Household water use and greywater management in Khulna city, Bangladesh

While substantial progress has been made in improving water and sanitation services in low- and middle-income countries, aligned basic services such as greywater, stormwater, and solid waste management have progressed little in recent decades. Data was collected in Khulna city, Bangladesh via a household survey (n = 192) of low-income areas exploring domestic water use and greywater volumes, characteristics, and disposal practices. Most households (71%) use a piped water supply for domestic purposes, supplemented by seasonal rainwater harvesting (26%) and greywater use (13%). Of the total water used by households (mean: 594 L/household/day and equivalent to 116 L/person/day), approximately 58% becomes greywater through bathing, dishwashing, religious practices, handwashing, laundry, and mopping. Greywater produced ranges from 61-1274 L/household/day, with a mean of 345 L/household/day and equivalent to 78.4 L/person/day. Greywater characteristics vary depending on the activity, individual behaviours and any products used during cooking, bathing, or cleaning. After generation, households dispose greywater to open drains (67%), nearby waterbodies (17%) directly to the ground (9%), or decentralised wastewater treatment system (7%). Without services for greywater management, greywater disposal may have considerable public and environmental health implications, necessitating careful attention and oversight from service-providers and stakeholders beyond the household-level.

Slow cycling and durable Flt3+ progenitors contribute to hematopoiesis under native conditions

The dynamics of the hematopoietic flux responsible for blood cell production in native conditions remains a matter of debate. Using CITE-seq analyses, we uncovered a distinct progenitor population that displays a cell cycle gene signature similar to the one found in quiescent hematopoietic stem cells. We further determined that the CD62L marker can be used to phenotypically enrich this population in the Flt3+ multipotent progenitor (MPP4) compartment. Functional in vitro and in vivo analyses validated the heterogeneity of the MPP4 compartment and established the quiescent/slow-cycling properties of the CD62L- MPP4 cells. Furthermore, studies under native conditions revealed a novel hierarchical organization of the MPP compartments in which quiescent/slow-cycling MPP4 cells sustain a prolonged hematopoietic activity at steady-state while giving rise to other lineage-biased MPP populations. Altogether, our data characterize a durable and productive quiescent/slow-cycling hematopoietic intermediary within the MPP4 compartment and highlight early paths of progenitor differentiation during unperturbed hematopoiesis.

MGMT Promoter Methylation: Prognostication beyond Treatment Response

MGMT promoter methylation is related to the increased sensitivity of tumour tissue to chemotherapy with temozolomide (TMZ) and thus to improved patient survival. However, it is unclear how the extent of MGMT promoter methylation affects outcomes. In our study, a single-centre retrospective study, we explore the impact of MGMT promoter methylation in patients with glioblastoma who were operated upon with 5-ALA. Demographic, clinical and histology data, and survival rates were assessed. A total of 69 patients formed the study group (mean age 53.75 ± 15.51 years old). Positive 5-ALA fluorescence was noted in 79.41%. A higher percentage of MGMT promoter methylation was related to lower preoperative tumour volume (p = 0.003), a lower likelihood of 5-ALA positive fluorescence (p = 0.041) and a larger extent of resection EoR (p = 0.041). A higher MGMT promoter methylation rate was also related to improved progression-free survival (PFS) and overall survival (OS) (p = 0.008 and p = 0.006, respectively), even when adjusted for the extent of resection (p = 0.034 and p = 0.042, respectively). A higher number of adjuvant chemotherapy cycles was also related to longer PFS and OS (p = 0.049 and p = 0.030, respectively). Therefore, this study suggests MGMT promoter methylation should be considered as a continuous variable. It is a prognostic factor that goes beyond sensitivity to chemotherapy treatment, as a higher percentage of methylation is related not only to increased EoR and increased PFS and OS, but also to lower tumour volume at presentation and a lower likelihood of 5-ALA fluorescence intraoperatively.

Prognostic Factors for Surgically Managed Spontaneous Spinal Epidural Hematoma: A Single-Center Case Series of 18 Patients

BACKGROUND

Spontaneous spinal epidural hematoma (SSEH) is a rare pathology, which carries a significant morbidity.

OBJECTIVE

To review our institutional experience of surgically managed patients with SSEH, seeking to better understand clinical prognostic factors related to postoperative outcomes and thereby improve counseling of patients before treatment.

METHODS

All patients who underwent surgical management of SSEH between September 2011 and 2021. Baseline and postoperative clinical and radiological characteristics are presented, including the American Spinal Injury Association grade (ASIA). Statistical analyses were performed using Stata 13.1.

RESULTS

Eighteen patients were identified in total (11 male patients and 7 female patients) with a median age of 59.5 (range 3-83) years. The most common spinal region affected was cervicothoracic (33.3%). Limb weakness (94.4%) and urinary dysfunction (83.3%) represented the most common presenting symptoms. Preoperatively, the presence of spinal cord edema on imaging was associated with worse preoperative Medical Research Council (MRC) grade ( P = .033), female sex was associated with preserved saddle sensation ( P = .04), and patients receiving antiplatelet medication were associated with a higher risk of preoperative axial back pain ( P = .005). Higher postoperative MRC grade was associated with higher preoperative ASIA ( P = .012) and MRC grade ( P = .005), and preservation of saddle sensation ( P = .018). Postoperative improvements in axial back pain were associated with higher preoperative ASIA grade ( P = .035) and anticoagulation treatment ( P = .029).

CONCLUSION

Neurosurgical intervention for SSEH yields positive outcomes and benefits patients. Patients with higher preoperative ASIA, MRC grade, and those presenting with preserved saddle sensation may experience further improved clinical outcomes after intervention.

Prognostic factors and surgical outcomes of spontaneous spinal epidural haematoma: a systematic review and meta-analysis

Spontaneous spinal epidural haematoma (SSEH) is a rare disease defined as blood accumulation within the vertebral epidural space without a cause identified, which can lead to severe neurological deficits. We aim to provide a comprehensive understanding of the prognostic factors affecting surgical outcomes in true SSEH and propose a critical time frame for operative management. A systematic literature search was performed and registered, using OVID Medline and EMBASE, in line with the PRISMA guidelines. Relevant demographic, clinical, surgical, and outcome data were extracted. The ASIA scale was uniformly used throughout our systematic review. Statistical analysis was performed via logistic regression. Of the 1179 articles examined, we included 181 studies involving 295 adult patients surgically treated for SSEH. SSEH were most commonly found in the cervicothoracic spine, with 2-4 spinal segments most commonly involved. Multivariable logistic regression model showed that the following factors were statistically significant in the post-operative outcome: operation type (P = 0.024), pre-operative neurologic status (P < 0.001), use of warfarin (P = 0.039), and operative interval (P = 0.006). Our retrospective analysis confirms the reversibility of severe neurological deficits after surgical intervention, with a prognosis of post-operative outcomes determined by the use of warfarin, pre-operative ASIA grade, and above all surgical evacuation within 12 h.

Prognostic factors for surgically managed intramedullary spinal cord tumours: a single-centre case series

PURPOSE

Intramedullary spinal cord tumours (IMSCTs) are comparatively rare neoplasms. We present a single-centre clinical case series of adult patients with surgically managed IMSCTs.

METHODS

We performed a retrospective analysis of electronic patient records in the time period spanning July 2010 to July 2021. All adult patients that had undergone surgical management for IMSCTs were eligible for inclusion. Baseline and post-operative clinical and radiological characteristics, along with follow-up data, were assessed. We also performed a literature review with a focus on surgical outcomes for IMSCTs.

RESULTS

Sixty-six patients matched our selection criteria, with a median age of 42 years (range 23-85). Thirty-four ependymomas, 17 haemangioblastomas, 12 astrocytomas, 2 lymphomas and 1 teratoma were included. Statistical analysis yielded several significant findings: IMSCTs spanning a greater number of vertebral levels are significantly associated with poor McCormick outcomes (p = 0.03), presence of gait disturbance before surgery is significantly associated with poor outcome for both post-operative McCormick and Nurick scores (p = 0.007), and radicular pain present pre-operatively is significantly associated with a good post-operative McCormick score (p = 0.045). Haemangioblastomas are significantly more likely to have a clear intra-operative dissection plane compared to ependymomas and astrocytomas (p = 0.009). However, astrocytomas have a significantly higher prevalence of good McCormick outcomes compared to ependymomas and haemangioblastomas (p = 0.03).

CONCLUSION

Histological diagnosis, cranio-caudal extent of the tumour and the presence or absence of baseline deficits-such as gait impairment and radicular pain-are significant in determining neurological outcomes after surgery for IMSCTs.

The new metabolic needs of hematopoietic stem cells

PURPOSE OF REVIEW

Hematopoietic stem cells (HSCs) are endowed with high regenerative potential to supply mature blood cells throughout life, under steady state or stress conditions. HSCs are thought to rely on glycolysis when in a quiescent state and to switch to oxidative phosphorylation to meet their metabolic needs during activation. Recently, a series of important studies reveals a higher degree of complexity that goes well beyond the dichotomy between glycolysis and oxidative phosphorylation. The purpose of this review is to summarize the recent findings highlighting the multifaceted metabolic requirements of HSC homeostasis.

RECENT FINDINGS

Emerging evidence points to the importance of lysosomal catabolic activity and noncanonical retinoic acid pathway in maintaining HSC quiescence and stemness. HSC activation into cycle seems to be accompanied by a switch to glycolysis-mitochondrial coupling and to anabolic pathways, including Myc, aspartate-mediated purine synthesis.

SUMMARY

Knowledge of metabolism of HSCs has dramatically increased in the past 2 years and reveals unexpected needs of HSCs during both their quiescent and activated state. Understanding how HSCs use metabolism for their functions will offer new opportunity for HSC-based therapies.

Surgical management and outcomes in spinal intradural arachnoid cysts: the experience from two tertiary neurosurgical centres

PURPOSE

Evaluation of the presentation and outcomes of different surgical treatment approaches for spinal intradural arachnoid cysts (SIAC).

METHODS

Cases were identified from electronic records of two major neurosurgical centres in London over the last 10 years (October 2009-October 2019) that have been surgically treated in both institutions. Clinical findings, surgical technique, and recurrence by procedure were statistically analysed. Statistical analysis was performed with STATA 13.1 Software.

RESULTS

A total of 42 patients with SIAC were identified for this study with a mean age at the time of surgery of 53.6 years and a male:female ratio of 8:13. There were 31 patients with primary SIACs and 11 with secondary SIACs. The most common presenting symptom was paraesthesia (n = 27). The most common location of the cyst was in the thoracic region (n = 33). Syrinx was present in 26.2% of SIACs (n = 11). Resection was associated with significantly better postoperative pain compared to other surgical techniques (p = 0.01), significantly poorer postoperative urinary function (p = 0.029), and lower rates of sensory recovery in patients who presented preoperatively with sensory deficit (p = 0.041). No significant difference was seen in symptomatic outcomes between patients with primary and secondary SIACs.

CONCLUSION

Resection and drainage are both effective methods of managing SIACs. In this observational study, resection was associated with significantly reduced pain postoperatively when compared with drainage, however also with significantly less improvement in postoperative urinary function. Therefore, resection should be the gold standard management option for SIACs, with drainage as an option where resection is unsafe, and drainage should also be considered in patients presenting with urinary dysfunction.

Sinonasal carcinosarcoma with cartilaginous and rhabdomyoblastic components: A previously undescribed entity

Carcinosarcomas are rare, aggressive tumors seldom found in the sinonasal region. They classically consist of sarcomatous spindle cell and carcinomatous squamous cell elements. A 61-year-old woman presented reporting right-sided nasal discharge and obstruction. Examination demonstrated a large right-sided nasal mass, from which a biopsy was taken. Computed tomography and magnetic resonance imaging revealed a mass arising from the maxillary antrum and extending into the nasal cavity, ethmoid air cells, and frontal sinus. Right total maxillectomy with resection of the nasal tumour component was performed. Histological analysis demonstrated a high-grade malignancy with features consistent with carcinosarcoma with cartilaginous and rhabdomyoblastic elements, a histologic pattern that has not previously been described at this site. Magnetic resonance imaging 5 weeks postoperatively showed sizeable recurrence. Adjuvant chemotherapy and radiotherapy were commenced to excellent effect. Carcinosarcomas, though very rare at sinonasal sites, should be considered if biopsy demonstrates undifferentiated high-grade neoplasm with cytokeratin expression. These tumors require aggressive multimodal therapy for optimal outcomes.

The deubiquitinase USP15 modulates cellular redox and is a therapeutic target in acute myeloid leukemia

Ubiquitin-specific peptidase 15 (USP15) is a deubiquitinating enzyme implicated in critical cellular and oncogenic processes. We report that USP15 mRNA and protein are overexpressed in human acute myeloid leukemia (AML) as compared to normal hematopoietic progenitor cells. This high expression of USP15 in AML correlates with KEAP1 protein and suppression of NRF2. Knockdown or deletion of USP15 in human and mouse AML models significantly impairs leukemic progenitor function and viability and de-represses an antioxidant response through the KEAP1-NRF2 axis. Inhibition of USP15 and subsequent activation of NRF2 leads to redox perturbations in AML cells, coincident with impaired leukemic cell function. In contrast, USP15 is dispensable for human and mouse normal hematopoietic cells in vitro and in vivo. A preclinical small-molecule inhibitor of USP15 induced the KEAP1-NRF2 axis and impaired AML cell function, suggesting that targeting USP15 catalytic function can suppress AML. Based on these findings, we report that USP15 drives AML cell function, in part, by suppressing a critical oxidative stress sensor mechanism and permitting an aberrant redox state. Furthermore, we postulate that inhibition of USP15 activity with small molecule inhibitors will selectively impair leukemic progenitor cells by re-engaging homeostatic redox responses while sparing normal hematopoiesis.

MRI Patterns in Pediatric CNS Hemophagocytic Lymphohistiocytosis

BACKGROUND AND PURPOSE

Neuroimaging has an important role in detecting CNS involvement in children with systemic or CNS isolated hemophagocytic lymphohistiocytosis. We characterized a cohort of pediatric patients with CNS hemophagocytic lymphohistiocytosis focusing on neuroradiologic features and assessed whether distinct MR imaging patterns and genotype correlations can be recognized.

MATERIALS AND METHODS

We retrospectively enrolled consecutive pediatric patients diagnosed with hemophagocytic lymphohistiocytosis with CNS involvement treated at 2 pediatric neurology centers between 2010 and 2018. Clinical and MR imaging data were analyzed.

RESULTS

Fifty-seven children (40 primary, 70%) with a median age of 36 months (interquartile range, 5.5-80.8 months) were included. One hundred twenty-three MR imaging studies were assessed, and 2 broad imaging patterns were identified. Pattern 1 (significant parenchymal disease, 32/57, 56%) was seen in older children (P = .004) with worse clinical profiles. It had 3 onset subpatterns: multifocal white matter lesions (21/32, 66%), brainstem predominant disease (5, 15%), and cerebellitis (6, 19%). All patients with the brainstem pattern failed to meet the radiologic criteria for chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids. An attenuated imaging phenotype (pattern 2) was seen in 25 patients (44%, 30 studies) and was associated with younger age.

CONCLUSIONS

Distinct MR imaging patterns correlating with clinical phenotypes and possible genetic underpinnings were recognized in this cohort of pediatric CNS hemophagocytic lymphohistiocytosis. Disruptive mutations and missense mutations with absent protein expression correlate with a younger onset age. Children with brainstem and cerebellitis patterns and a negative etiologic work-up require directed assessment for CNS hemophagocytic lymphohistiocytosis.

Systematic Review of Surgical Management of Spinal Intradural Arachnoid Cysts

OBJECTIVE

Spinal intradural arachnoid cysts (SIACs) are rare pathological lesions that can arise via outpouchings of the arachnoid layer in the spinal canal that can result in neurological deficits. We performed a systematic literature review regarding the current surgical techniques used in the management of SIACs and discussed the prevailing hypotheses surrounding the etiology of SIACs.

METHODS

A systematic search of the literature was performed in December 2020 using EMBASE and MEDLINE for reports regarding the surgical management of SIACs. Data were collected regarding the demographics of the patients, classification system used, presence or absence of syrinxes, preoperative imaging modality, surgical approach and extent of resection, and postoperative outcomes and follow-up.

RESULTS

Our search yielded 19 reports for inclusion in the present study. The 19 studies included a total of 414 cases, with an overall male/female ratio of 0.93:1. The most common site for the SIACs was the thoracic spinal cord at 77.5%. The symptoms were very similar across the 19 studies. Of the 19 studies, 15 had used resection to manage the SIACs, 10 had used fenestration or marsupialization, and 4 had used cystoarachnoid or cystoperitoneal shunts.

CONCLUSIONS

SIACs are rare and debilitating spinal pathological lesions, with the etiology of primary SIACs still not fully elucidated. Multiple surgical approaches have been effective, with the optimal operative strategy largely dependent on the individual patient and cyst factors on a case-by-case basis.

TGFβ signaling modifies hematopoietic acute inflammatory response to drive bone marrow failure

Bone marrow failure syndromes are characterized by ineffective hematopoiesis due to impaired fitness of hematopoietic stem cells. They can be acquired during bone marrow stress or innate and are associated with driver genetic mutations. Patients with a bone marrow failure syndrome are at higher risk of developing secondary neoplasms, including myelodysplastic syndromes and leukemia. Despite the identification of genetic driver mutations, the hematopoietic presentation of the disease is quite heterogeneous, raising the possibility that non-genetic factors contribute to the pathogenesis of the disease. The role of inflammation has emerged as an important contributing factor, but remains to be understood in detail. In this study, we examined the effect of increased transforming growth factor-b (TGFb) signaling, in combination or not with an acute innate immune challenge using polyinosinc:polycytidilic acid (pIC), on the hematopoietic system without genetic mutations. We show that acute rounds of pIC alone drive a benign age-related myeloid cell expansion and increased TGFb signaling alone causes a modest anemia in old mice. In sharp contrast, increased TGFb signaling plus acute pIC challenge result in chronic pancytopenia, expanded hematopoietic stem and progenitor cell pools, and increased bone marrow dysplasia 3-4 months after stress, which are phenotypes similar to human bone marrow failure syndromes. Mechanistically, this disease phenotype is uniquely associated with increased mitochondrial content, increased reactive oxygen species and enhanced caspase-1 activity. Our results suggest that chronic increased TGFb signaling modifies the memory of an acute immune response to drive bone marrow failure without the need for a preexisting genetic insult. Hence, non-genetic factors in combination are sufficient to drive bone marrow failure.

Surgical Management of Spinal Chordoma: A Systematic Review and Single-Center Experience

OBJECTIVE

Chordoma is a rare neoplasm of the neuraxis derived from remnants of the primitive notochord. The importance of wide margins and use of adjuvant therapy in spinal chordomas are still contentious points in the management of spinal chordomas. We conducted a systematic review of the surgical management of spinal chordomas alongside our 10-year institutional experience.

METHODS

A systematic search of the literature was performed in November 2020 using Embase and MEDLINE for articles regarding the surgical management of chordomas arising from the mobile spine and sacrum. We also searched for all adult patients who were surgically managed for spinal chordomas at our institute between 2010 and 2020. In both the systematic review and our institutional case series, data on adequacy of resection, use of adjuvant therapy, complications, recurrence (local or metastatic), and survival outcomes were collected.

RESULTS

We identified and analyzed 42 articles, yielding 1531 patients, from which the overall gross total or wide resection rate was 54.9%. Among the 8 cases in our institutional experience (4 sacral, 3 cervical, and 1 lumbar), we achieved gross total resection in 50% of initial operations. The recurrence rate was 25% in our gross total resection group and 50% where initial resection was subtotal. Of patients, 75% had no evidence of recurrence at most recent follow-up.

CONCLUSIONS

Albeit difficult at times because of the proximity to neurovascular tissue, achieving a wide resection followed by adjuvant therapy for spinal chordomas is of great importance. Multidisciplinary discussion is valuable to ensure the best outcome for the patient.

Asymmetrically Segregated Mitochondria Provide Cellular Memory of Hematopoietic Stem Cell Replicative History and Drive HSC Attrition

The metabolic requirements of hematopoietic stem cells (HSCs) change with their cell cycle activity. However, the underlying role of mitochondria remains ill-defined. Here we found that, after mitochondrial activation with replication, HSCs irreversibly remodel the mitochondrial network and that this network is not repaired after HSC re-entry into quiescence, contrary to hematopoietic progenitors. HSCs keep and accumulate dysfunctional mitochondria through asymmetric segregation during active division. Mechanistically, mitochondria aggregate and depolarize after stress because of loss of activity of the mitochondrial fission regulator Drp1 onto mitochondria. Genetic and pharmacological studies indicate that inactivation of Drp1 causes loss of HSC regenerative potential while maintaining HSC quiescence. Molecularly, HSCs carrying dysfunctional mitochondria can re-enter quiescence but fail to synchronize the transcriptional control of core cell cycle and metabolic components in subsequent division. Thus, loss of fidelity of mitochondrial morphology and segregation is one type of HSC divisional memory and drives HSC attrition.

Water safety plans for water supply utilities in China, Cuba, France, Morocco and Spain: costs, benefits, and enabling environment elements

Water Safety Plans (WSPs) are a management tool to identify and prioritize risks and implement appropriate control measures throughout the water supply chain, from catchment to consumer. WSPs have been implemented in over 90 countries; yet, costs, benefits and the enabling environment elements necessary for WSP implementation are under-studied. To better understand these factors, we conducted interviews with WSP implementation management teams from 20 private urban water utilities in China, Cuba, France, Morocco and Spain in 2014. Collectively, these utilities serve 10.6 million consumers and supply over 2.2 million m3/day of water to consumers. Time for WSP implementation to achieve certification averaged 13 months. The main startup cost was staff time, averaging 16.2 full-time equivalent person-months. Additional costs, averaging €16,777, were for training staff, hiring consultants, purchasing equipment, and certifying WSPs. Benefits commonly reported included improved hazard control, treatment practices, record keeping, and client and health agency confidence.

The implementation of environmental health policies in health care facilities: The case of Malawi

Establishing and maintaining safe and sufficient environmental health (EH) conditions in health care facilities (HCFs) is important to prevent and control infections. In 2018, the Government of Malawi finalized an environmental health policy that defines specific targets and programs for EH in healthcare settings. This and other related policies have been used since 2010 as a guide for EH practice in HCFs, but the implementation of these policies has been incomplete to-date. This study qualitatively examines the successes and shortcomings of implementing these policies in Malawi's public HCFs. Thematic analysis of interviews with 53 respondents from all levels of government was used to identify the successes of the policies and the barriers to effective implementation using Contextual Interaction Theory. The greatest identified strength lies in the design of the EH department and its ability to connect individual HCFs and EH actors directly to the policy-making level of government. Identified barriers to implementation include: insufficient financial support; lack of human resources; incomplete reporting; poor stakeholder coordination; and insufficient training of EH actors. We recommend refresher trainings for all EH actors, the establishment of a directorate level EH position, and strengthened coordination to improve the collection, analysis, and reporting of monitoring data to enable EH actors to advocate for the additional funding needed to develop programs for EH personnel and to apply effective EH interventions.

Assessing operational performance benefits of a Water Safety Plan implemented in Southwestern France

AIMS

The World Health Organization (WHO) has recommended Water Safety Plans (WSPs) since 2004 as a means to reduce drinking water contamination and risks to human health. These risk management programs have shown promise across several potential areas of evaluation, such as economic benefits and regulatory compliance. Since WSPs are largely carried out by people who interact with water treatment equipment and processes, operational performance indicators may be key to understanding the mechanisms behind desirable WSP impacts such as water quality and public health improvement.

METHOD

This study reports performance measures collected at a WSP implementation location in southwestern France over several years.

RESULTS

Quantitative assessment of performance measures supported qualitative reports from utility managers. Results indicate significantly reduced duration of low-chlorine events at one production facility and a significant decrease in customer complaints related to water quality, manifesting reported improvements in operational performance and the customer service culture.

CONCLUSION

The findings demonstrate some success stories and potential areas of future performance tracking. Cyclical iteration of the WSP can help to achieve continuous quality improvement. Successfully applied evaluation criteria such as the number of water quality complaints or alarm resolution time might be useful across other locations.

Pro-poor governance in water and sanitation service delivery: evidence from Global Analysis and Assessment of Sanitation and Drinking Water surveys

Aims:

The Sustainable Development Goal (SDG) for water and sanitation seeks to achieve universal and equitable access to safe and affordable drinking water and access to adequate and equitable sanitation and hygiene. This article examines what governments are doing to achieve this, paying particular attention to actions that governments report taking to better serve the poor and other vulnerable populations (i.e. pro-poor governance). This article also assesses the extent to which, and how, UN-Water’s Global Analysis and Assessment of Sanitation and Drinking Water (GLAAS) has tracked governments’ efforts to reach the poor since the inception of this global monitoring effort.

Method:

This article employs qualitative document analysis and iterative coding to identify pro-poor governance themes examined in GLAAS reports from 2008 to 2016 and provides a quantitative summary of findings related to pro-poor governance from the most recent GLAAS surveys.

Results:

The dimensions of pro-poor governance and number of questions related to pro-poor governance in GLAAS surveys have increased from 2008 to 2016. While the majority of countries report taking actions to promote equity, many countries did not provide information about specific actions they were taking to provide better services to the poor. Moreover, several actions countries reported taking (e.g. implementing an increasing block tariff) are likely to be ineffective.

Conclusion:

The findings of this study raise concerns about the extent to which governments are taking – or are positioned to take – effective action to meet the SDG aspiration of safe and affordable water and sanitation services for all. Without information on what countries are doing to promote equity, policy makers and researchers are unable to discern which policies are effective in different contexts.

Sanitation marketing: A systematic review and theoretical critique using the capability approach

Sanitation is a human right that benefits health. As such, technical and behavioural interventions are widely implemented to increase the number of people using sanitation facilities. These include sanitation marketing interventions (SMIs), in which external support agencies (ESAs) use a hybrid of commercial and social marketing tools to increase supply of, and demand for, sanitation products and services. However, there is little critical discourse on SMIs, or independent rigorous analysis on whether they increase or reduce well-being. Most available information is from ESAs about their own SMI implementation. We systematically reviewed the grey and peer-reviewed literature on sanitation marketing, including qualitatively analysing and calculating descriptive statistics for the parameters measured, or intended to be measured, in publications reporting on 33 SMIs. Guided by the capability approach to development we identified that publications for most SMIs (n = 31, 94%) reported on commodities, whilst fewer reported on parameters related to impacts on well-being (i.e., functionings, n = 22, 67%, and capabilities, n = 20, 61%). When evaluating future SMIs, it may be useful to develop a list of contextualised well-being indicators for the particular SMI's location, taking into account local cultural norms, with this list ideally co-produced with local stakeholders. We identified two common practices in SMIs that can reduce well-being and widen well-being inequalities; namely, the promotion of conspicuous consumption and assaults on dignity, and we discuss the mechanisms by which such impacts occur. We recommend that ESAs understand sanitation marketing's potential to reduce well-being and design SMIs to minimize such detrimental impacts. Throughout the implementation phase ESAs should continuously monitor for well-being impacts and adapt practices to optimise well-being outcomes for all involved.

Eye on the B-ALL: B-cell receptor repertoires reveal persistence of numerous B-lymphoblastic leukemia subclones from diagnosis to relapse

The strongest predictor of relapse in B-cell acute lymphoblastic leukemia (B-ALL) is the level of persistence of tumor cells after initial therapy. The high mutation rate of the B-cell receptor (BCR) locus allows high-resolution tracking of the architecture, evolution and clonal dynamics of B-ALL. Using longitudinal BCR repertoire sequencing, we find that the BCR undergoes an unexpectedly high level of clonal diversification in B-ALL cells through both somatic hypermutation and secondary rearrangements, which can be used for tracking the subclonal composition of the disease and detect minimal residual disease with unprecedented sensitivity. We go on to investigate clonal dynamics of B-ALL using BCR phylogenetic analyses of paired diagnosis-relapse samples and find that large numbers of small leukemic subclones present at diagnosis re-emerge at relapse alongside a dominant clone. Our findings suggest that in all informative relapsed patients, the survival of large numbers of clonogenic cells beyond initial chemotherapy is a surrogate for inherent partial chemoresistance or inadequate therapy, providing an increased opportunity for subsequent emergence of fully resistant clones. These results frame early cytoreduction as an important determinant of long-term outcome.

Icelandic experience with water safety plans

The aim of this study was to investigate accumulated experience with water safety plans in one of the first countries to adopt systematic preventive management for drinking-water safety. Water utilities in Iceland have had a legal obligation since 1995 to implement a systematic preventive approach to secure safety of drinking water and protect public health. The water utilities responded by implementing either an adapted HACCP (Hazard Analysis Critical Control Points) model for larger water utilities or a simpler five step model for smaller water utilities. The research was carried out at 16 water utilities that serve about two-thirds of the population of Iceland. Both qualitative and quantitative methods were used with the aim of analysing if and what benefits water safety plans bring for water utilities and what is needed for successful implementation and operation of such systems. The results of the study show that numerous benefits and even the process of going through the implementing process were considered to be of advantage and change the attitude of the staff and the utility culture. Some obstacles and shortcomings came to light, such as lack of documentation and lack of regular internal and external audit. There was little communication with the public, although some mentioned that good public relations are important to succeed with water safety plans. Many important elements of success were revealed of which intensive training of staff and participation of staff in the whole process are deemed the most important. It is also important to have simple and well-structured guidelines, and good cooperation with the health authorities.

Diagnostic difficulties in the management of H-type tracheoesophageal fistula

PURPOSE

To evaluate the diagnostic difficulties and pitfalls in establishing the diagnosis of congenital H-type tracheoesophageal fistula.

MATERIAL AND METHODS

A retrospective review of all cases of H-type tracheoesophageal fistula that were diagnosed in a single unit over a 6-year period. The variables assessed were age at presentation, presenting symptoms, time to diagnosis, investigations, and time to surgical repair of H-type fistula. The investigations leading to a definitive diagnosis are assessed and discussed.

RESULTS

Between 1998 and 2004, five cases of H-type tracheoesophageal fistula presented to our unit. All cases had an upper gastrointestinal contrast study/tube esophagogram. In addition, four cases had a chest radiograph, three cases had a bronchoscopy, and one case an esophagoscopy. The median delay from the time of first presentation to diagnosis of H-type tracheoesophageal fistula was 14 days (7-58 days). Median age at surgery was 15 days (8-60 days).

CONCLUSION

Although symptoms are usually present from birth, the diagnosis of H-type fistula is difficult and often delayed. The various diagnostic techniques are not entirely reliable and fistula identification can be elusive. The authors present recommendations for the diagnostic work-up, which may increase the diagnostic potential and avoid unnecessary delays in the diagnosis and management of H fistula.

Heterotrophic plate count measurement in drinking water safety management

A group of microbiology and public health experts including regulatory and medical expertise was convened in Geneva, Switzerland, 25-26 April 2002 to consider the utility of heterotrophic plate count (HPC) measurements in addressing drinking water quality and safety. The group was convened following the NSF International/World Health Organization Symposium on HPC Bacteria in Drinking Water--Public Health Implications? The Expert Meeting was attended by 31 participants from Australia, Canada, France, Germany, Italy, Japan, the Netherlands, South Africa, Switzerland, UK and USA.

Providing clean water, keeping water clean: an integrated approach

Millions of people, most of whom are children in developing countries, die of basic hygiene-related diseases every year. Interventions in hygiene, sanitation and water supply have been shown to control disease burden. Universal access to improved water sources and basic sanitation remains elusive but is an important long-term goal. Studies have shown that improving the microbiological quality of household water by on-site or point-of-use treatment and safe storage in improved vessels reduces diarrhoeal and other waterborne diseases in communities and households of developing and developed countries. The extent to which improving drinking water quality at the household level reduces diarrhoeal disease probably depends on a variety of technology-related and site-specific environmental and demographic factors that require further investigation, characterisation and analyses.

Waterborne health risks and the WHO perspective

The benefits of improved water and sanitation include both health and non-health effects. The direct health benefits are related to two contrasting roles of water: that of disease vector when it carries pathogens; and that of health mediator through its use in personal and domestic hygiene. Indirect effects related to health include for example improved quality of life and decreased expenditure on medical expenses. Non-health effects include time savings for productive activity or education. The fact that the health impact of inadequate water supply services, especially in the developing world, has never been established is recognised (Troare, 1992) and recent work highlights unrecognised health burdens elsewhere--both from apparently good quality supplies (Payment et al., 1991; Payment et al., 1997); and from outbreaks of disease (Ford and Colwell, 1996). This paper looks at the WHO perspective on waterborne health risks and is divided into three main sections: our knowledge of the existing situation; recognised and emerging priorities arising from the changing context; and the availability of approaches and tools to meet the recognised and emerging priorities.

Not just a drop in the bucket: expanding access to point-of-use water treatment systems

Since 1990, the number of people without access to safe water sources has remained constant at approximately 1.1 billion, of whom approximately 2.2 million die of waterborne disease each year. In developing countries, population growth and migrations strain existing water and sanitary infrastructure and complicate planning and construction of new infrastructure. Providing safe water for all is a long-term goal; however, relying only on time- and resource-intensive centralized solutions such as piped, treated water will leave hundreds of millions of people without safe water far into the future. Self-sustaining, decentralized approaches to making drinking water safe, including point-of-use chemical and solar disinfection, safe water storage, and behavioral change, have been widely field-tested. These options target the most affected, enhance health, contribute to development and productivity, and merit far greater priority for rapid implementation.

Health risks caused by freshwater cyanobacteria in recreational waters

Toxic cyanobacteria are increasingly being perceived as a potential health hazard, particularly in waters used for recreation. A few countries are developing regulations to protect human health from these toxins, and the World Health Organization (WHO) has published both a guideline value for one cyanotoxin in drinking water and a procedural guideline for recreational waters. This article presents an overview of the currently known cyanotoxins and of documented cases of human illnesses attributed to them. It further discusses exposure pathways and approaches to risk management. In this context, the WHO guideline for recreational waters is presented, and monitoring approaches are outlined.

Evaluation of cold-recombinant influenza A/Korea (CR-59) virus vaccine in infants

Twenty-four infants 5 to 13 months of age were intranasally vaccinated with a live cold-recombinant influenza A/Korea (CR-59, H3N2) virus vaccine. Nineteen infants served as controls. The inocula ranged from 10(3.2) to 10(6.2) 50% tissue culture infective doses (TCID50) per infant. Zero of six, one of four, seven of ten, and four of four infants receiving 10(3.2), 10(4.2), 10(5.2), and 10(6.2) TCID50, respectively, were infected by the intranasal vaccine. The amount of virus required to infect 50% of infants was calculated to be 10(4.6) TCID50. The occurrence of fever, respiratory illness, and otitis media was common among both controls and vaccinees in the postinoculation period. Maternal antibody was present in low titers in some infants and did not inhibit replication of the vaccine virus.

Differences in reactogenicity and antigenicity of acellular and standard pertussis vaccines combined with diphtheria and tetanus in infants

Clinical and serological responses of infants to primary immunization with diphtheria-tetanus-pertussis (DTP) vaccine containing components of acellular pertussis vaccine (DTP-AC) were compared in a double-blind study with responses of infants receiving whole-cell DTP vaccine (DTP-WC). Three doses of either DTP-AC containing lymphocytosis-promoting factor (LPF) and filamentous hemagglutinin (FHA) or DTP-WC vaccine were given to infants at two, four, and six months of age. Nineteen infants received DTP-AC vaccine, and 20 infants received DTP-WC vaccine. Significantly more infants who received DTP-WC vaccine manifested fever, swelling, and/or total reactions than did infants who received DTP-AC vaccine. Infants who received DTP-AC vaccine had comparable antibody titers to LPF and significantly higher titers to FHA after three immunizations, as compared with the infants who received DTP-WC vaccine (P less than or equal to .001). The DTP-WC vaccine stimulated higher pertussis agglutination titers (P = .04) than did DTP-AC. The DTP-AC vaccine was immunogenic and significantly less reactogenic in infants than was the currently used DTP-WC vaccine.

Clinical and serologic responses to acellular pertussis vaccine in infants and young children

We administered diphtheria, tetanus, and pertussis (DTP) vaccine containing acellular (lymphocytosis promoting factor and filamentous hemagglutinin) pertussis vaccine to three groups of 20 children each (4 to 6 years, 17 to 21 months, and 5 to 9 months of age). All the children tolerated the vaccine well; no reactions occurred that contraindicated further immunization. Older children had significantly more local (redness or swelling) and systemic (fever or fretfulness) reactions than younger children. Eighty percent to 90% of the children in the two older age groups had fourfold or greater increases in antibody titers to DTP antigens one month after vaccination. The postvaccine concentrations of antibody to tetanus and diphtheria were greater than 0.01 IU/mL in all children. Serologic responses to lymphocytosis promoting factor and filamentous hemagglutinin varied with age; significantly more older children than younger children had four-fold or greater increases. Acellular pertussis DTP vaccine was antigenic in young children and was less reactogenic than standard whole cell DTP vaccine according to rates reported in previous studies.

Pharmacokinetics of a single dose of rimantadine in young adults and children

Single doses of rimantadine were given to children and young adults to evaluate the safety and pharmacokinetics of this antiviral compound. The half-life of rimantadine in young adults was 27.7 +/- 4.9 h for tablets and 27.8 +/- 8.0 h for syrup preparations. A total of 10 children, 5 to 8 years old, received a syrup preparation of rimantadine. The half-life of rimantadine in children was 24.8 +/- 9.4 h. A single dose of rimantadine was well tolerated in young adults and children.

Evaluation of rhesus rotavirus vaccine (MMU 18006) in infants and young children

Orally administered rhesus rotavirus vaccine was evaluated in a placebo-controlled study in young children and infants (ages, eight months to 61 months). Thirteen children received the rotavirus vaccine, and ten children served as the control group. The vaccine was well tolerated. There were no significant differences between the vaccine recipients and the control group in the number of child-days with temperatures greater than or equal to 37.8 C, vomiting, diarrhea, or cough. There were significantly more child-days of rhinorrhea among the vaccine recipients than there were among the control group. The vaccine recipients under two years of age passed a larger number of stools than did the children in the control group, and vaccine recipients had significantly more semiformed and unformed stools than did the children receiving the placebo. All twelve of the children tested were positive for viral shedding. Peak viral shedding occurred on days three and five postvaccination. On day eight, over one-half of the children from whom a stool specimen was obtained were still shedding rotavirus. Children less than two years old shed more rotavirus in their stool than did children more than two years old. All 13 vaccine recipients had a fourfold or greater rise in titer of antibody as measured by plaque reduction, tube neutralization, complement fixation, and/or immune adherence hemagglutination.

Live attenuated influenza A virus vaccines in children: results of a field trial

One hundred three young children were inoculated intranasally with either influenza A/California/10/78 cold-recombinant vaccine (10(6.7) 50% tissue culture infective doses [TCID50] per child), CR-37 (H1N1), or influenza A/Washington/897/80 cold-recombinant vaccine (10(6.5) TCID50 per child), CR-48 (H3N2). The vaccine was well tolerated. Of the 51 children vaccinated with CR-37 (H1N1), 45 were initially seronegative for this virus; 33 of the 45 became infected with the vaccine virus, as indicated by a fourfold rise in antibody titer or by shedding of vaccine virus. Of the 52 children vaccinated with CR-48 (H3N2), six were initially seronegative and all were infected; 46 were initially seropositive and 25 of these children developed fourfold rises in antibody titer. An outbreak of influenza A (H3N2 type predominated) occurred in Huntington one to three months after the children were vaccinated. Significantly fewer febrile illnesses occurred in the CR-48 (H3N2) vaccine group than among the CR-37 (H1N1) vaccine group. Hemagglutination inhibition antibody (titer, greater than or equal to 1:32) to H3N2 was significantly associated with protection from illness and infection with influenza A/H3N2.