Study of two approaches for the process water management from hydrothermal carbonization of swine manure: Anaerobic treatment and nutrient recovery

Hydrothermal carbonization (HTC) is a promising alternative to transform biomass waste into a solid carbonaceous material (hydrochar) and a process water with potential for material and energy recovery. In this study, two alternatives for process water treatment by conventional and acid-assisted HTC of swine manure are discussed. Process water from conventional HTC at 180 °C showed high biodegradability (55% COD removal) and methane production (∼290 mL STP CH4 g-1 CODadded) and the treatment in an upflow anaerobic sludge blanket reactor allowed obtaining a high methane production yield (1.3 L CH4 L-1 d-1) and COD removal (∼70%). The analysis of the microbiota showed a high concentration of Synergistota and Firmicutes phyla, with high degradation of organic nitrogen-containing organic compounds. Acid-assisted HTC proved to be a viable option for nutrient recovery (migration of 83% of the P to the process water), which allowed obtaining a solid salt by chemical precipitation with Mg(OH)2 (NPK of 4/4/0.4) and MgCl2 (NPK 8/17/0.5), with a negligible content of heavy metals. The characteristics of the precipitated solid complied with the requirements of European Regulation (2019)/1009 for fertilizers and amendments in agricultural soils, being a suitable alternative for the recycling of nutrients from wastes.

Swine manure management by hydrothermal carbonization: Comparative study of batch and continuous operation

Hydrothermal carbonization (HTC) is considered a promising technology for biomass waste management without pre-drying. This study explores the potential for swine manure management by comparing batch and continuous processes, emphasizing the benefits of the continuous mode, particularly for its potential full-scale application. The continuous process at low temperature (180 °C) resulted in a hydrochar with a lower degree of carbonization compared to the batch process, but similar characteristics were found in both hydrochars at higher operating temperatures (230-250 °C), such as C content (∼ 52 wt%), fixed carbon (∼ 24 wt%) and higher calorific value (21 MJ kg-1). Thermogravimetric and combustion analyses showed that hydrochars exhibited characteristics suitable as solid biofuels for industrial use. The process water showed a high content of organic matter as soluble chemical oxygen demand (7-22 g L-1) and total organic carbon (4-10 g L-1), although a high amount of refractory species such as N- and O-containing long aromatic compounds were detected in the process water from the batch process, while the process water from the continuous process presented more easily biodegradable compounds such as acids and alcohols, among others. The longer time required to reach operating temperature in the case of the batch system (longer heating time to reach operating temperature) resulted in lower H/C and O/C ratios compared to hydrochar from the continuous process. This indicates that the dehydration and decarboxylation reactions of the feedstock play a more important role in the batch process. This study shows the efficiency of the continuous process to obtain carbonaceous materials suitable for use as biofuel, providing a solution for swine manure management.

In-Hospital Clinical Features, Morbidity, and Mortality of Patients with Neurofibromatosis 1 in France: A Nationwide, Population-Based Retrospective Cohort Study

Neurofibromatosis 1 (NF1) is a multisystem disease that can affect nearly every organ system. The aim of our study was to describe the in-hospital population with NF1 in France. We conducted a nationwide retrospective cohort study using the French hospital administrative database. A total of 11,425 patients with NF1 (53.4% female, 19,080 person years) were identified from January 2013 to December 2019. A total of 23% had at least one diagnosis of a comorbidity or NF1-associated complication or disease, and it was highest in the age group of 10-15 years. A total of 2,601 (22.8%) had a diagnosis of cancer. There were 366 (3.2%) in-hospital deaths, and we observed a standardized mortality ratio of 4.14 (95% confidence interval = 3.71-4.56), with a higher standardized mortality ratio in women and in the age group of 10-15 years. The standardized incident ratio (SIR) of cancer was 10.3 (95% confidence interval = 9.6-11.1). We observed high SIR values for cancer in childhood, with a decrease toward that of the general population by age 70 years. We observed high SIRs for NF1-associated cancers: CNS SIR of 195.4 (95% confidence interval = 172.2-220.9) and small intestine SIR of 102.9 (95% confidence interval = 71.7-143.2). The study provides a better understanding of the prognosis in people living with NF1.

Co-hydrothermal carbonization of swine manure and lignocellulosic waste: A new strategy for the integral valorization of biomass wastes

Co-hydrothermal carbonization (co-HTC) is a promising strategy to improve hydrothermal carbonization (HTC) of low-quality wastes. HTC of swine manure (SM), with high N (2.9 wt%), S (0.7 wt%) and ash (22.6 wt%) contents, as well as low C (35.6 wt%) and higher heating value (HHV; 14.3 MJ kg-1), resulted in a hydrochar with unsuitable characteristics as a solid fuel. Co-HTC of SM and garden and park waste (GPW) improved hydrochar properties (C content (43 - 48 wt%) and HHV (18 - 20 MJ kg-1), and decreased N (∼2 wt%), S (<0.3 wt%) and ash (<15 wt%) content. A high GPW ratio (>50 wt%) during co-HTC resulted in a hydrochar similar to that obtained from GPW. The co-HTC increased nutrient migration to the process water, which allowed the precipitation of salt with high P (7.8 wt%) and negligible heavy metal content. Anaerobic digestion of co-HTC process water allowed high organic matter removal (up to 65%), and methane production (315 - 325 mL CH4 g-1CODadded). Gross energy recovery by HTC and anaerobic digestion was 5 - 6-fold higher than anaerobic treatment of feedstocks. Therefore, co-HTC of SM and GPW with a ratio > 50% GPW proved to be a suitable approach to valorize and manage SM and obtain value-added products (hydrochar, mineral fertilizer and methane).

Critical review of technologies for the on-site treatment of hospital wastewater: From conventional to combined advanced processes

This review aims to assess different technologies for the on-site treatment of hospital wastewater (HWW) to remove pharmaceutical compounds (PhCs) as sustances of emerging concern at a bench, pilot, and full scales from 2014 to 2020. Moreover, a rough characterisation of hospital effluents is presented. The main detected PhCs are antibiotics and psychiatric drugs, with concentrations up to 1.1 mg/L. On the one hand, regarding the presented technologies, membrane bioreactors (MBRs) are a good alternative for treating HWW with PhCs removal values higher than 80% in removing analgesics, anti-inflammatories, cardiovascular drugs, and some antibiotics. Moreover, this system has been scaled up to the pilot plant scale. However, some target compounds are still present in the treated effluent, such as psychiatric and contrast media drugs and recalcitrant antibiotics (erythromycin and sulfamethoxazole). On the other hand, ozonation effectively removes antibiotics found in the HWW (>93%), and some studies are carried out at the pilot plant scale. Even though, some families, such as the X-ray contrast media, are recalcitrant to ozone. Other advanced oxidation processes (AOPs), such as Fenton-like or UV treatments, seem very effective for removing pharmaceuticals, Antibiotic Resistance Bacteria (ARBs) and Antibiotic Resistance Genes (ARGs). However, they are not implanted at pilot plant or full scale as they usually consider extra reactants such as ozone, iron, or UV-light, making the scale-up of the processes a challenging task to treat high-loading wastewater. Thus, several examples of biological wastewater treatment methods combined with AOPs have been proposed as the better strategy to treat HWW with high removal of PhCs (generally over 98%) and ARGs/ARBs (below the detection limit) and lower spending on reactants. However, it still requires further development and optimisation of the integrated processes.

Aortic and vascular involvement in Loeys-Dietz Syndrome. Results from the REPAG registry (Spanish network of genetic aortic diseases)

Background

LDS is a rare disease due to genetic variants in the TGFB pathway. Limited information is available regarding the overall aortic and vascular outcome of these patients

Purpose

To evaluate aortic and vascular complications of patients with mutations in the TGFB pathway.

Methods

Retrospective longitudinal study including patients with (likely) pathogenic (LP/P) variants in the TGFbeta pathway from 10 tertiary centers. Clinical and imaging data were reviewed and data on aortic and vascular outcome included.

Results

A total of 163 patients were included (47.9% women, 38.6% index cases), mean age at first evaluation 32.3±20.4 years, 27.0% with age &lt;16 years. 70 TGFBR1, 43 TGFBR2, 29 SMAD3, 9 TGFB2 and 12 TGFB3 (Table1)

During a mean follow-up of 4.7±3.7 years, 54 (33.1%) patients had at least 1 aortic surgery (max 6). Mean age at first aortic surgery was 37.2±16.8 years (Range 1.2–72.9). First surgery was elective in 42 (77.8%), and included aortic root or ascending aorta in 40 (95.2%) and isolated descending aorta in 2 (4.8%). Emergent surgery included aortic root or ascending aorta in 11 (92.7%). Ascending aorta-root diameter previous to elective surgery was 48.9±4.9mm (range 41–65). 7 patients died during follow-up (2 intracranial bleeding, 1 SD, 2 aortic ruptures, 1post aortic surgery, 1 non-CV). Furthermore, 19 acute aortic syndromes (AAS) were reported (17 dissections, 2 haematomas) in 18 patients, 10 type A (52.6%). Mean age at first AAS was 42.3±11.1 years (min 19.7 years to 62.9 years)

Median survival free of intervention, dissection or death was 57.1 years, being worst for men than women (44.7 yrs vs 69.1 years, p&lt;0.001) (Figure 1), these gender-difference only remained significant in the TGFBR1 and SMAD3 groups (p=0.005 and p=0.008) Regarding aortic branch and intracranial aneurysms, a total of 383 imaging studies of aortic branches and 223 cranial imaging studies were performed during the clinical follow-up. 21 cranial aneurysms and 73 aortic branch aneurisms were reported. 14 (11.5%) patients suffered 19 aneurysms-related events (3 dissections, 3 ruptures, 13 interventions).

Conclusions

In patients with Loeys-Dietz Syndrome, there's a high prevalence of aortic surgeries and acute aortic events, with high numbers of peripheral and intracranial aneurysms. A worst prognosis in men than in women is observed in TGFBR1 and SMAD3 variants. Thus, specialized clinical and imaging follow-up is crucial in the management of these patients

Funding Acknowledgement

Type of funding sources: None.

Energy recovery from garden and park waste by hydrothermal carbonisation and anaerobic digestion

Hydrothermal carbonisation (HTC) can transform wet lignocellulosic biomass, which is not considered an effective biofuel for energy production at the industrial level, into a carbonaceous product called hydrochar (HC) that is suitable for combustion and a process water (PW). PW is an interesting by-product that can be valorised for biogas production via anaerobic digestion (AD). This study presents a new approach for the valorisation of garden and park wastes (GPW) by integrating HTC to generate HC for energy production, while PW is subjected to AD for biogas production. The hydrothermal treatment was performed at 180, 210, and 230 °C, yielding HC with improved physicochemical properties, such as an elevated higher heating value (21-25 MJ kg^-1); low ash (<5 wt.%), nitrogen (1.3 wt.%), and sulphur (0.2 wt.%) contents; better fuel ratio (0.4-0.6); and a broad comprehensive combustibility index (8.0×10^-7 to 9.6×10^-7 min^-2 °C^-3). AD of the generated PW was conducted under mesophilic conditions (35 °C), resulting in a methane production in the range of 253-326 mL g^-1 COD_added and COD removal of up to 65%. The combination of HTC and AD allowed the recovery of 91% and 94% of the energy content feedstock, as calculated from the combustion of HC and methane, respectively.

Clinical risk factors for early mortality in patients with community-acquired septic shock. The importance of adequate source control

OBJECTIVE

To evaluate the incidence and risk factors for early mortality (EM) in the ICU in patients with community-acquired septic shock (CASS).

DESIGN

A retrospective cohort study of patients with CASS admitted to the ICU (2003-2016).

SETTING

ICU at a University Hospital in Spain.

PATIENTS

All consecutive patients admitted to the ICU with CASS.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

CASS was defined according to the Sepsis-3 definitions. EM were defined as occurring within of 72h following ICU admission. A multinomial logistic regression analysis was performed to identify the risk factors associated with early deaths.

RESULTS

During the study period, 625 patients met the Sepsis-3 criteria and admitted with CASS. 14.4% of all patients died within the first 72h. Of 161 patients who died in the ICU, 90 (55.9%) died within the first 72h. The percentage of early and late mortality did not vary significantly during the study period. The need and adequacy of source control were significantly lower in patients with EM. In the multivariate analysis, ARDS, non-respiratory infections, bacteremia and severity at admission were variables independently associated with EM. The only factor that decreased EM was adequate source control in patients with infections amenable to source control.

CONCLUSIONS

The incidence of EM has remained stable over time, which means that more than half of the patients who die from CASS do so within the first 72h. Infections where adequate source control can be performed have lower EM.

Access to health services for non-Covid-19 causes during the pandemic. A literature review

Background

Negative effects of the Covid-19 pandemic on access to care for other diseases are currently at debate.

Aim

To review existing literature on care access for non-Covid-19 conditions since the pandemic onset.

Methods

Scoping review using various databases (Medline, VHL, Web of Science, 2020/21). Terms used: ‘access', ‘health services', ‘Covid-19'. Out of 4,060 identified articles, 37 were selected after reviewing and assessing titles, abstracts and full text. Aday and Andersen's framework guided the analysis.

Results

Of selected articles, 21 analyse impact on health services use; 8 on performance; 8 on access barriers. Most analyse specific services during early pandemic stages through register review, showing an initial decline in use with inconsistent results on recovery. Some indicate increased complexity of treated patients and treatment delays. Studies surveying professionals analyse the impact on services performance or clinical practice, reporting a decrease in consultations/interventions for diverse pathologies and response implementation (e.g. telemedicine), but not how they affected access. Few studies focus on social inequalities in use, showing a greater reduction in low-income or ethnic minority users. Studies on unmet needs, access or barriers based on user surveys or qualitative methods are scarce, focused on a pathology or clinical area. Particularly in Spain, studies analyse impact on use of emergency, primary care and cancer diagnosis, and on emergency and cardiology services functioning. Studies based on user surveys are lacking: only a qualitative study analysed access difficulties for chronic patients in confinement. Methodological weaknesses are identified.

Conclusions

Although currently emerging, studies analysing the pandemic impact on equal access to care for non-Covid-19 conditions are scarce, limited in focus and methodology, especially in Spain. Comprehensive medium/long-term impact assessments, including analysis of causes, are needed.

Key messages

Research is lacking on the impact of the COVID-19 pandemic on healthcare access, particularly for vulnerable groups. Further evidence is needed to improve health systems resilience in the future.

The Bergen Declaration 2018: Did it drive the Migration Health Agenda forward in Norway?

 

The growing body of migrant health research at all levels focuses around disease burden, risk factors/behaviours and on distal factors but research on policy issues remains limited. Internationally published declarations and recommendations to take the migrant health agenda forward address policy issues. However declarations at country are few and not systematically followed up.

The Bergen Declaration was endorsed at Norway's' First National Conference on Migration Health (2018) by the multi-disciplinary participants. The declaration reflects the ‘upstream' and ‘downstream' areas addressed and discussed at the conference and includes concrete recommendations for key areas. It was widely disseminated, including high-level policy makers. Prior to the second Migration Health Conference (2020), the progress of the recommendations were reviewed. Since 2018, Migrant Integration Policy Index (MIPEX) in Norway from 2015 was updated in 2019 and a Country Assessment as part of the WP7 of Joint Action on Health Equity Europe (JAHEE) was conducted providing the basis to review the recommendations of the Bergen Declaration. In addition, the 2020 Committee conducted a desk review and search to follow up the recommendations. The review revealed that among identified ‘upstream' areas most progress had been made with data collection and research and the least in policy and governance. Among the ‘downstream' areas some progress was observed regarding practise and access to health services. Education and Training had received some attention. The Bergen Declaration reflects the consensus regarding migrant health and recommendations to address these issues in Norway. Monitoring the progress made through data that included policy review revealed progress and gaps. Progress in research, education and practise was evident whereas policy change was not. Policy makers have not paid heed to the Bergen Declaration.

Key messages

The Bergen Declaration was a useful tool for initiating and monitoring progress in research, education and practice. Declarations do not support advancement of policies and other means are required to push the policies forward.

Validation of New Methods of Using Simulated Whole-Body Movements as Implicit Indicators of Sound and Odor Preferences

Would you get close to a stinky perfume bottle or to a loudspeaker producing noise? In this paper, we present two procedures that allowed us to assess the ability of auditory and olfactory cues to elicit automatic approach/avoidance reactions toward their sources. The procedures resulted from an adaptation of the Visual Approach/Avoidance by the Self Task (VAAST; Rougier et al., 2018), a task having the peculiarity of simulating approach/avoidance reactions by using visual feedback coming from the whole-body movements. In the auditory VAAST (Experiment 1), participants were instructed to move forward or backward from a loudspeaker that produced spoken words differentiated by their level of distortion and thus by their hedonic value. In the olfactory VAAST (Experiment 2), participants were asked to move forward or backward from a perfume bottle that delivered pleasant and unpleasant odors. We expected, consistent with the approach/avoidance compatibility effect, shorter latencies for approaching positive stimuli and avoiding negative stimuli. In both experiments, we found an effect of the quality of the emotional stimulus on forward actions of participants, with undistorted words and pleasant odors inducing faster forward movements compared with that for distorted words and unpleasant odors. Notably, our results further suggest that the VAAST can successfully be used with implicit instructions, i.e., without requiring participants to explicitly process the valence of the emotional stimulus (in Experiment 1) or even the emotional stimulus itself (in Experiment 2). The sensitivity of our procedures is analyzed and its potential in cross-modal and (contextualized) consumer research discussed.

Effect of group treatment on physical inactivity among Syrian refugees. Randomized controlled trial

Background

Refugees in Norway show low levels of physical activity, and have relatively high prevalence of pain disorders and post-traumatic symptoms. Physical inactivity can be both a cause of and a consequence of physical and mental symptoms. In CHART study (Changing Health and health care needs Along the Syrian Refugees' Trajectories to Norway), two group interventions, one based on physiotherapy and body awareness (PAAI) and the other on Teaching Recovery Techniques (TRT), were developed to treat patients with pain disorders and/or post-traumatic symptoms.

Objective

As a secondary outcome of study, we assessed the effect of these group interventions on physical inactivity.

Methods

We conducted a randomized controlled trial testing two group interventions. Syrian adults ≥16 years with pain and/or post-traumatic symptoms were randomized to either intervention group or control group. Effect of the intervention was measured after 8 (PAAI) and 6 (TRT) weeks, as relative risk (RR) with 95% confidence intervals for being inactive for intervention versus control groups, using log-binomial regression with adjustment for baseline inactivity and type of intervention (PAAI or TRT).

Results

177 Syrian refugees were recruited between July 2018-September 2019. 88 were randomized to the intervention group and 89 to the control group. Mean age was 35 years (SD 11) and 38% were women. Inactivity at recruitment was reported by 126 (71%) participants. The follow-up questionnaire was completed at 6/8 weeks by 116 (66%) participants. At that point, 39% in the intervention group were inactive as compared to 56% in the control group. RR for inactivity for the intervention group adjusted for inactivity at baseline was 0.68 (0.47-0.99) and remained 0.68 (0.48-0.99) when further adjusting for type of intervention (PAAI vs TRT).

Conclusions

PAAI and TRT group interventions reduced inactivity among refugees by 32%. Effect on physical inactivity was similar between PAAI and TRT interventions.

Key messages

Public health care should be aware of physical inactivity, especially in relation to pain disorders and post-traumatic symptoms among refugees. Group treatment interventions succeeded to encourage refugees to increase their physical activity.

Access to healthcare and self-rated health among refugees in transit and after arrival in Norway

Background

Lack of basic infrastructure and poor provision of health services in conflict settings and during flight can have a negative impact on health. The overall health status of refugees seems to improve after arrival at a safe destination. This may be related to a safer environment and better access to health care services, but prior studies on this topic are limited. This study aims to assess self-perceived access to healthcare and its relationship with self-rated health (SRH) among refugees in transit and when settled in a host country.

Methods

We used data from the CHART study (Changing Health and health care needs Along the Syrian Refugees' Trajectories to Norway), which includes a cohort of 353 Syrian refugees who were contacted in 2017-2018 in Lebanon while waiting for relocation, and one year after their arrival to Norway. Information on self-perceived access to healthcare and its association with SRH was analyzed separately at each time-point. Data analysis was performed with STATA using logistic regression adjusting for age, gender, ethnicity and years of education and presented as adjusted odds ratios (AOR) with 95% CI.

Results

Fifteen percent reported good access to healthcare and 62% reported good SRH in Lebanon vs. 91% and 77% respectively, in Norway. Measures in Lebanon showed no association between access to healthcare and good SRH (AOR: 1.2 (0.6-2.2)), and men reported worse access to healthcare than women (AOR: 0.5 (0.3-1.0). In Norway, access to healthcare was strongly associated with good SRH (AOR: 4.7 (2.1-10.7) and was negatively associated with belonging to one specific minority group (AOR: 0.1 (0.0-0.3)).

Conclusions

Both SRH and perceived access to care improved from being in transit to being settled in Norway, the latter substantially more. There was a significant association between access to healthcare and good SRH after the refugees' arrival to a safe host country but not in transit.

Key messages

Refugee’s self-reported health and access to healthcare seem to improve shortly after arrival to a host country. To ensure that the UN’S Sustainable Development Goals concerning health equity are reached, refugees’ access to healthcare in transit and its impact on overall health needs to be addressed.

Non-communicable diseases and use of medication among Syrian refugees: a prospective cohort study

Background

Conflict-driven disruption in continuity of care for non-communicable diseases (NCDs) is likely to have adverse public health impact. Yet, data on the prevalence and treatment coverage of NCDs among refugees is scarce. In this study we aim to assess the changes in prevalence of NCDs and use of relevant medication among Syrian refugees from a near-conflict phase in Lebanon to a resettlement phase in Norway.

Methods

This is a prospective cohort study. Survey data were collected during 2017-2018 among adult Syrian refugees in Lebanon selected for quota resettlement and at follow-up approximately one year after resettlement in Norway. Our primary outcomes were changes in NCDs as defined by the WHO and use of relevant medication. We calculated prevalence proportions with confidence intervals and assessed changes in prevalence over time using generalized estimating equations.

Results

Altogether 353 Syrians participated. The median age was 34 years and 51 percent were women. The overall prevalence of NCDs was 12 (9-16) percent at baseline and 9 (6-12) percent at follow-up. The odds ratio for reporting any NCD at follow-up compared to baseline was 0.68 (0.46, 1.00). Among those reporting NCDs, the prevalence of using either antithrombotic or cholesterol lowering medication, antihypertensives, antidiabetics, or drugs for asthma or chronic obstructive pulmonary disease was 55 (39-70) percent at baseline and 63 (44-80) percent at follow-up. The odds ratio for using relevant medication at follow-up compared to baseline was 1.01 (0.63, 2.05).

Conclusions

In our study around one tenth of the refugees reported at least one NCD. Nearly half of those reporting NCDs in a conflict-near setting did not seem to receive relevant medication, while the same was true for more than one third of respondents after resettlement. We call for innovative public health approaches and interventions to protect continuity of care for NCDs in settings of conflict-driven exodus.

Key messages

A high share of Syrian refugees reporting NCDs do not seem to receive relevant medication. The management of NCDs among refugees needs attention in order to avoid negative health effects.

Changes in health among Syrian refugees along their migration trajectories from Lebanon to Norway: a prospective cohort study

OBJECTIVES

Conflict-driven displacement is an indisputable social determinant of health. Yet, data on changes in health along the migration trajectories of refugees are scarce. This study aims to assess the longitudinal changes in somatic and mental health and use of medication among Syrian refugees relocating from a conflict-near transit setting in the Middle East to a resettlement setting in Europe. Further, we examine different health status trajectories and factors that predict health in the early postmigration period.

STUDY DESIGN

This is a prospective cohort study.

METHODS

Survey data were collected during 2017-2018 among adult Syrian refugees in Lebanon selected for quota resettlement and at follow-up approximately one year after resettlement in Norway. Our primary outcomes were non-communicable disease (NCD), chronic impairment, chronic pain, anxiety/depression, post-traumatic stress symptoms, and daily use of drugs. We estimated longitudinal changes in prevalence proportions using generalized estimating equations and evaluated effect modification of health outcomes.

RESULTS

Altogether, 353 Syrians participated. NCDs declined (12%-9%), while the prevalence of chronic impairment, chronic pain, and use of drugs remained nearly unchanged (29%-28%, 30%-28%, and 20%-18%) between baseline and follow-up. Conversely, mental health outcomes improved (anxiety/depression 33%-11%, post-traumatic stress disorder 5%-2%). Effect modifiers for improvement over time included younger age, short length of stay, and non-legal status in the transit country before resettlement in Europe.

CONCLUSIONS

We find that mental health outcomes improve from a conflict-near transit setting in Lebanon to an early resettlement setting in Norway, while somatic health outcomes remain stable. Temporal changes in health among moving populations warrant attention, and long-term changes need further scrutiny.

Clinical risk factors for early mortality in patients with community-acquired septic shock. The importance of adequate source control

OBJECTIVE

To evaluate the incidence and risk factors for early mortality (EM) in the ICU in patients with community-acquired septic shock (CASS).

DESIGN

A retrospective cohort study of patients with CASS admitted to the ICU (2003-2016).

SETTING

ICU at a University Hospital in Spain.

PATIENTS

All consecutive patients admitted to the ICU with CASS.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

CASS was defined according to the Sepsis-3 definitions. EM were defined as occurring within of 72h following ICU admission. A multinomial logistic regression analysis was performed to identify the risk factors associated with early deaths.

RESULTS

During the study period, 625 patients met the Sepsis-3 criteria and admitted with CASS. 14.4% of all patients died within the first 72h. Of 161 patients who died in the ICU, 90 (55.9%) died within the first 72h. The percentage of early and late mortality did not vary significantly during the study period. The need and adequacy of source control were significantly lower in patients with EM. In the multivariate analysis, ARDS, non-respiratory infections, bacteremia and severity at admission were variables independently associated with EM. The only factor that decreased EM was adequate source control in patients with infections amenable to source control.

CONCLUSIONS

The incidence of EM has remained stable over time, which means that more than half of the patients who die from CASS do so within the first 72h. Infections where adequate source control can be performed have lower EM.

Severe Attack of Henoch-Schönlein Purpura With Neurological Involvement During Adalimumab Treatment for Crohn's Disease

Tumour necrosis factor-α [TNF-α] inhibitors have revolutionised the management of chronic inflammatory conditions. A number of cutaneous adverse events have been reported with TNF inhibition, including vasculitis. Most reactions are mild and rarely warrant treatment withdrawal. Here we describe a patient with Crohn's disease treated with adalimumab in whom severe multivisceral Henoch-Schönlein purpura developed, including neurological involvement, requiring definitive TNF blocker withdrawal.

Cation and anion effect on the biodegradability and toxicity of imidazolium- and choline-based ionic liquids

This work studies the effect of the cation and anion on the biodegradability and inhibition of imidazolium- and choline-based ionic liquids (ILs) using activated sludge. Six commercial ILs, formed by combination of 1-Butyl-3-methylimidazolium (Bmim⁺) and N,N,N-trimethylethanolammonium (Choline⁺) cations and chloride (Cl^-), acetate (Ac^-) and bis(trifluoromethanesulfonyl)imide (NTf₂^-) anions were evaluated, all representative counter-ions with markedly different toxicity and biodegradability. Inherent and fast biodegradability tests were used to evaluate both the microorganism inhibition and the IL biodegradability. In addition, the ecotoxicological response (EC₅₀) of the ILs was studied using activated sludge and Vibrio fischeri (Microtox® test). Bmim⁺ and NTf₂^- can be considered as non-biodegradable, whereas aerobic microorganisms easily degraded Choline⁺ and Ac^-. The biodegradation pattern of each cation/anion is nearly unaffected by counter-ion nature. Moreover, concentrations of CholineNTf₂ higher than 50 mg/L caused a partial inhibition on microbial activity, in good concordance with its low EC₅₀ (54 mg/L) measured by respiration inhibition test, which alerts on the negative environmental impact of NTf₂-containing ILs on the performance of sewage treatment plants.

Self Rated Health among Syrian refugees in Lebanon and Norway – a cross sectional study

Background

Refugees are often exposed to various stressors before, during and after migration that can cause adverse health effects. Prior research indicates that the health status of refugees is a significant factor in determining their success in resettlement. This study aims to assess self-rated health (SRH) and factors associated with SRH among Syrian refugees in Lebanon and Norway.

Methods

The study uses a cross-sectional design with data from a self-administered survey among 827 adult Syrian asylum seekers of whom 506 were recruited in Lebanon, and 321 in Norway. Inclusion criteria were subjects who self-identified as Syrian nationals above the age of 16. The survey was conducted in 2017 and 2018 in collaboration with International Organization of Migration in Lebanon and through mandatory educational activities in Norway. Data analysis was performed for the main outcome self-rated health (SRH), a validated health status indicator, which was dichotomized into “good” and “poor” SRH. Odds Ratios for poor SRH were estimated adjusting for age, gender and country of residence.

Results

A total of 827 of 972 (85%) who were invited answered the questionnaire. The mean age was 33 years and 74% were men. Factors associated with good SRH were being Kurdish (AOR: 0.48 (0.23 to 0.97)) compared to Arabic ethnicity, being married (AOR 0.54 (0.29 to 0.99)) compared to being single, migrating alone (AOR 0.59 (0.37 to 0.96)) compared to co-migration and having low health literacy level (AOR: 0.64 (0.42 to 0.93)). In contrast, poor SRH was significantly increased with long time in transit country/ies (AOR 1.49 (1.07 to 2.06)) and with older age (age 30-34 AOR 3.2, age 35-39 AOR 2.2, age 40 + AOR 2.6) compared to age group 16-24.

Conclusions

Older refugees and those who stay long time in transit are at great risk of reporting poor SRH. Some of the factors associated with better health, like Kurdish ethnicity, low health literacy or migrating alone, deserve further research.

Key messages

Age and long stay in transit is associated with poor SRH among Syrian refugees. Demographic background and migrant related factors should be taken into account when planning refugee resettlement and healthcare provision.

Chronic pain and migration-related factors among Syrian refugees: a cross-sectional study

Background

Refugees display high rates of chronic pain. However, the relationship between refugee-related exposures introduced along their migration trajectories and the development of chronic pain remains unclear. The aim of this study was to assess the impact of stressors induced at various migration stages on chronic pain in Syrian refugees.

Methods

This is a cross-sectional survey among adult Syrian refugees in Lebanon and in Norway. We conducted logistic regression to study the associations between chronic pain and migration-related factors experienced prior to or during flight (trauma exposure, migrating alone and detainment) and after arrival in a new country (legal status, social relationships, living conditions and access to health care).

Results

Altogether 827 Syrians participated (response rate 85%). The mean age was 33 years and 41% were women. The overall prevalence of chronic pain was 30%. The mean WHO Quality of Life (WHOQOL) domain scores for both social relationships (13.4) and environment (10.2) were significantly lower among those reporting chronic pain, with low scores indicating less satisfaction. Regression analyses revealed an association between chronic pain and exposure to trauma (adjusted odds ratio (AOR) 2.5 (1.8; 3.4)), but no clear association between chronic pain and migrating alone or history of detention. Poor social relationships (AOR 1.9 (1.2; 3.1)), poor support from friends (AOR 1.5 (1.0; 2.1)) and poor living place (AOR 1.4 (1.0; 2.0)) were associated with reporting chronic pain, although associations reduced when adjusting for traumatic experiences. The associations between chronic pain and poor economy (AOR 1.6 (1.1; 2.5)) and poor access to health care (AOR 1.5 (1.0; 2.1)) persisted after trauma exposure adjustment.

Conclusions

We found a strong relationship between trauma exposure and chronic pain. Further, perceived poor economy and poor access to health care were associated with chronic pain regardless of trauma history.

Key messages

Trauma exposure, perceived poor economy and poor access to health care are associated with chronic pain among Syrian refugees. Public health care interventions should consider the combined impact of risk factors throughout the migration trajectory.

Robotic-assisted gastrectomy compared with open resection: a comparative study of clinical outcomes and cost-effectiveness analysis

In the last decade, there have clearly been important changes in the surgical approach of gastric cancer treatment due to an increased interest in the minimally invasive surgical approach (MIS). The higher cost of robotic surgery procedures remains an important issue of debate. The objective of the study is to compare the main operative and clinical outcomes and to assess the incremental cost-effectiveness ratios (ICERs) of the two techniques. This is a prospective cost-effectiveness and clinical study when comparing the robotic gastrectomy (RG) technique with open gastrectomy (OG) in gastric cancer. Outcome parameters included surgical and post-operative costs, quality-adjusted life years (QALY) and incremental cost per QALY gained or the incremental cost-effectiveness ratio (ICER). The incremental utility was 0.038 QALYs and the estimated ICER for patients was dominated by robotic approach. The probability that the robotic approach was cost effective was 94.04% and 94.20%, respectively, at a WTP threshold of 20,000€ and 30,000€ per QALY gained. RG for gastric cancer represents a cost-effective procedure compared with the standard OG.

The learning curve of contrast-enhanced 'microbubble' voiding urosonography-validation study

INTRODUCTION

Vesicoureteral reflux (VUR) is a common pediatric urologic condition associated with urinary tract infection and pyelonephritis. It can be diagnosed via fluoroscopic voiding cystourethrogram (VCUG) and, more recently, contrast-enhanced voiding ultrasonography (ceVUS), which does not expose the patient to ionizing radiation. Voiding urosonography contrast agents used for the diagnosis of VUR have been widely available in Europe but were approved by the Food and Drug Administration for use in the United States only in 2016.

OBJECTIVE

The objective was to optimize a protocol and compare the diagnostic performance of ceVUS to fluoroscopic VCUG in an academic medical center naïve to previous use of contrast-enhanced voiding urosonography.

STUDY DESIGN

Thirty-nine patients referred for clinically indicated evaluation of VUR were enrolled between September 2016 and March 2017. Patients underwent contrast-enhanced ultrasonography with prediluted Lumason and under the same catheterization underwent fluoroscopic VCUG. Comparative grading was performed by pediatric radiologists on-site at the time of examination.

RESULTS

Reflux was observed in 16 of 39 patients (20 of 64 renal units) ranging from grades 1 through 5. VCUG and ceVUS were concordant for detecting reflux in 10 of 39 patients (14 of 84 renal units) and excluding reflux in 23 of 39 patients (64 of 84 renal units) (Fig. 1). Using contrast enhanced voiding urosonography, 1 of 20 renal units had high-grade and 2 of 20 renal units had low-grade reflux that was not found on fluoroscopy. Using fluoroscopy, 1 of 20 renal units had high-grade and 2 of 20 renal units had low-grade reflux that had not been found on ceVUS. Two of 20 renal units were upgraded from low-grade on ceVUS to high-grade on fluoroscopy. This corresponds to a Cohen's kappa of 0.72 (confidence interval [CI] 0.54-0.91) or 'moderate.'

DISCUSSION

During our investigation, we noted that there was a technical learning curve related to poor contrast mixing and the need to titrate the concentration of Lumason. However, over the course of the study, we were able to correct the technical aspects. Ultimately, our results showed good correlation between VCUG and Lumason ceVUS and only slightly less correlation than published studies by experienced centers. Future studies with voiding should allow for improved urethral visualization.

CONCLUSION

While there is a considerable learning curve to the implementation of ceVUS for the diagnosis of pediatric VUR, these technical aspects can be corrected. Even a center previously naïve to contrast-enhanced ultrasound technology can, over a short period of time, demonstrate good correlation between VCUG and ceVUS in the diagnosis of VUR. Translation of ceVUS into clinical practice is an alternative to VCUG for diagnosis of reflux, is feasible, and can eliminate the radiation exposure associated with a VCUG.

Comparison of the defined daily dose and days of treatment methods for evaluating the consumption of antibiotics and antifungals in the intensive care unit

OBJECTIVE

To compare the measurement of antimicrobial consumption by defined daily dose (DDD) versus by days of therapy (DOT).

DESIGN

Retrospective analysis of clinical and administrative data from patients admitted to a polyvalent ICU.

SETTING

ICU at a University Hospital in Spain.

PATIENTS

All patients admitted to the ICU.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

For the DDD method, the World Health Organization (WHO)-assigned DDD was determined for the all the prescribed antimicrobials. For the DOT method, one DOT represented the administration of a single agent on a given day regardless of the number of doses administered. To express aggregate use, total DDDs and total DOTs were normalized to 100 patient-days.

RESULTS

During the study period, 2393 adult patients were admitted to the ICU. Total median antimicrobial drugs measured by DDDs was 535.3 (IQR 319.8-845.5) vs. 344.0 (IQR 117.2-544.5) when measured by DOTs, p<0.001. When antimicrobial consumption was normalized to 100 patient-days, median antimicrobial consumption was also higher when measured by DDDs [2.98/100 patient-days (IQR 1.76-5.25) vs. 1.89/100 patient-days (IQR 0.64-3.0) when measured by DOTs, p<0.001].

CONCLUSIONS

For most antibacterial and antifungal drugs used in critically ill patients, estimates of aggregate antibiotic use by DDDs per 100 patient-days and DOTs per 100 patient-days are discordant because the administered dose is dissimilar from the WHO-assigned DDD. DOT methods should be recommended to avoid the overestimation that occurs with DDDs in adult critically ill patients.

Detection and prediction of driver drowsiness using artificial neural network models

Not just detecting but also predicting impairment of a car driver's operational state is a challenge. This study aims to determine whether the standard sources of information used to detect drowsiness can also be used to predict when a given drowsiness level will be reached. Moreover, we explore whether adding data such as driving time and participant information improves the accuracy of detection and prediction of drowsiness. Twenty-one participants drove a car simulator for 110min under conditions optimized to induce drowsiness. We measured physiological and behavioral indicators such as heart rate and variability, respiration rate, head and eyelid movements (blink duration, frequency and PERCLOS) and recorded driving behavior such as time-to-lane-crossing, speed, steering wheel angle, position on the lane. Different combinations of this information were tested against the real state of the driver, namely the ground truth, as defined from video recordings via the Trained Observer Rating. Two models using artificial neural networks were developed, one to detect the degree of drowsiness every minute, and the other to predict every minute the time required to reach a particular drowsiness level (moderately drowsy). The best performance in both detection and prediction is obtained with behavioral indicators and additional information. The model can detect the drowsiness level with a mean square error of 0.22 and can predict when a given drowsiness level will be reached with a mean square error of 4.18min. This study shows that, on a controlled and very monotonous environment conducive to drowsiness in a driving simulator, the dynamics of driver impairment can be predicted.

[The value of healthy skin biopsy in the diagnosis of intravascular B-cell lymphoma: A case report and systematic literature review]

BACKGROUND

Intravascular large B-cell lymphoma (ivLBCL) is a rare blood dyscrasia that is difficult to diagnose. Healthy skin biopsies may prove useful in diagnosis of the condition. Herein we report a case of ivLBCL diagnosed using this type of examination, and we provide a literature review to determine the sensitivity of such testing.

PATIENTS AND METHODS

A 67-year-old woman was hospitalised for unexplained prolonged fever (UPF) and impaired general well-being. Laboratory tests revealed inflammatory syndrome, elevated LDH>2000IU/L, hepatic cytolysis and decreased prothrombin time at 47 %. Analysis for infection and medical imaging ruled out both an infectious or inflammatory origin and solid tumour. A healthy skin biopsy enabled confirmation of the diagnosis of ivLBCL.

DISCUSSION

This clinical case illustrates the value of healthy skin biopsy in establishing a diagnosis of ivLBCL in patients hospitalised for UPF. Following a systematic literature review in PubMed/Medline, we included eight studies involving at least three patients designed to assess the value of healthy skin biopsy in the diagnosis of ivLBCL. The diagnostic sensitivity of this approach ranged from 67% to 100%, with a sensitivity of 100% being seen in four of the eight studies. Details of the biopsy sites were available in three studies and diagnostic sensitivity was similar overall between samples taken from the thigh, abdomen and arms.

CONCLUSION

Healthy skin biopsy sampling from at least two sites constitutes a sensitive and relatively non-invasive procedure for early diagnosis of ivLBCL.

Assessment the ecotoxicity and inhibition of imidazolium ionic liquids by respiration inhibition assays

The ecotoxicity and inhibition of 12 imidazolium ionic liquids (ILs) with alkyl chain from C4 to C10 and chloride (Cl^-), tetrafluoroborate (BF₄^-) and bis(trifluoromethanesulfonyl)imide (NTf₂^-) anions have been studied by means of respiration inhibition assays using activated sludge collected from a wastewater treatment plant. This test represents an alternative easy, economic and quick way to evaluate the true impact of ILs on activated sludge-based wastewater treatment. For comparison purposes, the EC₅₀ values were also determined by the Microtox test (Vibrio fischeri). It was observed that this widely used microbial test overestimates the effect of the ILs on biological wastewater treatment facilities, especially in the case of ILs with lower ecotoxicity. The results of the biological tests showed that the alkyl chain length plays a crucial role in the ecotoxicity of ILs. A significant increase of the toxicity with the length of the n-alkyl chain was found. Regarding to the impact of the anion, the ecotoxicity measured by respiration inhibition assays follows the order NTf₂^- > Cl^- > BF₄^-, being the anion effect higher as decreasing the length of cation alkyl chain. According to the hazard substances ranking for aquatic organisms (Passino and Smith, 1987), imidazolium ILs with C4 alkyl chain can be classified as "practically harmless" compounds whereas those with alkyl chains C8 or C10 correspond to "highly toxic" species.

Perception of Ultrasonic Switches Involves Large Discontinuity of the Mechanical Impedance

The distinct tactile feedback provided by mechanical keyboards notifies users that their actions have been successfully recorded. The presence of these subtle yet informative tactile cues is one of the reasons why mechanical keyboards are still preferred to their virtual counterparts. An artificial sensation of pressing a mechanical switch can be produced by varying the coefficient of friction as the user is pressing down on a glass surface using ultrasonic vibration. We examined the factors involved in producing a vivid sensation of a stimulus by measuring the mechanical impedance, the frictional behavior of the fingertip and the perceptual thresholds. Subjects who experienced weaker sensations also showed a weaker sensitivity to friction modulation, which may in turn be attributable to the presence of a larger or a smaller than average impedance. In the second experiment, the user's finger impedance was measured during the click, and it was observed that the successful detection of the stimulus was correlated with the presence of considerable discontinuity in the mechanical impedance added to the plate by the finger. This discontinuity in the evolution of the impedance supports the idea that the skin is being reconfigured towards a new equilibrium state after the change in friction.

Developing culturally adapted lifestyle interventions for South Asian migrant populations: a qualitative study of the key success factors and main challenges

OBJECTIVES

South Asian migrant populations have a high risk of non-communicable diseases, such as type 2 diabetes (T2D). The aim of this study is to provide in-depth insight into key success factors and challenges in developing culturally adapted lifestyle interventions to prevent T2D within South Asian migrant populations.

STUDY DESIGN

The study has a qualitative research design.

METHODS

In-depth interviews, using a semi-structured interview guide, were conducted with eight researchers and project leaders from five studies of culturally adapted lifestyle interventions for South Asian migrant populations. Data were analysed using a grounded theory approach.

RESULTS

Four main themes emerged as key factors for success: 'approaching the community in the right way', 'the intervention as a space for social relations', 'support from public authorities' and 'being reflexive and flexible'. Two themes emerged as challenges: 'struggling with time' and 'overemphasising cultural differences'.

CONCLUSIONS

Our findings augment existing research by establishing the importance of cooperation at the organisational and institutional levels, of fostering the creation of social networks through interventions and of acknowledging the multiplicity of identities and resources among individuals of the same ethnic origin.