A participatory multi-criteria decision analysis framework reveals transition potential towards non-grid wastewater management.

Many public environmental decisions are wicked problems due to high complexity and uncertainty. We test a participatory value-based framework based on multi-criteria decision analysis (MCDA) to tackle such problems. Our framework addresses two important gaps identified in reviews of MCDA applications to environmental problems: including stakeholders and treating uncertainty. We applied our framework in two complex real-world cases concerning a paradigm shift in the wastewater sector; the transition from centralized wastewater systems to decentralized non-grid systems. Non-grid systems may solve some problems of centralized systems by reducing costs, increasing flexibility, and addressing growing demands on environmental issues, especially in rural areas. But non-grid systems have rarely been implemented in OECD countries, because it is unclear whether a transition is recommendable, and whether stakeholders would accept this shift. This problem allows addressing several fundamental research questions. As theoretical contribution, we found that stakeholder participation in MCDA is necessary, because different preferences of stakeholders can lead to different best-performing options in the assessments. Compared to the typical integrated assessment (IA) approach that excludes stakeholders' preferences, the MCDA process led to clearer outcomes. Results indicate that including the uncertainty of predicted consequences of options with Monte Carlo simulation helped discriminate between options and identify best-performing options. Challenging the uncertainty of elicited stakeholder preferences with sensitivity analyses, we found that best-performing options were especially sensitive to the MCDA aggregation model. Despite the high uncertainty, it was possible to suggest robust consensus options that would perform reasonably well for all stakeholders. As practical contribution, results indicated that a transition from the centralized to decentralized non-grid systems seems feasible. Most stakeholders assigned highest weights to environmental protection objectives in decision-making workshops. These stakeholder preferences implemented in MCDA led to a generally better assessment of innovative non-grid systems, especially when including urine source separation. Stakeholders perceived the MCDA process as beneficial and found results plausible. We conclude that the proposed participatory value-based framework is rigorous, but still feasible in practice. The framework is certainly transferable to any context and is open to testing and refinement in various applications to wicked decision problems.

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

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

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

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

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

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

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

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

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

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

Benchmarking Soft Sensors for Remote Monitoring of On-Site Wastewater Treatment Plants.

On-site wastewater treatment plants (OSTs) are usually unattended, so failures often remain undetected and lead to prolonged periods of reduced performance. To stabilize the performance of unattended plants, soft sensors could expose faults and failures to the operator. In a previous study, we developed soft sensors and showed that soft sensors with data from unmaintained physical sensors can be as accurate as soft sensors with data from maintained ones. The monitored variables were pH and dissolved oxygen (DO), and soft sensors were used to predict nitrification performance. In the present study, we use synthetic data and monitor three plants to test these soft sensors. We find that a long solids retention time and a moderate aeration rate improve the pH soft-sensor accuracy and that the aeration regime is the main operational parameter affecting the accuracy of the DO soft sensor. We demonstrate that integrated design of monitoring and control is necessary to achieve robustness when extrapolating from one OST to another in the absence of plant-specific fine-tuning. Additionally, we provide a unique labeled dataset for further feature and data-driven soft-sensor development. Our benchmarking results indicate that it is feasible to monitor OSTs with unmaintained sensors and without plant-specific tuning of the developed soft sensors. This is expected to drastically reduce monitoring costs for OST-based sanitation systems.

A Research Agenda for the Future of Urban Water Management: Exploring the Potential of Nongrid, Small-Grid, and Hybrid Solutions.

Recent developments in high- and middle-income countries have exhibited a shift from conventional urban water systems to alternative solutions that are more diverse in source separation, decentralization, and modularization. These solutions include nongrid, small-grid, and hybrid systems to address such pressing global challenges as climate change, eutrophication, and rapid urbanization. They close loops, recover valuable resources, and adapt quickly to changing boundary conditions such as population size. Moving to such alternative solutions requires both technical and social innovations to coevolve over time into integrated socio-technical urban water systems. Current implementations of alternative systems in high- and middle-income countries are promising, but they also underline the need for research questions to be addressed from technical, social, and transformative perspectives. Future research should pursue a transdisciplinary research approach to generating evidence through socio-technical "lighthouse" projects that apply alternative urban water systems at scale. Such research should leverage experiences from these projects in diverse socio-economic contexts, identify their potentials and limitations from an integrated perspective, and share their successes and failures across the urban water sector.

Developing sanitation planning options: A tool for systematic consideration of novel technologies and systems.

To provide access to sustainable sanitation for the entire world population, novel technologies and systems have been developed. These options are often independent of sewers, water, and energy and therefore promise to be more appropriate for fast-growing urban areas. They also allow for resource recovery and and are adaptable to changing environmental and demographic conditions what makes them more sustainable. More options, however, also enhance planning complexity. Structured decision making (SDM) can help balance opposing interests. Yet, most of the current research focuses on the selection of a preferred option, assuming that a set of appropriate options is available. There is a lack of reproducible methods for the identification of sanitation system planning options that can consider the growing number of available technology and the many possible system configurations. Additionally, there is a lack of data, particularly for novel options, to evaluate the various sustainability criteria for sanitation.To overcome this limitation, we present a novel software supported approach: the SANitation sysTem Alternative GeneratOr (Santiago). To be optimally effective, Santiago is required to be integrated into an SDM approach. In this paper, we present all the elements that such an integration requires and illustrate these methods at the case of Arba Minch, a fast growing town in Ethiopia. Based on this example and experiences from other cases, we discuss the lessons learnt and present the advantages potentially brought by Santiago for sanitation planning The integration requires four elements: a set of technologies to be looked at, decision objectives for sustainable sanitation, screening criteria to evalute technology appropriateness, and about the technologies and the casea. The main output is a set of sanitation system options that is locally appropriate, diverse in order to reveal trade-offs, and of a manageable size. To support the definition of decision objectives, we developed a generic objective hierarchy for sustainable sanitation. Because one of the main challenges lies in the quantification of screening criteria, we established the data for 27 criteria and 41 technologies in a library.The case studies showed, that if the integration is successful, then Santiago can provide substantial benefits: (i) it is systematic and reproducible; (ii) it opens up the decision space with novel and potentially more appropriate solutions; (iii) it makes international data accessible for more empirical decision making; (iv) it enables decisions based on strategic objectives in line with the sustainable development goals; (v) it allows to prioritise appropriate and resource efficient systems right from the beginning (vi) and it contributes to a more citywide inclusive approach by birding strategic objectives with an area-based appropriateness assessment. The here presented approach enables the prioritisation of appropriate and resource efficient sanitation technologies and systems in strategic planning. Thereby this approach contributes to SDG 6.2, 6.3, and 11, sustainable sanitation for all.

Liver transplantation for Hepatitis-B-associated liver disease - Three decades of experience.

BACKGROUND: Hepatitis B (HBV)-associated end-stage liver disease used to be a relevant indication for liver transplantation (LT). After transplantation, HBV-reinfection remains a serious issue. Different strategies to prevent HBV-reinfection range from the single application of immunoglobulins (HBIG), to the use of modern nucleoside/nucleotide analogues (NUC) in combination with HBIG, followed by HBIG-discontinuation. The aim of this analysis was to compare different strategies and to sum up the results of 30 years at a high-volume transplant center and deliver additional information on the histopathological level. METHODS: Data of 372 liver transplantations performed for the HBV-induced liver disease in 352 patients were extracted from a prospectively organized database. HBV-reinfection was determined in the entire cohort, according to the mode of HBV-prophylaxis. Differences in survival rates were analyzed in patients with successful prophylaxis, untreated and controlled HBV-reinfection. Histopathological results were obtained from protocol biopsies in 151 patients. RESULTS: HBV-reinfection was significantly associated with the type of prophylaxis, presence of HBs-Antigen at the moment of LT, transplant year and influencing the overall survival before 2005. After the introduction of modern NUCs, HBV-reinfection stopped to impact HBV-associated transplant loss and survival. Controlled HBV-infection prevents from HBV-associated transplant hepatitis and fibrosis development. The role of HBIG declines in favor of NUCs. CONCLUSIONS: Uncontrolled HBV-reinfection does not occur any more. Even in the presence of Hbs-antigen, transplant fibrosis does not develop. The most reliable mode to prevent HBV-recurrence remains the combination of NUCs with a high genetic barrier and HBIG. However, HBIG can safely be discontinued after LT.

Evaluation of histological dynamics, kidney function and diabetes in liver transplant patients after antiviral treatment with direct-acting antivirals: Therapy of HCV-recurrence.

BACKGROUND: Direct-acting antivirals allow efficient and safe treatment of hepatitis C (HCV) before and after liver transplantation (LT). However, the impact of sofosbuvir on the graft, diabetes, and on kidney function is not answered yet. Primary endpoint of this analysis was the evaluation of kidney function after antiviral treatment (AVT). Secondary endpoints were the assessment of extrahepatic manifestation of HCV-infection by diabetes mellitus and the histopathological changes in terms of inflammation, content of fat, and fibrosis stage. METHODS: From 2014 to 4/2015, 100 patients with HCV-recurrence after LT were successfully treated with AVT. Ninety-eight received a sofosbuvir-based regimen. Indication was based on genotype, transplant fibrosis stage, and urgency. Biopsies were evaluated before and after treatment. Renal function and diabetes were assessed before, during, and after AVT. RESULTS: All patients achieved sustained virological response. A significant improvement of inflammation (P = 0.001) and fibrosis stage (P = 0.031) were observed. Significantly less insulin was required in 32 patients with diabetes (P < 0.001) to keep Hb1Ac unchanged after AVT. Kidney function was stable during, 12 weeks after and 48 weeks after antiviral therapy. Stages of renal insufficiency were comparable before and after AVT. CONCLUSION: Successful sofosbuvir-based AVT leads to a variety of positive development in transplant patients including a significant improvement of inflammation, fat content and fibrosis, a significant decrease in daily insulin dose and no significant impairment of kidney function.

Integrating uncertainty of preferences and predictions in decision models: An application to regional wastewater planning.

Decision-making in environmental management requires eliciting preferences of stakeholders and predicting outcomes of decision alternatives. Usually, preferences and predictions are both uncertain. Uncertainty of predictions can be tackled by multi-attribute utility theory, but the uncertainty of preferences remains a challenge. We demonstrate an approach for including both uncertainties in a multi-criteria decision analysis (MCDA), using utility theory and the concept of expected expected utility. For a decision regarding a regional merger of wastewater infrastructure in Switzerland, we constructed preference models for four stakeholders. These models also allowed for non-additive interactions between objectives. We evaluated the performance of eleven decision alternatives for which we predicted potential outcomes. Even though uncertainties were high, we could draw conclusions based on the expected expected utility of alternatives. Building a pipeline to discharge treated wastewater to a larger river emerged as a potential consensus alternative to mitigate the problem of micropollutants in a small stream. We investigated the robustness of the findings with sensitivity analysis regarding the preference parameters and the included objectives. In their actual decision, the stakeholders partly preferred other alternatives than those proposed by the model. Their choices could be explained by reduced decision models in which only few objectives were included. This may indicate the use of simplified choice heuristics by the stakeholders. The presented approach is feasible for supporting other difficult environmental or engineering decisions in practice, for which we give a number of recommendations.

Efficacy of a long-term home parenteral nutrition regimen containing fish oil-derived n-3 polyunsaturated fatty acids: a single-centre, randomized, double blind study.

BACKGROUND: Data on the use of lipid emulsions containing fish-oil (FO) derived n-3 polyunsaturated fatty acids (n-3 PUFAs) in addition to medium- and long-chain triglycerides (MCT/LCT) for long-term home parenteral nutrition (HPN) are limited. This study aimed to compare HPN regimens containing either MCT/LCT/FO-derived n-3 PUFAs (test group) or MCT/LCT (control group) with respect to efficacy and safety during 8 weeks of HPN using a non-inferiority trial design with change of body mass index (BMI) as primary endpoint. METHODS: This prospective, randomized, double-blind study was conducted at the Charité, Berlin, Germany, from 02/2008 until 01/2014. Adult patients (n = 42; aged 18 to 80 years) requiring HPN for at least 8 weeks were randomly assigned to the test or control group. Assessments included weight, height, physical examination (cardiovascular system, abdomen, respiratory tract, liver, spleen, kidney, urine tract, skin, mucous membrane, neurology, psyche, musculoskeletal system, lymph nodes), bio impedance analysis, calorimetry, blood samplings (haematology, biochemistry, fatty acid analysis) and quality of life questionnaire. RESULTS: BMI increased in both groups with 8 weeks of HPN (ΔBMI(test group) = 1.3 ± 1.1 kg/m2; ΔBMI(control group) = 0.6 ± 0.9 kg/m2) demonstrating non-inferiority of the test regimen regarding nutritional efficacy. Assessment of secondary efficacy endpoints revealed that after 8 weeks of HPN with the test regimen, the proportion of n-3 PUFAs in serum, platelet and red blood cell phospholipids significantly increased, while the proportion of n-6 PUFAs decreased. The fatty acid pattern in the control group remained mostly stable. No statistically significant differences were detected between groups regarding inflammatory markers or quality of life. Laboratory parameters reflecting the safety endpoints liver function, bone metabolism, renal function, metabolic activity, lipid metabolism, coagulation and haematology were stable in both groups and no group differences were detected regarding (serious) adverse events. CONCLUSIONS: The HPN regimen prepared with MCT/LCT/FO-derived n-3 PUFAs was at least as efficient in maintaining or even improving nutritional status during HPN as the control MCT/LCT regimen. Administration of FO-derived n-3 PUFAs for 8 weeks altered the fatty acid pattern of serum, platelet and red blood cell phospholipids. Both regimens were safe and well tolerated. TRIAL REGISTRATION: www.clinicaltrials.gov , registration number: NCT00530738.

The Potential of Knowing More: A Review of Data-Driven Urban Water Management.

The promise of collecting and utilizing large amounts of data has never been greater in the history of urban water management (UWM). This paper reviews several data-driven approaches which play a key role in bringing forward a sea change. It critically investigates whether data-driven UWM offers a promising foundation for addressing current challenges and supporting fundamental changes in UWM. We discuss the examples of better rain-data management, urban pluvial flood-risk management and forecasting, drinking water and sewer network operation and management, integrated design and management, increasing water productivity, wastewater-based epidemiology and on-site water and wastewater treatment. The accumulated evidence from literature points toward a future UWM that offers significant potential benefits thanks to increased collection and utilization of data. The findings show that data-driven UWM allows us to develop and apply novel methods, to optimize the efficiency of the current network-based approach, and to extend functionality of today's systems. However, generic challenges related to data-driven approaches (e.g., data processing, data availability, data quality, data costs) and the specific challenges of data-driven UWM need to be addressed, namely data access and ownership, current engineering practices and the difficulty of assessing the cost benefits of data-driven UWM.

Neural Correlates of Sevoflurane-induced Unconsciousness Identified by Simultaneous Functional Magnetic Resonance Imaging and Electroencephalography.

BACKGROUND: The neural correlates of anesthetic-induced unconsciousness have yet to be fully elucidated. Sedative and anesthetic states induced by propofol have been studied extensively, consistently revealing a decrease of frontoparietal and thalamocortical connectivity. There is, however, less understanding of the effects of halogenated ethers on functional brain networks. METHODS: The authors recorded simultaneous resting-state functional magnetic resonance imaging and electroencephalography in 16 artificially ventilated volunteers during sevoflurane anesthesia at burst suppression and 3 and 2 vol% steady-state concentrations for 700 s each to assess functional connectivity changes compared to wakefulness. Electroencephalographic data were analyzed using symbolic transfer entropy (surrogate of information transfer) and permutation entropy (surrogate of cortical information processing). Functional magnetic resonance imaging data were analyzed by an independent component analysis and a region-of-interest-based analysis. RESULTS: Electroencephalographic analysis showed a significant reduction of anterior-to-posterior symbolic transfer entropy and global permutation entropy. At 2 vol% sevoflurane concentrations, frontal and thalamic networks identified by independent component analysis showed significantly reduced within-network connectivity. Primary sensory networks did not show a significant change. At burst suppression, all cortical networks showed significantly reduced functional connectivity. Region-of-interest-based thalamic connectivity at 2 vol% was significantly reduced to frontoparietal and posterior cingulate cortices but not to sensory areas. CONCLUSIONS: Sevoflurane decreased frontal and thalamocortical connectivity. The changes in blood oxygenation level dependent connectivity were consistent with reduced anterior-to-posterior directed connectivity and reduced cortical information processing. These data advance the understanding of sevoflurane-induced unconsciousness and contribute to a neural basis of electroencephalographic measures that hold promise for intraoperative anesthesia monitoring.

Cost-benefit analysis of the Swiss national policy on reducing micropollutants in treated wastewater.

Contamination of freshwater with micropollutants (MPs) is a growing concern worldwide. Even at very low concentrations, MPs can have adverse effects on aquatic ecosystems and possibly also on human health. Switzerland is one of the first countries to start implementing a national policy to reduce MPs in the effluents of municipal sewage treatment plants (STPs). This paper estimates the benefits of upgrading STPs based on public's stated preferences. To assess public demand for the reduction of the environmental and health risks of MPs, we conducted a choice experiment in a national online survey. The results indicate that the average willingness to pay per household is CHF 100 (US$ 73) annually for reducing the potential environmental risk of MPs to a low level. These benefits, aggregated over households in the catchment of the STPs to be upgraded, generate a total annual economic value of CHF 155 million (US$ 113 million). This compares with estimated annual costs for upgrading 123 STPs of CHF 133 million (US$ 97 million) or CHF 86 (US$ 63) per household connected to these STPs. Hence, a cost-benefit analysis justifies the investment decision from an economic point of view and supports the implementation of the national policy in the ongoing political discussion.

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

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

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

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

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

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