Direct Synthesis of C4-Acyl Indoles via C-H Acylation.

The direct synthesis of C4-acyl indoles deprived of C2 and C3 substituents has proven to be challenging, with scarce efficient synthetic routes being reported. Herein, we disclose a highly site-selective palladium-catalyzed C-H acylation for the construction of C4-acyl indoles via a Catellani-Lautens cyclization strategy. In addition, we systematically studied the ortho C-H acylation mechanism of iodoaniline through density functional theory (DFT) calculations and combined experimental results to elucidate the principle of high chemoselectivity brought by triazine benzoate as an acylation reagent.

Refined image quality assessment for color fundus photography based on deep learning.

Purpose: Color fundus photography is widely used in clinical and screening settings for eye diseases. Poor image quality greatly affects the reliability of further evaluation and diagnosis. In this study, we developed an automated assessment module for color fundus photography image quality assessment using deep learning. Methods: A total of 55,931 color fundus photography images from multiple centers in Shanghai and the public database were collected and annotated as training, validation, and testing data sets. The pre-diagnosis image quality assessment module based on the multi-task deep neural network was designed. The detailed criterion of color fundus photography image quality including three subcategories with three levels of grading was applied to improve precision and objectivity. The auxiliary tasks such as the localization of the optic nerve head and macula, the classification of laterality, and the field of view were also included to assist the quality assessment. Finally, we validated our module internally and externally by evaluating the area under the receiver operating characteristic curve, sensitivity, specificity, accuracy, and quadratic weighted Kappa. Results: The "Location" subcategory achieved area under the receiver operating characteristic curves of 0.991, 0.920, and 0.946 for the three grades, respectively. The "Clarity" subcategory achieved area under the receiver operating characteristic curves of 0.980, 0.917, and 0.954 for the three grades, respectively. The "Artifact" subcategory achieved area under the receiver operating characteristic curves of 0.976, 0.952, and 0.986 for the three grades, respectively. The accuracy and Kappa of overall quality reach 88.15% and 89.70%, respectively, on the internal set. These two indicators on the external set were 86.63% and 88.55%, respectively, which were very close to that of the internal set. Conclusions: This work showed that our deep module was able to evaluate the color fundus photography image quality using more detailed three subcategories with three grade criteria. The promising results on both internal and external validation indicated the strength and generalizability of our module.

Vaginal metastasis from breast cancer: A case report.

Breast cancer is one of the most common malignancies in women. However, cases of vaginal metastases of breast cancer are rarely reported in China and abroad. The main clinical symptom of vaginal metastases of breast cancer is vaginal bleeding. This article aims to provide a reference for the diagnosis and clinical management of vaginal metastases from breast cancer. This article describes in detail the management of a 50-year-old woman with vaginal metastases from breast cancer, who was admitted to the hospital with persistent vaginal bleeding without apparent causes. Persistent vaginal bleeding was found after two and a half years when her breast cancer surgery was performed. After comprehensive evaluation, vaginal mass resection was performed. Postoperative histopathology confirmed that the vaginal mass was breast cancer metastasis. The patient was treated with local radiotherapy and three cycles of eribulin and bevacizumab after the vaginal mass was removed. A reexamination of computed tomography showed that the chest wall metastases were less extensive than before. Orbital metastases were also reduced in size, which was revealed by the physical examination. The patient had since failed to return to hospital on time for a regular treatment due to personal reasons. After 9 months of follow-up, the patient died of multiple metastases. The diagnosis of vaginal masses is based on pathological examination, and systemic treatment should be the mainstay when extensive metastases are presented.

Study on the correlation between false-positive filling defect in LAA CT and LAA structure in patients with atrial fibrillation based on TEE.

OBJECTIVE: This study aims to explore the actual meaning of "false positive filling defect" in left atrial appendage (LAA) computed tomography (CT) in patients with atrial fibrillation (AF), with transesophageal echocardiography (TEE) as the gold standard. METHODS: Patients with AF undergoing cardiac CT angiography and TEE examinations for proposed radiofrequency catheter ablation between October 2020 and October 2021 were selected as the study subjects. Transesophageal echocardiography was taken as the "gold standard," and spontaneous echocardiographic contrast (SEC) and thrombus events were defined as positive events. The CT manifestations were classified into three groups (true positive, false positive, and true negative) to evaluate the differences in left atrium (LA) anterior-posterior diameter (LAAP), LA anterior wall thickness, and LAA orifice long diameter and short diameter, area, and depth between the three groups. RESULTS: (1) There was no statistical difference in LA anterior wall thickness between the three groups (p > .05); there was a statistical difference in LAAP (only) between the true-positive group and the true-negative group (p < .05). (2) There was a statistical difference in LAA orifice long diameter, short diameter, and area between the true-positive group and the true-negative group as well as between the false-positive group and the true-negative group (p < .05). (3) There was a statistical difference in LAA depth between the true-positive group and the false-positive group as well as between the true-positive group and the true-negative group (p < .05). (4) The area under the receiver operator characteristic curve (AUC) of LAA depth affecting the LAA thrombus and SEC was 0.863 (confidence interval = 0.718-1.000), the sensitivity was 77.8%, and the specificity was 90.6% for predicting the occurrence of LAA thrombus and SEC in patients with nonvalvular AF (NVAF) and an LAA depth of ≥50.84 mm. CONCLUSIONS: There was a difference in LAA diameter between the TEE-based CT false-positive group and the other groups. A "CT false positive" is an objectively existing state, and CT might be able to identify the LAA hemodynamic disorder earlier than TEE. Furthermore, a CT + TEE combined application could more accurately evaluate LAA hemodynamics in patients with AF.

Learning for retinal image quality assessment with label regularization.

BACKGROUND AND OBJECTIVE: The assessment of the image quality is crucial before the computer-aided diagnosis of fundus images. This task is very challenging. Firstly, the subjective judgments of graders on image quality lead to ambiguous labels. Secondly, despite being treated as classification in existing works, grading has regression properties that cannot be ignored. Solving the ambiguity problem and regression problem in the label space, and extracting discriminative features, have become the keys to quality assessment. METHODS: In this paper, we proposed a framework that can assess the quality of fundus images accurately and reasonably based on deep convolutional neural networks. Drawing on the experience of human graders, a dual-path convolutional neural network with attention blocks is designed to better extract discriminative features and present the bases of decision. Label smoothing and cost-sensitive regularization are designed to solve the label ambiguity problem and the potential regression problem respectively. Besides, a large number of images are annotated by us to further improve the results. RESULTS: We conducted our experiments on the largest retinal image quality assessment dataset with 28,792 retinal images. Our approach achieves 0.8868 precision, 0.8786 recall, 0.8820 F1, and 0.9138 Kappa score. Results show that our approach outperforms state-of-the-art methods. CONCLUSIONS: The promising performances reveal that our methods are beneficial to retinal image quality assessment and have potential in other grading tasks.

The Comparison of the Diagnostic Value of Left Atrial Pulmonary Vein Single-Phase and Dual-Phase Enhanced CT Scanning for Left Atrial Appendage Thrombosis and SEC in Patients with Atrial Fibrillation.

Objective: The accuracy of left atrial pulmonary vein CT enhanced single-phase and dual-phase scanning in the detection of left atrial appendage (LAA) thrombosis and spontaneous echo contrast (SEC) before radio frequency ablation was compared in atrial fibrillation patients, so as to optimize the scanning scheme. Methods: 78 patients with atrial fibrillation who were admitted to Cangzhou Central Hospital from October 2020 to September 2021 and underwent bilateral enhanced CT scan of left atrial pulmonary vein and transesophageal echocardiography (TEE) examination for planned frequency ablation were selected. TEE results were used as the "gold standard" to compare the diagnostic efficacy of the first phase, second phase, and double-phase comprehensive mode of enhanced left atrial pulmonary vein CT in detecting left atrial thrombosis and SEC. Results: The sensitivity, specificity, positive predictive value, and negative predictive value were 88.9%, 84.1%, 42.1%, and 98.3%, respectively, in the detection of left atrial thrombosis and SEC by the first phase of CT enhanced scan. The sensitivity, specificity, positive predictive value, and negative predictive value were 22.2%, 98.6%, 66.6%, and 90.7%, respectively, in the detection of left atrial thrombosis and SEC by the second phase of CT enhanced scan. The sensitivity, specificity, positive predictive value, and negative predictive value were 88.9%, 84.1%, 42.1%, and 98.3%, respectively, in the detection of left atrial thrombosis and SEC by the double-phase comprehensive mode of CT enhanced scan. There was no statistically significant difference in the accuracy of CT diagnosis of left atrial appendage thrombosis and SEC between the three modes of the first phase, the second phase, and the double-phase comprehensive CT (P > 0.05). The mean effective radiation dose of double-phase enhanced scan was 7.49 ± 1.02 mSv. Conclusion: Single-phase enhanced CT scan of left atrial pulmonary vein can meet clinical requirements and significantly reduce the radiation dose compared with double-phase enhanced CT scan. Therefore, it is recommended as an initial screening examination for patients with atrial fibrillation before radiofrequency ablation.

Mechanism of Propane Adsorption and the Following NO x Reduction over an In/BEA Catalyst: A Computational Study.

To expand the knowledge on hydrocarbon selective catalytic reduction (SCR) and follow the research steps of methane-SCR and propane-SCR in our previous work, we studied the characteristics of propane adsorption on In/BEA zeolite, explored the NO and NO2 activation process on a propane adsorbed catalyst, and calculated the reaction enthalpy of two reaction pathways. Results showed that O site in the L-model (the [InO]+/BEA structure) was the main active site in the adsorption process, and any of the carbon atoms in the propane molecule could react with it, with a lower adsorption energy than methane (-3.20 vs -2.98 eV). Also, NO or NO2 could not be directly activated on the propane adsorbed catalyst, indicating that the process may be complicated. In addition, propane reduces the NO or NO2 molecule with two different pathways and the final products were less stable than those of methane (-5.6 vs -20 eV). These results could explain the fact that propane and methane had different reaction temperatures and would further deepen our understanding of the propane-SCR process.

Pollution characteristics and source analysis of microplastics in the Qiantang River in southeastern China.

Microplastic pollution resulting from industrialization and urbanization is increasingly serious. Hangzhou is a city with high industrial/urban growth in Southeast China. Focusing on the microplastic pollution in the Hangzhou section Qiantang River, six samples were collected and analyzed during different hydrological periods (normal, wet, and dry periods) and the relationship between microplastic pollution and economic development was investigated. Results showed that more microplastics were found during the dry period than that of the wet period (49.8 vs. 13.2%). Microplastic abundance was 1.5-9.4 items L-1, showing significant spatial differences in sampling sites. Among the collecting microplastics, debris and fibers accounted for 36.4 and 30.9%. Polyethylene terephthalate and polyvinyl chloride were the main polymers, accounting for 48.3 and 31.8%, respectively. Microplastics with size <1 mm accounted for 60% of the microplastics in surface water samples. Spatially, microplastic abundance was the highest in the middle of the river. Redundant analysis revealed that the per capita GDP (p = 0.002), high-end equipment industry (p = 0.028) and fashion manufacturing (p = 0.006) influenced microplastic abundance. Urbanization coupled with rapid economic development led to increase in local microplastic pollution. Our results provide insight into microplastic distribution patterns in urban river systems in China.

Mutual inhibition mechanism of simultaneous catalytic removal of NOx and toluene on Mn-based catalysts.

NOx and toluene have been identified as the dominant air pollutants in solid wasted combustion, and it is of great importance to remove these two pollutants simultaneously. Here, we found that Mn/CeO2 and Mn/TiO2 exhibited a bifunctional property in both NO reduction and toluene oxidation, and both of which could achieve 80% of conversion rate in NO reduction and toluene oxidation processes. However, the activity of both Mn/CeO2 and Mn/TiO2 decreased in simultaneous removal of NOx and toluene compared with separate NOx reduction and toluene oxidation. This indicates that there is a mutual inhibition between NOx reduction and toluene oxidation in simultaneous removal process over Mn-based catalysts, attributing to the competitive adsorption and utilization of active oxygen. In detail, the adsorption of toluene occupied the Lewis acid sites and restrained the NH3 adsorption. Meanwhile, the competitive utilization of active oxygen by NH3/NOx inhibited toluene oxidation to CO2 by active oxygen species as the reaction between NH3/NOx and active oxygen species would occur more easily.

RETRACTED: Cytotoxicity and genotoxicity evaluation of polystyrene microplastics on Vicia faba roots.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editors and Corresponding Author. The authors have plagiarized part of a paper that had already appeared in Environmental and Experimental Botany, 179 (2020) 104227, https://doi.org/10.1016/j.envexpbot.2020.104227. One of the conditions of submission of a paper for publication is that authors declare explicitly that their work is original and has not appeared in a publication elsewhere. Re-use of any data should be appropriately cited. As such this article represents a severe abuse of the scientific publishing system. The scientific community takes a very strong view on this matter and apologies are offered to readers of the journal that this was not detected during the submission process.

Enhanced adsorption and reduction performance of nitrate by Fe-Pd-Fe3O4 embedded multi-walled carbon nanotubes.

Multi walled carbon nanotubes (MWCNTs) have attracted more and more attention as adsorbents due to their excellent adsorption properties. By loading metal particles on MWCNTs, the chemical reduction ability of adsorbed pollutants could be provided, so as to achieve the purpose of adsorption and degradation of pollutants. Therefore, the removal process of NO3--N by Fe-Pd-Fe3O4/MWCNTs was studied, including rapid adsorption of initial pollutants, gradual reduction of intermediate products and re-adsorption of final products. The results showed that Fe-Pd-Fe3O4/MWCNTs completely removed NO3--N within 2 h, 39% and 25% of which were converted into NO2--N and NH4+-N. The adsorption efficiency, kinetics, capacity and adsorption energy all followed the order of NH4+-N > NO2--N > NO3--N. With the recoverability and reusability of Fe-Pd-Fe3O4/MWCNTs having been confirmed in 5 consecutive cycles, the removal rate of NO3--N still reached 43%. It has been shown that MWCNTs prolonged the reducing power for NO3--N, due to avoiding the aggregation of metal particles. The rapid adsorption of initial pollutants, effective stepwise reduction and convenient recovery processes were of great value for the rehabilitation of polluted water.

Improvement of Alcaligenes sp.TB performance by Fe-Pd/multi-walled carbon nanotubes: Enriched denitrification pathways and accelerated electron transport.

Aiming at the accumulation of NO2--N and N2O during denitrification process, this work focused to improve the denitrification performance by Pd-Fe embedded multi-walled carbon nanotubes (MWCNTs). The main conclusions were as follows: 30 mg/L Pd-Fe/MWCNTs have shown an excellent promotion on denitrification (completely TN removal at 36 h). Meanwhile, enzyme activity results indicated that the generation of NO2--N, NH4+-N by Pd-Fe/MWCNTs led the occur of short-cut denitrification by increasing 203.9% the nitrite reductase activity. Furthermore, electrochemical results and index correlation analysis confirmed that the electron exchange capacity (1.401 mmol eg-1) of Pd-Fe/MWCNTs was positively related to nitrite reductase activity, indicating its crucial role in electron transport activity (0.46 µg O2/(protein·min) at 24 h) during denitrification process by Pd-Fe/MWCNTs played a role of chemical reductant and redox mediator.

An integrated chemical mass balance and source emission inventory model for the source apportionment of PM2.5 in typical coastal areas.

The source apportionment of PM2.5 is essential for pollution prevention. In view of the weaknesses of individual models, we proposed an integrated chemical mass balance-source emission inventory (CMB-SEI) model to acquire more accurate results. First, the SEI of secondary component precursors (SO2, NOx, NH3, and VOCs) was compiled to acquire the emission ratios of these sources for the precursors. Then, a regular CMB simulation was executed to obtain the contributions of primary particle sources and secondary components (SO42-, NO3-, NH4+, and SOC). Afterwards, the contributions of secondary components were apportioned into primary sources according to the source emission ratios. The final source apportionment results combined the contributions of primary sources by CMB and SEI. This integrated approach was carried out via a case study of three coastal cities (Zhoushan, Taizhou, and Wenzhou; abbreviated WZ, TZ, and ZS) in Zhejiang Province, China. The regular CMB simulation results showed that PM2.5 pollution was mainly affected by secondary components and mobile sources. The SEI results indicated that electricity, industrial production and mobile sources were the largest contributors to the emission of PM2.5 gaseous precursors. The simulation results of the CMB-SEI model showed that PM2.5 pollution in the coastal areas of Zhejiang Province presented complex pollution characteristics dominated by mobile sources, electricity production sources and industrial production sources. Compared to the results of the CMB and SEI models alone, the CMB-SEI model completely apportioned PM2.5 to primary sources and simultaneously made the results more accurate and reliable in accordance with local industrial characteristics.

Multi-factorial analysis of the removal of dichloromethane and toluene in an airlift packing bioreactor.

Biotechnology has proven effective in removing a wide variety of VOCs. In this study, the effects of pH (from 3 to 7), operating temperature (20-30 °C), empty bed residence time (EBRT, 10-40 s) and transient inlet concentration (400-4000 mg m-3) on the removal performance of an airlift packing bioreactor (ALPR) was investigated. The removal efficiency (RE) and stability of the ALPR was evaluated and compared with the conventional airlift bioreactor (ALR). The results showed that under the influence of single factor variation, the ALPR showed significant higher RE and better stability than the ALR in removing dichloromethane (DCM) and toluene. Besides, a factorial design was used to analyses the interaction of multiple factors and their influence on the removal of DCM and toluene in the ALPR and ALR. It shows that pH value has the most significant influence, and plays a crucial role in maintaining high RE of DCM and toluene in both of the ALPR and ALR. Temperature has a great effect on the removal of toluene. EBRT has certain effect on the removal of DCM in the ALPR. The transient concentration of a single substrate has a significant negative effect on the RE of this substrate, while it does not significantly affect the removal of another substrate in the ALPR. However, the steep increase of DCM concentration has an adverse effect on the RE of high concentration toluene in the ALR. The overall RE and degradation capacity of both toluene and DCM by the ALPR are much higher than that of the conventional ALR.

Effectiveness of fecal microbiota transplantation for severe diarrhea after drug-induced hypersensitivity syndrome.

The aim of this study was to assess effectiveness of fecal microbiota transplantation (FMT) in treating intestinal failure associated with drug-induced hypersensitivity syndrome (DIHS).A 32-year-old Chinese woman, who developed DIHS-associated multiple organ dysfunction syndrome (MODS) manifesting as combined dysfunction of the intestine, liver, and kidney, was treated with 4 times of FMT at a frequency of once every 6 days. The structure and composition of the patient's fecal microbiota were analyzed by 16S rRNA-based molecular techniques. The clinical outcomes after FMT treatment were assessed by abdominal contrast-enhanced computed tomography (CT), characterization of fecal microbiota, measurement of serum inflammatory markers, and other clinical examinations.After 4 rounds of FMT were administered, the patient showed dramatic improvement in MODS and severe diarrhea with these clinical conditions under control. We consistently observed significant alteration in her gut microbiota, mainly involving considerable enrichment in Firmicutes members and depletion of Proteobacteria opportunistic organisms. Moreover, this reconstituted bacterial community composition correlated with fecal output, T helper cells, and inflammatory markers. Abdominal contrast-enhanced CT scans before and after FMT indicated significant improvement in inflammation and edema within the small intestine and colon of the patient. Notably, after completion of the fourth FMT, the level of inflammation in the intestine and colon had returned to normal. Over 6 months of follow-up, the intestinal mucous remained normal.Our results represent a breakthrough in the clinical management of MODS and suggest new therapeutic avenues to pursue for microbiota-related indications.

Evaluation of polypyrrole-modified bioelectrodes in a chemical absorption-bioelectrochemical reduction integrated system for NO removal.

A Chemical absorption-bioelectrochemical reduction (CABER) system is based on Chemical absorption-biological reduction (CABR) system, which aims at NO removal and has been studied in many of our previous works. In this paper, we applied polypyrrole (PPy) on the electrode of bioelectrochemical reactor (BER) of CABER system, which induced a much higher current density in the cyclic voltammetry (CV) curve for the electrode itself and better NO removal rate in the system. In addition, a Microbial Electrolysis Cell (MEC) is constructed to study its strengthening mechanism. Results shows that PPy-MEC has a greater Faraday efficiency and higher reduction rate of Fe(III)EDTA and Fe(II)EDTA-NO in the solution when compared to original Carbon MEC, which confirms the advantage of PPy-modified electrode(s) in the CABER system. The results of this study are reported for illustration of potential of CABER technology and design of low-cost high-efficiency NOx control equipment in the future.

Evaluation on the removal performance of dichloromethane and toluene from waste gases using an airlift packing reactor.

Biological removal of dichloromethane (DCM) from pharmaceutical industry is limited by its recalcitrance. In this study, an airlift packing reactor (ALPR), which combined the suspended and fixed-film microbial growth system, was set up to remove DCM and co-existed toluene. The removal performance of the ALPR for DCM was greater than traditional airlift reactor (ALR). The maximum elimination capacity (ECmax) of the ALPR for DCM reached 108 g m-3 h-1 with removal efficiency (RE) of 41%, increased by 145% if compared to the ALR. The ECmax for toluene was 172 g m-3 h-1 with RE of 70%, decreased by 25% if compared to the ALR, which was mainly due to the higher liquid-phase biomass in the ALR. The results of high-throughput sequencing showed that the microbial composition on the packings of the ALPR had a large difference from its liquid-phase or the liquid-phase of the ALR. Gemmobacter, Rhizomicrobium, Chitinophaga, Vampirovibrio, and Fodinicurvata were genera with great abundance fixed on the packings and Rhizomicrobium, Chitinophaga, Vampirovibrio, and Fodinicurvata are first to be reported in VOCs biological removal. This study indicated that the ALPR can augment the microbial community and effectively improve the removal of recalcitrant VOCs.

Diagnostic performance of magnifying endoscopy with narrow-band imaging in differentiating neoplastic colorectal polyps from non-neoplastic colorectal polyps: a meta-analysis.

Colorectal polyps are commonly seen in colonoscopy and the management of neoplastic polyps and non-neoplastic polyps are different. It is necessary to distinguish neoplastic polyps from non-neoplastic polyps in real-time. Therefore, we conducted a meta-analysis to assess the diagnostic accuracy of magnifying endoscopy with narrow-band imaging (ME-NBI) in diagnosing neoplastic colorectal polyps from non-neoplastic colorectal polyps. PubMed and EMBASE were searched for trials that used magnifying endoscopy with ME-NBI for diagnosing neoplastic colorectal polyps. Sixteen articles and 20 fourfold tables were obtained. Sensitivity (Sen), specificity (Spe), positive likelihood ratios (+ LRs), negative likelihood ratios (- LRs) and diagnostic odds ratios (DORs) were calculated. A summary receiver-operating characteristic (SROC) curve was constructed, and the area under the ROC curve (AUC) was calculated. We performed subgroup analyses based on polyp size and assessment criteria: (1) According to data extracted from 20 fourfold tables, the pooled Sen and Spe of ME-NBI for diagnosing neoplastic colorectal polyps < 10 mm were 0.94 (95% CI 0.92-0.95) and 0.76 (95% CI 0.72-0.80),respectively. The pooled Sen and Spe of ME-NBI for diagnosing all neoplastic polyps were 0.98 (95% CI 0.98-0.99) and 0.88 (95% CI 0.85-0.90), respectively. (2) Data pertaining to the following three assessment methods were analysed from 15 fourfold tables: surface pattern (SP), vessel pattern (VP) and the combination of SP and VP. The AUCs for these assessment criteria were 0.9533, 0.9518 and 0.9954, respectively. Conclusions were made that ME-NBI has high diagnostic accuracy in diagnosing neoplastic colorectal polyps based on the combination of SP with VP and is helpful in making real-time diagnoses.

Applicability of energy-positive net-zero water management in Alaska: technology status and case study.

Challenges of water and wastewater management in Alaska include the potential need for above-grade and freeze-protected piping, high unit energy costs and, in many rural areas, low population density and median annual income. However, recently developed net-zero water (NZW), i.e., nearly closed-loop, direct potable water reuse systems, can retain the thermal energy in municipal wastewater, producing warm treated potable water without the need for substantial water re-heating, heat pumping or transfer, or additional energy conversion. Consequently, these systems are projected to be capable of saving more energy than they use in water treatment and conveyance, in the temperate USA. In this paper, NZW technology is reviewed in terms of potential applicability in Alaska by performing a hypothetical case study for the city of Fairbanks, Alaska. Results of this paper study indicate that in municipalities of Alaska with local engineering and road access, the use of NZW systems may provide an energy-efficient water service option. In particular, case study modeling suggests hot water energy savings are equivalent to five times the energy used for treatment, much greater savings than in mid-latitudes, due largely to the substantially higher energy needed for heating water from a conventional treatment system and lack of need for freeze-protected piping. Further study of the applicability of NZW technology in cold regions, with expanded evaluation in terms of system-wide lifecycle cost, is recommended.