Solving the Autism Puzzle: Creating a Broad-Spectrum Tool to Improve Care Delivery in the Clinical Setting.

PURPOSE: The purpose of this quality improvement (QI) project was to develop and implement an assessment tool to identify a patient's specific needs due to autism spectrum disorder (ASD). The use of an individualized plan of care related to sensory and behavioral differences correlates with improved experiences in the perioperative setting for patients with ASD. DESIGN: Mixed methods, pre-post survey, retrospective data comparison. METHODS: Metrics planned to evaluate intervention outcomes included: (1) Comparison of pre and postsurvey data obtained from perioperative staff members following ASD education, (2) Evaluation of the number of behavior response team calls made compared to retrospective data, and (3) Survey response data from families assessing the perceived experience of perioperative stay. FINDINGS: Two hundred and fifty staff members responded to the learning needs survey; 164 in the preperiod and 86 in the postperiod. The perioperative process for these patients improved from the pre- to the postperiod in its ability to meet the needs of patients with autism (P < .001). Overall, respondents rated the sensory aids and the behavioral and sensory assessment tool as very useful (Median = 5, IQR = 2) and stated that they are likely to continue to use the tools in the future when caring for patients with autism (Median = 5, IQR = 1). CONCLUSIONS: The caregivers of study patients felt they had a high level of satisfaction with their surgery or procedure experience. Health care providers also reported increased confidence working with individuals with ASD in the perioperative environment and satisfaction with the intervention program.

Assessing the impact of wastewater treatment works effluent on downstream water quality.

The impact of wastewater treatment works (WwTW) effluent on downstream river water quality is of increasing concern, particularly owing to the presence in effluents of a range of trace substances. In the case of contamination by metals the question of bioavailability has recently been accounted for in setting water quality standards for several metals. In the UK over the past decade the Chemical Investigations Programme (CIP) has generated upstream and downstream river quality data as well as associated WwTW effluent monitoring for over 600 sites, for the main contaminants of regulatory interest under the Water Framework Directive. Data presented here show that at a local level WwTW discharges have little impact for many contaminants. Soluble reactive phosphorus, hexabromocyclododecane (HBCDD), cypermethrin, perfluorooctanoic acid (PFOA) and perfluorooctane sulfonic acid (PFOS) have been shown to be the principal substances where downstream concentrations were at least 10 % larger than the upstream value. Otherwise, poor compliance with riverine water quality standards tends to be associated with contamination at the river catchment scale, with corresponding implications for the nature of remedial actions that are likely to be successful. Compliance with water quality criteria for metals, taking account of bioavailability, is high overall.

Relationships among owner consideration of euthanasia, caregiver burden, and treatment satisfaction in canine osteoarthritis.

Although diagnosis of osteoarthritis (OA) has been recently linked to euthanasia in dogs, no prior work has examined the roles of caregiver burden or treatment satisfaction in this relationship. We expected that there would be an indirect effect of caregiver burden on the association between consideration of euthanasia and clinical signs of OA, but that this effect would be influenced by owner satisfaction. Cross-sectional online evaluations were completed by 277 owners of dogs with OA recruited through social media. Canine OA-related pain and functional impairment, owner consideration of euthanasia, caregiver burden, and satisfaction were examined. Relationships among OA-related pain and functional impairment, owner consideration of euthanasia, caregiver burden, and satisfaction were statistically significant (P 0.01 for all). Cross-sectional mediation analysis demonstrated a statistically significant indirect effect of caregiver burden on the relationship between consideration of euthanasia and OA-related clinical signs (bias-corrected 95% confidence interval [BC 95% CI], 0.001-0.009), which was significantly moderated by owner satisfaction (BC 95% CI, -0.003 to -0.0002). Findings align with prior work connecting canine OA to euthanasia. The current study extends past research to demonstrate that caregiver burden in the owner may be partially responsible for this relationship. The moderating role of owner satisfaction suggests that optimizing owner impressions of treatment and the veterinary team could attenuate these relationships, potentially decreasing the likelihood of premature euthanasia for dogs with OA.

Summary of data from the UKWIR chemical investigations programme and a comparison of data from the past ten years' monitoring of effluent quality.

This paper reports summary data from a ten-year programme of investigation into the composition of wastewater treatment works' effluents in the UK. The so-called Chemical Investigations Programme focused on determinands of regulatory importance and involved monitoring of effluents for over seventy trace substances and sanitary determinands at more than 600 UK treatment works sites. The results provide a definitive overview of effluent quality. Although raw data are available, this publication of summary data provides a convenient résumé of the current state of knowledge. An analysis of changes in concentrations over the monitoring period between 2010 and 2020 shows that for several substances (nickel, diethylhexylphthalate, nonylphenol, tributyltin, the brominated diphenyl ethers and triclosan) significant reductions in wastewater concentration have occurred over the period of interest, these are likely to have resulted from a combination of tighter regulatory controls and/or improved wastewater treatment.

Comparing steam-flaked and pelleted barley grain in a feed-first guided-flow automated milking system for Holstein cows.

Provision of a palatable feed in automated milking systems (AMS) is considered an essential motivating factor to encourage voluntary visits to the milking stall. Although the quantity and composition of AMS concentrates have been previously investigated, the form of the concentrate has not been extensively evaluated. The objective of this study was to evaluate the effects of feeding pelleted (PB; 132.9 ± 56 DIM, 47.4 ± 9.51 kg/d milk yield) versus steam-flaked barley (SFB; 133.0 ± 63 DIM, 40.5 ± 8.23 kg/d milk yield) in an AMS on dry matter intake, AMS visits, milk and milk component yield, and partial mixed ration (PMR) feeding behavior. Twenty-nine Holstein cows of varying parities were enrolled in this study. Cows were housed in freestall housing with a feed-first guided-flow barn design; 7 cows were housed in a separate freestall pen to enable individual PMR intake and feeding behavior monitoring. This study was conducted as a 2-way crossover, with two 21-d periods in which each cow received the same basal PMR but was offered 2 kg/d (dry matter basis) of PB or SFB in the AMS. Cows receiving the SFB had fewer voluntary AMS visits (2.71 vs. 2.90 ± 0.051, no./d), tended to have a longer interval between milkings (541.7 vs. 505.8 ± 21.02 min), spent more time in the holding pen before entering the AMS (139.9 vs. 81.2 ± 11.68 min/d), and had lower total box time (19.7 vs. 21.4 ± 0.35 min/d) than cows fed PB. Despite changes in AMS attendance, there were no differences for average milk (44.0 kg/d), fat (1.62 kg/d), and protein (1.47 kg/d) yields or AMS concentrate intake (2.02 kg/d). These behavioral changes indicate that offering SFB as an alternative to PB may reduce motivation for cows to voluntarily enter the AMS.

Perfluorinated alkyl substances: Sewage treatment and implications for receiving waters.

This study comprises a detailed analysis of data for perfluorooctanesulfonic acid (PFOS), and perfluorooctanoic acid (PFOA) for over 600 wastewater treatment works effluents (WwTW) as well as samples upstream and downstream of each discharge of effluent into its receiving water. This has allowed an investigation of not only the effectiveness of removal of the perfluoroalkyl substances (PFAS) compounds during wastewater treatment but also implications for compliance with the environmental quality standard (EQS) set for PFOS under the Water Framework Directive. It is shown that effluents contain concentrations of PFOS that exceed the annual average EQS by a factor between 1.1-fold and 40-fold. The corresponding factors for PFOA are between 2-fold and 22-fold. The presence of high concentrations upstream, means that between a quarter and a third of individual effluents are found to reduce the concentration of fluorocarbons in the river downstream of the discharge point. The elevated concentrations upstream of the studied wastewater treatment works suggest inputs of these perfluoro compounds into the aquatic environment are ubiquitous and therefore difficult to address from simply setting permit conditions for individual WwTW. The freshwater EQS set for PFOS is based on several worst-case accumulation coefficients and large safety factors, which, when combined, result in a sub ng/L EQS. Consequently, the use of the biota derived quality standard may be a more realistic measure of environmental risk. It may be prudent, to assess the effectiveness of controls implemented in the last few years before considering widespread end-of-pipe treatment.

Effects of iron dosing used for phosphorus removal at wastewater treatment works; impacts on forms of phosphorus discharged and secondary effects on concentrations and fate of other contaminants.

Iron dosing for phosphorus reduction during wastewater treatment is wide practised across the globe. However, the impacts of this dosing in terms of the speciation of phosphorus discharged and secondary effects on removing or introducing other trace elements from or into the effluent have not been studied. Results are presented for concentrations of a range of contaminants in over 600 wastewater treatment works, reported as mean concentration values derived from 20 effluent samples taken over a period of two years. Approximately half of the treatment works employed iron dosing to reduce concentrations of phosphorus in effluents. In addition to the expected effects on level of phosphorus discharged to surface waters, it is shown that these measures are shown to have unintended and beneficial consequences for concentrations of several other constituents of wastewater. Reductions of more than 40% in the concentrations of dissolved metals (copper, lead) benzo(a)pyrene and hexabromocyclododecane are observed. Lower but still significant decreases in concentration (>30%) are evident for dissolved cadmium, fluoranthene cypermethrin and biochemical oxygen demand. Small but less environmentally important increases are seen for iron and nickel, in the case of the latter this is presumably because nickel is a contaminant of the iron reagent used for dosing. These reductions are shown to offer significant benefits in terms of levels entering surface waters relating to the in-river environmental quality standards.

Depression in multiple sclerosis patients associated with risk variant near NEGR1.

BACKGROUND: A substantial number of patients diagnosed with multiple sclerosis (MS) suffer from depression in addition to physical symptoms and disability. Recent evidence suggests a stronger relationship may exist between MS and depression than previously thought, in which a diagnosis of depression may be prodromic to the development of MS. METHODS: A genome-wide association study (GWAS) was performed to identify genetic variants associated with the development of depression in a cohort of MS patients. The control group (n = 1180) was composed of MS patients with no diagnoses of depression as determined by ICD-9 and ICD-10 billing codes present in the electronic health record (EHR). Separate analyses were performed for three different case groups: 1) MS patients having a depression diagnosis at any time (n = 182), 2) MS patients having a depression diagnosis one year pre-MS diagnosis (n = 27), and 3) MS patients having a depression diagnosis one year post-MS diagnosis (n = 130). Logistic regression analyses were also performed to test for associations between the development of depression and an APOE tagging variant, as APOE was previously linked to depressive affect in MS. An additional logistic regression analysis tested for associations between depression in MS patients and SNPs associated with depression in the general population. Pathway enrichment analyses were also conducted to identify pathways that link the two diseases. RESULTS: GWAS identified no novel associations between variants and a diagnosis of depression relative to a diagnosis of MS. One variant, rs1432639, associated with depression in the general population, was significantly associated with the development of depression post-MS diagnosis. The APOE-related SNPs were not associated with depression in this study population. An IGF1 pathway approached statistical significance in patients diagnosed with depression prior to a diagnosis of MS. CONCLUSION: rs1432639 and the IGF1 pathway provide evidence for a genetic link between MS and depression that warrants further research.

Venous drainage of the left liver: an evaluation of anatomical variants and their clinical relevance.

AIM: To evaluate the variations in venous drainage from the left liver. MATERIALS AND METHODS: A retrospective evaluation was performed of all consecutive abdominal computed tomography (CT) examinations at a tertiary referral facility between 1 January and 30 June 2018. Osirix (Pixmeo SARL, Bernex, Switzerland) was used to examine the major hepatic veins and their tributaries in each scan. The classification of variants as proposed by Nakamura and Tsuzuki was used to describe the findings. The following information was collected: ramification pattern, number, length and diameter of middle (MHV) and left (LHV) hepatic vein tributaries. Two researchers collected data independently, and the average measurements were used as the final dimensions. RESULTS: Of 102 examinations evaluated, only 27 demonstrated the conventional venous drainage patterns. The LHV and MHV combined to form a common trunk that emptied into the inferior vena cava (IVC) in 75 (73.5%) cases. The common trunk had a mean length of 8.89 mm and mean diameter of 20.18 mm. Other patterns included Nakamura and Tsuzuki type I (27.5%), type II (29.4%) and type III variants (16.7%). In addition, 4.9% of patients had absent superior middle veins and 80% had supernumerary short hepatic veins (4%). CONCLUSION: Only 26.5% of patients in this population had conventional venous drainage from the left liver. Surgeons and radiologists in hepatobiliary practice should be aware of these variants in order to minimise morbidity when performing invasive procedures.

Modelling scenarios of environmental recovery after implementation of controls on emissions of persistent organic pollutants.

Comparison of monitoring data with toxicologically-derived environmental quality standards (EQSs) forms the basis of assessments of the quality status of the water environment. Having established the status quo, the logical next step is to address instances of non-compliance with EQSs by applying remedial measures, including reducing the use or at least the emission of the substances of concern or by taking steps to reduce concentrations already present using technological solutions such as enhanced wastewater treatment. The selection of suitable remedial measures must be a compromise between cost, likely effectiveness and the timescale over which improvements might be acceptable. The decision on overall environmental management has also to take into account the need for demonstrable progress; this might mean that it is preferable to address some more readily achievable goal rather than to attempt to solve a more serious, but ultimately intractable problem. This paper describes the development and application of a generic modelling tool that provides a way of assessing the potential requirements for remedial actions and their likely outcomes over a timescale of up to forty years taking account of sediment partitioning, environmental degradation and biological accumulation. The tool was validated using a detailed UK wastewater treatment works effluent discharge dataset. Examples involving several chemicals that are of current concern are provided. Some substances (e.g. tributyltin, PFOS) are identified as likely to meet EQS values in sediments or biota in a relatively short timescale; others (PAHs, DEHP) appear to represent more intractable problems.

Seasonal variation of contaminant concentrations in wastewater treatment works effluents and river waters.

Results are presented for 170 wastewater treatment works sites (20 per substance in influent, effluent and 36 per substance in river water upstream and downstream of the WwTW discharge) over a period of two years between 2015 and 2017; this comprises data for approximately 3000 samples for effluent and 6000 for river samples taken downstream of effluent discharges. Seasonal trends in contaminant concentrations for several substances are reported. Two clear patterns of seasonal variation are proposed over and above all of the variables associated with environmental data including process technology, dilution and geography. Firstly, variation of riverine concentrations caused by seasonal fluctuations in river flow (sewage flow being relatively consistent) resulting in summer maxima and winter minima. Alternatively, variation is observed that is attributable to the improved performance of wastewater treatment processes under warmer conditions. This leads to the lowest concentrations in autumn when surface water/sewage treatment temperatures tend to peak. Seasonality for trace contaminants is more difficult to characterise than that of sanitary parameters owing to the higher variability in the concentration of the substances of interest. The data also provide an insight into the amplitude of such variations. This makes it possible to assess the likely effects of seasonality and its impact on aquatic life. For example, the existence of seasonality (perhaps due only to dilution effects) might be demonstrated, but the amplitude might be too small in relation to the potential ecotoxicological effects to be of any consequence.

Characterisation and cross-amplification of 42 microsatellite markers in two Amphiprion species (Pomacentridae) and a natural hybrid anemonefish to inform genetic structure within a hybrid zone.

The hybrid anemonefish, Amphiprion leucokranos, is known to be the product of ongoing, introgressive hybridization between parent taxa Amphiprion sandaracinos and Amphiprion chrysopterus. Hybridization is an important evolutionary phenomenon contributing to biodiversity within marine systems, where hybrid zones provide ideal systems in which to study hybridization events. Here, a suite of 42 Amphiprion microsatellite markers (including development of 8 novel markers) were cross-amplified in individuals from parent taxa and hybrid populations to facilitate investigation into the relatedness of hybridizing species across the A. leucokranos hybrid zone. Analysis revealed 15, 20 and 24 highly polymorphic loci (PIC > 0.5) in the two parent species and hybrid, respectively, for use in population genetic and parentage studies, with 305 unique alleles found overall (ranging from 1 to 13 alleles per locus) and 7 alleles per locus on average. Observed and expected heterozygosities ranged from 0.000 to 1.000 and 0.000 to 0.978, respectively. Significant deviations from Hardy-Weinberg equilibrium were found in eight loci, possibly due to relatedness among samples or the presence of null alleles. Use of the suite of markers tested here will provide valuable insights into the contemporary population structure and introgression among species and hybrids within the Amphiprion leucokranos hybrid zone, as well as inform future ecological and evolutionary studies of anemonefishes more broadly.

The association between five forms of child maltreatment and depressive and anxiety disorders: A systematic review and meta-analysis.

BACKGROUND: Child maltreatment is a global public health issue that encompasses physical abuse, sexual abuse, emotional abuse, neglect, and exposure to intimate partner violence (IPV). This systematic review and meta-analysis summarises the association between these five forms of child maltreatment and depressive and anxiety disorders. METHODS: Published cohort and case-control studies were included if they reported associations between any form of child maltreatment (and/or a combination of), and depressive and anxiety disorders. A total of 604 studies were assessed for eligibility, 106 met inclusion criteria, and 96 were included in meta-analyses. The data were pooled in random effects meta-analyses, giving odds ratios (ORs) with corresponding 95% confidence intervals (CIs) for each form of child maltreatment. RESULTS: All forms of child maltreatment were associated with depressive disorders (any child maltreatment [OR = 2.48, 2.14-2.87]; sexual abuse [OR = 2.11, 1.83-2.44]; physical abuse [OR = 1.78, 1.57-2.01]; emotional abuse [OR = 2.35, 1.74-3.18]; neglect [OR = 1.65, 1.35-2.02]; and exposure to IPV [OR = 1.68, 1.34-2.10]). Several forms of child maltreatment were significantly associated with anxiety disorders ('any child maltreatment' [OR = 1.68, 1.33-2.4]; sexual abuse [OR = 1.90, 1.6-2.25]; physical abuse [OR = 1.56, 1.39-1.76]; and neglect [OR = 1.34, 1.09-1.65]). Significant associations were also found between several forms of child maltreatment and post-traumatic stress disorder (PTSD). CONCLUSIONS: There is a robust association between five forms of child maltreatment and the development of mental disorders. The Global Burden of Disease Study (GBD) includes only sexual abuse as a risk factor for depressive and anxiety disorders. These findings support the inclusion of additional forms of child maltreatment as risk factors in GBD.

Cost minimization analysis of the treatment of distal radial fractures in the elderly.

AIMS: The aim of this study was to test the null hypothesis that there is no difference, from the payer perspective, in the cost of treatment of a distal radial fracture in an elderly patient, aged > 65 years, between open reduction and internal fixation (ORIF) and closed reduction (CR). MATERIALS AND METHODS: Data relating to the treatment of these injuries in the elderly between January 2007 and December 2015 were extracted using the Humana and Medicare Advantage Databases. The primary outcome of interest was the cost associated with treatment. Secondary analysis included the cost of common complications. Statistical analysis was performed using a non-parametric t-test and chi-squared test. RESULTS: Our search yielded 8924 patients treated with ORIF and 5629 patients treated with CR. The mean cost of an uncomplicated ORIF was more than a CR ($7749 versus $2161). The mean additional cost of a complication in the ORIF group was greater than in the CR group ($1853 versus $1362). CONCLUSION: These findings show that there are greater payer fees associated with ORIF than CR in patients aged > 65 years with a distal radial fracture. CR may be a higher-value intervention in these patients. Cite this article: Bone Joint J 2018;100-B:205-11.

Detecting environmental change: how many samples are required?

One of the most important functions of environmental monitoring is the detection of change. This can be the delineation of deteriorating circumstances or the identification of the success of remedial measures. The design of effective monitoring of change (and hence the optimisation of resources devoted to monitoring) relies on appropriate replication - knowing how many samples are required. Lack of information on the variance of the measured parameter is often a barrier to determining the optimum sampling strategy. An important new information resource on within-site variance of the concentrations of over 60 trace substances in wastewater treatment works effluents has been provided by the UK water industry research programme. This paper makes use of this resource in order to explore the potential to design monitoring programmes that will be capable of demonstrating the success of planned remedial measures that will be implemented in the coming years. Two approaches to experimental design (simple before-and-after sampling and detection of trends via correlation) are examined. It is concluded that for programmes involving numbers of samples of less than 30 the detection of a change in concentration of less than 50% might be very challenging for many of the trace substance of greatest interest. Knowledge of the difficulty of the task in hand should make it possible to design programmes that optimise the use of resources and the approaches taken, such that effects of interest are detected as soon and as economically as possible.

A new apparatus to induce lysis of planktonic microbial cells by shock compression, cavitation and spray.

Experiments were conducted on an aqueous growth medium containing cultures of Escherichia coli (E. coli) XL1-Blue, to investigate, in a single experiment, the effect of two types of dynamic mechanical loading on cellular integrity. A bespoke shock tube was used to subject separate portions of a planktonic bacterial culture to two different loading sequences: (i) shock compression followed by cavitation, and (ii) shock compression followed by spray. The apparatus allows the generation of an adjustable loading shock wave of magnitude up to 300 MPa in a sterile laboratory environment. Cultures of E. coli were tested with this apparatus and the spread-plate technique was used to measure the survivability after mechanical loading. The loading sequence (ii) gave higher mortality than (i), suggesting that the bacteria are more vulnerable to shear deformation and cavitation than to hydrostatic compression. We present the results of preliminary experiments and suggestions for further experimental work; we discuss the potential applications of this technique to sterilize large volumes of fluid samples.

Coming Up Short: Risks of Bias in Assessing Psychological Outcomes in Growth Hormone Therapy for Short Stature.

CONTEXT: Two often cited assumptions for treating children with GH are that short stature (SS), as an isolated physical characteristic, is associated with psychosocial morbidity and that GH treatment may increase height and improve psychological adjustment. Findings across studies regarding the psychological consequences associated with GH management of children with SS are variable and frequently contradictory. The purpose of this systematic review is to evaluate the degree to which any conclusions about the relative risks or benefits of GH treatment on psychological outcomes can be made based on the published literature. EVIDENCE ACQUISITION: Electronic databases were searched for randomized clinical trials and nonrandomized studies, published between 1958-2014, in which GH was administered for management of children with SS and psychosocial, cognitive, academic, or health-related quality of life outcomes were assessed. Methodological quality of each study was assessed using the Cochrane Collaboration's tool for assessing risk of bias. EVIDENCE SYNTHESIS: Eighty studies were evaluated. No studies were rated as having a low risk of bias, the risk of bias was unclear in seven study outcome areas, and the remaining studies were judged as having a high risk of bias. CONCLUSIONS: The high risk of bias present in the majority of the literature on GH treatment effects on psychological outcomes (in particular, lack of blinding) substantially weakens confidence in their results. This may serve to explain the variability of findings for these outcomes across studies.

Beta Cell Regenerating Potential of Azadirachta indica (Neem) Extract in Diabetic Rats.

OBJECTIVE: This study evaluated the ability of 0.8% neem leaf extract (NLE) to treat diabetes mellitus by assessing its effects on blood glucose, insulin levels and islet morphology in streptozotocin (STZ)-induced diabetic Sprague-Dawley rats. METHODS: Diabetes was induced in two to three-day old rat pups by STZ intraperitoneally (60 mg/kg), followed by a further 40 mg/kg dose 12-23 weeks later. The diabetic treated (DT) rats received 0.8% w/v NLE in tap water while diabetic control (DC) and normal control (NC) rats received water ad libitum. Body weight, water and chow consumption, and blood glucose were evaluated weekly. Blood and pancreas were collected at the end of the study to evaluate serum insulin and islet histology, respectively. RESULTS: Neem leaf extract (0.8%) improved weight gain and beta cell regeneration but did not reduce blood glucose. Serum insulin increased slightly in the treated group and three-fold in the DC group (p < 0.05). CONCLUSION: The results suggest that NLE has beta cell regenerating potential.

The impact of tertiary wastewater treatment on copper and zinc complexation.

Tightening quality standards for European waters has seen a move towards enhanced wastewater treatment technologies such as granulated organic carbon treatment and ozonation. Although these technologies are likely to be successful in degrading certain micro-organic contaminants, these may also destroy compounds which would otherwise complex and render metals significantly less toxic. This study examined the impact of enhanced tertiary treatment on the capacity of organic compounds within sewage effluents to complex copper and zinc. The data show that granulated organic carbon treatment removes a dissolved organic carbon (DOC) fraction that is unimportant to complexation such that no detrimental impact on complexation or metal bioavailability is likely to occur from this treatment type. High concentrations of ozone (>1 mg O3/mg DOC) are, however, likely to impact the complexation capacity for copper although this is unlikely to be important at the concentrations of copper typically found in effluent discharges or in rivers. Ozone treatment did not affect zinc complexation capacity. The complexation profiles of the sewage effluents show these to contain a category of non-humic ligand that appears unaffected by tertiary treatment and which displays a high affinity for zinc, suggesting these may substantially reduce the bioavailability of zinc in effluent discharges. The implication is that traditional metal bioavailability assessment approaches such as the biotic ligand model may overestimate zinc bioavailability in sewage effluents and effluent-impacted waters.