into runoff from wind driven rain. The following field study correlates wind driven rain to runoff and measured the release of several commonly used organic biocides (terbutryn, Irgarol 1051, diuron, isoproturon, OIT, DCOIT) in organic façade coatings from four coating systems. During one year of exposure of a west oriented model house façade in the Zurich, Switzerland area, an average of 62.7 L/m(2), or 6.3% of annual precipitation came off the four façade panels installed as runoff. The ISO method for calculating wind driven rain loads is adapted to predict runoff and can be used in the calculation of emissions in the field. Biocide concentrations tend to be higher in the early lifetime of the coatings and then reach fairly consistent levels later, generally ranging on the order of mg/L or hundreds of µg/L. On the basis of the amount remaining in the film after exposure, the occurrence of transformation products, and the calculated amounts in the leachate, degradation plays a significant role in the overall mass balance.

Leaching of additives from construction materials to urban storm water runoff.

Urban water management requires further clarification about pollutants in storm water. Little is known about the release of organic additives used in construction materials and the impact of these compounds to storm water runoff. We investigated sources and pathways of additives used in construction materials, i.e., biocides in facades' render as well as root protection products in bitumen membranes for rooftops. Under wet-weather conditions, the concentrations of diuron, terbutryn, carbendazim, irgarol 1051 (all from facades) and mecoprop in storm water and receiving water exceeded the predicted no-effect concentrations values and the Swiss water quality standard of 0.1 microg/L. Under laboratory conditions maximum concentrations of additives were in the range of a few milligrams and a few hundred micrograms per litre in runoff of facades and bitumen membranes. Runoff from aged materials shows approximately one to two orders of magnitude lower concentrations. Concentrations decreased also during individual runoff events. In storm water and receiving water the occurrence of additives did not follow the typical first flush model. This can be explained by the release lasting over the time of rainfall and the complexity of the drainage network. Beside the amounts used, the impact of construction materials containing hazardous additives on water quality is related clearly to the age of the buildings and the separated sewer network. The development of improved products regarding release of hazardous additives is the most efficient way of reducing the pollutant load from construction materials in storm water runoff.

Determination of biocides as well as some biocide metabolites from facade run-off waters by solid phase extraction and high performance liquid chromatographic separation and tandem mass spectrometry detection.

Biocides are used to protect buildings, boats, and other materials from microbial infestations. A huge variety of compounds are being used: isothiazolinones, e.g., to prevent bacterial growth in paints, triazines and phenylureas against algal growth on water exposed materials while carbamates are used against fungal investations. However these biocides can be leached from the respective materials. As these are very effective compounds it is important to know the concentrations of these biocides in the leachates as well as their leaching behaviour to assess their risk to the environment. In this study, a method for the determination of biocides from facade material run-off water by means of high performance liquid chromatography coupled to tandem mass spectrometry (HPLC-MS/MS) was developed. Due to the amphiphilic character and the expected varying pH-values in the samples, the extractions as well as the HPLC-method development proved to be demanding. The water samples (leachates) were buffered with a phosphate buffer to pH 7. As some of the biocides are very hydrophilic, different SPE cartridges were tested to identify the SPE material with the highest recovery rates for all compounds. For gaining a good separation, analyte trapping was performed on the HPLC column. Quantification was performed using a mass spectrometer in multi-reaction monitoring with two transitions per compound. The final recovery rates were conducted using a cartridge with a divenylbenzyl polymer sorbent. A combination of methanol and acetonitrile as eluents was used to reach recovery rates in the range of 70-100%. The limit of quantification for the compounds of interest ranged from 0.01 to 0.1 microg/L.

Elimination of macrolides, tiamulin, and salinomycin during manure storage.

The extensive use of veterinary drugs in livestock farming increases the risk that these compounds end up in the environment when manure is used as fertilizer. This study focuses on the fate of antibiotics in liquid manure tanks before the liquid manure is spread on fields. A 180-day degradation experiment of four commonly used antibiotics erythromycin, roxithromycin, salinomycin, and tiamulin in liquid manure was performed. The resulting half-lives during manure storage were calculated as follows: 41 days for erythromycin, 130 days for roxithromycin, and 6 days for salinomycin. A first-order degradation rate was calculated for these three antibiotics. The concentration of tiamulin remained unchanged during the entire experiment. No degradation of tiamulin was detected even after 180 days.

Organophosphorus flame retardants and plasticisers in surface waters.

Organophosphates used as flame retardants, plasticisers and lubricants such as tris-(2-chloro-, 1-methyl-ethyl)-phosphate (TCPP), tris-(2-chloroethyl)-phosphate (TCEP) or tris-(2-chloro-, 1-chloromethyl-ethyl)-phosphate (TDCP), tri-n-butylphosphate (TnBP), tri-iso-butylphosphate (TiBP), triphenylphosphate (TPP) and tris-(butoxyethyl)-phosphate (TBEP) have been analysed in several rivers and sewage treatment plant (STP) effluents. The concentrations in the River Ruhr are 20-200 ng/l TCPP, 13-130 ng/l TCEP, about 50 ng/l TDCP, 10-200 ng/l TBEP and up to 40 ng/l TPP. The STP effluents exhibit concentrations up to 400 ng/l TCPP, 130 ng/l TCEP, about 120 ng/l TDCP and 500 ng/l TBEP, respectively. The main sources for the load of organophosphates are sewage treatment plants, but not all contribute equivalent to the amount of inhabitants they serve.

Organophosphate flame retardants and plasticisers in wastewater treatment plants.

Previous studies have revealed that chlorinated and non-chlorinated organophosphorous flame retardants and plasticisers are important contaminants in German surface waters and it has been demonstrated that wastewater treatment plants contribute to the emission of these substances. In this study temporal development as well as elimination efficiency were determined in two wastewater treatment plants (STP) in the Ruhr/Rhine area at different stages of the wastewater treatment process. The samples were analysed for the non-chlorinated organophosphate esters tri-n-butylphosphate (TnBP), tri-iso-butylphosphate (TiBP), tris-(butoxyethyl)-phosphate (TBEP) and triphenylphosphate (TPP) and the chlorinated organophosphate esters tris-(2-chloro, 1-methylethyl)-phosphate (TCPP), tris-(2-chloro-, 1-chloromethylethyl)-phosphate (TDCP) and tris-(2-chloroethyl)-phosphate (TCEP). The study showed that there were significant differences in the elimination of chlorinated and non-chlorinated organophosphorous flame retardants. The elimination rates ranged from 57-86% for TiBP, TnBP and TBEP at both STP's. No elimination of the chlorinated flame retardants TCPP, TDCP and TCEP was observed in any of the sampled STPs. At both STPs the first treatment steps and the final filtration did not contribute to the elimination of the non-chlorinated organophosphorous flame retardants while the aeration step did. At both STPs the efficiency of the cleaning process concerning the flame retardants was comparable. Thus the type of construction of the STP was not relevant for the elimination of these substances. Additionally a strong day-to-day variation was observed, while in one STP a temporal trend for TCPP during the week was found.

Triclosan in a sewage treatment process--balances and monitoring data.

In a German sewage treatment plant that processes 200000 m(3) wastewater per day, the concentrations of 2,4,4'-trichloro, 2'-hydroxy-phenylether (triclosan) in the in-flowing ( approximately 1000 ng x l(-1)) as well as in the out-flowing water ( approximately 50 ng x l(-1)) are compared to the concentrations measured in sludge (1200 ng x g(-1)). Considering the mass flow of water and sludge in the respective plant, balances including water and sludge are calculated. Thirty percent of the triclosan is sorbed with weak bonds to the sludge, while some amounts are sorbed as bound residues in the sludge. About 5% is dissolved in the out-flowing water. Thus most of the in-flowing material is not recovered as the parent compound but it is likely that it is transformed to other metabolites or unrecovered bound residues. These data are compared to the monitoring of sewage sludge of 20 different plants in this region, most of which are smaller, though. The concentrations found in these sludges vary from 1000-8000 ng x g(-1).