Brain and Lung Imaging Correlation in Patients with COVID-19: Could the Severity of Lung Disease Reflect the Prevalence of Acute Abnormalities on Neuroimaging? A Global Multicenter Observational Study.

PURPOSE: Our aim was to study the association between abnormal findings on chest and brain imaging in patients with coronavirus disease 2019 (COVID-19) and neurologic symptoms. MATERIALS AND METHODS: In this retrospective, international multicenter study, we reviewed the electronic medical records and imaging of hospitalized patients with COVID-19 from March 3, 2020, to June 25, 2020. Our inclusion criteria were patients diagnosed with Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection with acute neurologic manifestations and available chest CT and brain imaging. The 5 lobes of the lungs were individually scored on a scale of 0-5 (0 corresponded to no involvement and 5 corresponded to >75% involvement). A CT lung severity score was determined as the sum of lung involvement, ranging from 0 (no involvement) to 25 (maximum involvement). RESULTS: A total of 135 patients met the inclusion criteria with 132 brain CT, 36 brain MR imaging, 7 MRA of the head and neck, and 135 chest CT studies. Compared with 86 (64%) patients without acute abnormal findings on neuroimaging, 49 (36%) patients with these findings had a significantly higher mean CT lung severity score (9.9 versus 5.8, P < .001). These patients were more likely to present with ischemic stroke (40 [82%] versus 11 [13%], P < .0001) and were more likely to have either ground-glass opacities or consolidation (46 [94%] versus 73 [84%], P = .01) in the lungs. A threshold of the CT lung severity score of >8 was found to be 74% sensitive and 65% specific for acute abnormal findings on neuroimaging. The neuroimaging hallmarks of these patients were acute ischemic infarct (28%), intracranial hemorrhage (10%) including microhemorrhages (19%), and leukoencephalopathy with and/or without restricted diffusion (11%). The predominant CT chest findings were peripheral ground-glass opacities with or without consolidation. CONCLUSIONS: The CT lung disease severity score may be predictive of acute abnormalities on neuroimaging in patients with COVID-19 with neurologic manifestations. This can be used as a predictive tool in patient management to improve clinical outcome.

Combining environmental isotopes with Contaminants of Emerging Concern (CECs) to characterise wastewater derived impacts on groundwater quality.

The potential for Wastewater Treatment Plants (WWTPs) to cause adverse impacts to groundwater quality is a major global environmental challenge. Robust and sensitive techniques are required to characterise these impacts, particularly in settings with multiple potential contaminant sources (e.g. agricultural vs. site-derived). Stable (δ2HH2O, δ18OH2O, δ15NNO3, δ18ONO3 and δ13CDIC) and radioactive (3H and 14C) isotopes were used in conjunction with three Contaminants of Emerging Concern (CECs) - carbamazepine, simazine and sulfamethoxazole - to discriminate between multiple potential contamination sources at an Australian WWTP. The radioactive isotope tritium provided a sensitive indicator of recent (post-1990s) leakage, with groundwater activities between 0.68 and 1.83 TU, suggesting WWTP infrastructure (activities between 1.65 and 2.41) acted as a recharge 'window', inputting treated or partially treated effluent to the underlying groundwater system. This was corroborated by water stable isotopes, which showed clear demarcation between δ18OH2O and δ2HH2O in background groundwater (δ18OH2O and δ2HH2O values of approximately -5 and -28‰, respectively) and those associated with on-site wastewater (median δ18OH2O and δ2HH2O values of -1.2 and -7.6‰, respectively), with groundwater down-gradient of the plant plotting on a mixing line between these values. The CECs, particularly the carbamazepine:simazine ratio, provided a means to further distinguish wastewater impacts from other sources, with groundwater down-gradient of the plant reporting elevated ratios (median of 0.98) compared to those up-gradient (median of 0.11). Distinctive CEC ratios in impacted groundwater close to the WWTP (∼3.0) and further down-gradient (2.7-9.3) are interpreted to represent a change in composition over time (i.e., recent vs. legacy contamination), consistent with the site development timeline and possible changes in effluent composition resulting from infrastructure upgrades over time. The data indicate a complex set of co-mingled plumes, reflecting different inputs (in terms of both quantity and concentration) over time. Our approach provides a means to better characterise the nature and timing of wastewater derived impacts on groundwater systems, with significant global implications for site management, potentially allowing more targeted monitoring, management and remedial actions to be undertaken.

Contaminants of Emerging Concern as novel groundwater tracers for delineating wastewater impacts in urban and peri-urban areas.

Management and treatment of environmental impacts from wastewater treatment plants (WWTPs) is a major, worldwide, sustainability challenge. One issue associated with WWTP operation is the potential for groundwater contamination via leaking or infiltration of wastewater, particularly with inorganic nutrients (ammonia and nitrate) as well as persistent organic compounds. Despite the potential for such contamination to create environmental and health risks, conventional methods, such as the assessment of major ions, nutrients, bacteriological indicators and conventional tracers (such as stable and radiogenic isotopes) are often unable to provide accurate delineation of multiple potential sources of contamination. This is particularly important for WWTPs which often occur in urban, peri-urban or intensively farmed agricultural areas where multiple potential sources (such as livestock, fertilisers, wastewater irrigation, and domestic septic systems) may contribute similar contaminants. This review explores the applicability of promising novel groundwater tracers, such as Contaminants of Emerging Concern (CECs) and isotopic tracers, which can be used in conjunction with conventional tracers (i.e. 'co-tracers') to provide a more definitive assessment of contaminant sources, plume delineation and even (potentially) indicating the age of contamination (e.g., recent vs. legacy). The suitability of the novel groundwater tracers is evaluated according to four key criteria: (i). sufficient presence in raw wastewater and/or treated effluents; (ii) diagnostic of WWTP impacts as opposed to other potential off-site contamination sources; (iii) persistence in the subsurface environment; and (iv) amenable to rapid and sensitive analysis. Further analysis of various classes of CECs along with improved detection limits associated with improvements in analytical methodologies should allow for future application of promising groundwater tracers, providing WWTP operators and regulatory authorities a more definitive toolbox with which to assess groundwater contamination associated with site operations. These include: persistent pharmaceuticals and personal care products (carbamazepine, crotamiton, primidone, atenolol and sulfamethoxazole), artificial sweeteners (acesulfame, sucralose, saccharin and cyclamate) and potentially, certain pesticides (atrazine and simazine).