Four buildings and a flush: Lessons from degraded water quality and recommendations on building water management

A reduction in building occupancy can lead to stagnant water in plumbing, and the potential consequences for water quality have gained increasing attention. To investigate this, a study was conducted during the COVID-19 pandemic, focusing on water quality in four institutional buildings. Two of these buildings were old (>58 years) and large (>19,000 m2), while the other two were new (>13 years) and small (<11,000 m2). The study revealed significant decreases in water usage in the small buildings, whereas usage remained unchanged in the large buildings. Initial analysis found that residual chlorine was rarely detectable in cold/drinking water samples. Furthermore, the pH, dissolved oxygen, total organic carbon, and total cell count levels in the first draw of cold water samples were similar across all buildings. However, the ranges of heavy metal concentrations in large buildings were greater than observed in small buildings. Copper (Cu), lead (Pb), and manganese (Mn) sporadically exceeded drinking water limits at cold water fixtures, with maximum concentrations of 2.7 mg Cu L-1, 45.4 μg Pb L-1, 1.9 mg Mn L-1. Flushing the plumbing for 5 min resulted in detectable residual at fixtures in three buildings, but even after 125 min of flushing in largest and oldest building, no residual chlorine was detected at the fixture closest to the building's point of entry. During the pandemic, the building owner conducted fixture flushing, where one to a few fixtures were operated per visit in buildings with hundreds of fixtures and multiple floors. However, further research is needed to understand the fundamental processes that control faucet water quality from the service line to the faucet. In the absence of this knowledge, building owners should create and use as-built drawings to develop flushing plans and conduct periodic water testing.

Effects of the low-speed continuous infusion catheter technique on double-lumen central venous catheters: A randomized controlled trial

BACKGROUND

Central venous catheters are widely used in clinical practice, and the incidence of central venous catheter occlusion is between 25 % and 38 %. The turbulence caused by the pulsatile flushing technique is harmful to the vascular endothelium and may lead to phlebitis. The low-speed continuous infusion catheter technique is a new type of continuous infusion that ensures that the catheter is always in a keep-vein-open state by continuous low-speed flushing; hence, avoiding the problem of catheter occlusion.

OBJECTIVE

To investigate the effectiveness of the low-speed continuous infusion catheter technique and the routine care of double-lumen central venous catheters.

DESIGN

This was a prospective, randomized, controlled, open-label trial.

SETTING

Patients were recruited from 14 medical institutions in China between February and June 2023.

PARTICIPANTS

In total, 251 patients were recruited, with 125 in the intervention group and 126 in the control group.

METHODS

Patients who used double-lumen central venous catheters for infusion treatment were selected, and those who met the sampling criteria were randomly divided into intervention and control groups using the random envelope method. The intervention group used the low-speed continuous infusion catheter technique to maintain catheter patency, whereas the control group used routine care with a trial period of 7 days. The primary outcome was the occlusion rate. The secondary outcomes included nursing satisfaction and complication rates of the two groups.

RESULTS

After 7 days, the rate of catheter occlusion was 28.0 % (35/125, 95 % confidence interval (CI):0.203, 0.367) in the intervention group and 53.97 % (68/126, 95 % CI: 0.449-0.629) in the control group, with a statistically significant difference (χ2 = 17.488, p < 0.001); at 3 days of intervention, the rate of catheter blockage was 8.0 % (10/125, 95 % CI: 0.039-0.142) in the intervention group and 23.8 % (30/126, 0.167-0.322) in the control group, with a statistically significant difference (χ2 = 11.707, p < 0.001). Nurse satisfaction was significantly higher in the intervention group (115/125, 92.0 %, 95 % CI: 0.858-0.961) than in the control group (104/126, 82.54 %, 95 % CI: 0.748-0.887) (χ2 = 5.049, p = 0.025). There were no statistically significant complication rates in either group (p = 0.622).

CONCLUSION

The low-speed continuous infusion catheter technique helps maintain catheter patency, improves nurse satisfaction, and provides a high level of safety.

REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2200064007, www.chictr.org.cn). The first recruitment was conducted in February. https://www.chictr.org.cn/showproj.html?proj=177311.

The potential to manage releases of Bacillus anthracis using bioretention and a high flow media filter: Results of simulated runoff testing with tracer spores Bacillus globigii

The threat of bioterrorism has spurred research on the decontamination and containment of different agents. Anthrax [causative agent Bacillus anthracis (Ba)] is a disease that can lead to severe infections within human and animals, particularly when inhaled. This research investigated the use of spore-contaminated simulated runoff events into stormwater control measures (SCMs), which are designed to retain and improve the quality of runoff and may have the potential to filter and contain the spores. In this study, the effectiveness of a bioretention cell (BRC) and high flow media filter (HFMF) in Huron, Ohio, were evaluated for removal of Bacillus globigii (Bg) spores (a harmless cognate of Ba). Three 4-8 mm simulated runoff events were created for each SCM using a fire hydrant and Bg spores were injected into the runoff upstream of the SCM inlets. The BRC significantly (p < 0.001) outperformed the HFMF in reducing Bg concentrations and loads, with an average load reduction of 1.9 log (∼99% reduction) compared to 0.4 (∼60% reduction), respectively. A probable critical design factor leading to these differences was the infiltration rate of the media and subsequent retention time within the filters, which was supported by similar disparities in suspended solids reductions. Differences in spore removal may also have been due to particle size distribution of the HFMF, which was more gravelly than the bioretention cell. At 3 and 6 months after the-simulated runoff tests, soil samples taken from both SCMs, yielding detectable Bg spores within the top 15 cm of media, with increased spore concentrations where ponding occurred for longer durations during the tests. This suggests that forebays and areas near inlets may be hotspots for spore cleanup in a real-world bioterrorism incident.

Field demonstration of in-situ microemulsion flushing for enhanced remediation of multiple chlorinated solvents contaminated aquifer

The remediation of in-situ microemulsion flushing for multiple chlorinated solvents contaminated groundwater is challenging, because different chlorinated solvent has major influence on microemulsion formation and solubilization behaviors. This work was conducted to evaluate the remediation effectiveness for various chlorinated solvents contaminated site and monitor the disturbance of groundwater during in-situ microemulsion flushing process. Groundwater at this site was contaminated with chlorobenzene (MCB), chloroaniline and nitrochlorobenzene. The medium layer was mainly composed of fine and silty sand, with average hydraulic conductivity of 4.97 m/d. Results of this field-scale test indicated in-situ microemulsion flushing successfully enhanced the apparent solubility of various chlorinated solvents. Post-flushing concentration of various chlorinated solvents were 1.33-71.6-fold the concentration of pre-flushing values at 10 sampling locations within the test zone. This field was flushed with 16.8 m3 microemulsion, removing approximately 18.49 kg chlorinated solvents. Besides, a trend in the desorption order of various chlorinated solvents was observed. The least hydrophobic pollutant was flushed first, followed by contaminants of increasing hydrophobicity. In addition, during remediation process, the indexes of groundwater fluctuated insignificantly, indicating the reagent had little disturbance to aquifer. This field work demonstrated the feasibility of in-situ microemulsion enhanced remediation via increasing apparent solubility of multiple chlorinated solvents.

Collection of epididymal semen in the tomcat (Felix catus) by stereomicroscope-aided retrograde flushing (SARF) improves sample quality

In small and laboratory animals epididymal spermatozoa can be collected only by the mincing technique however, blood and cell debris contamination may adversely affect the quality of the samples. This study aimed at performing the retrograde flushing technique, for the first time, in the tomcat. In the first experiment attempts to insert a blunted needle into tomcats' ductus deferentes were made and the cannulation time and the success rate were recorded. In the second experiment, insertion of the needle into the ductus was carried out under a stereomicroscope for one testis, while the other was submitted to mincing for sperm recovery and the samples obtained from paired testes were compared. In the first study, only twenty-eight percent of the cannulation attempts were successful whereas in the second experiment, 91% of the deferentes were successfully cannulated: 80% of the ducts were cannulated in less than three minutes. The stereomicroscope-aided retrograde flushing samples showed significantly higher sperm viability, motility and velocities, as compared to those resulted from mincing. The domestic cat serves as a model for more than 36 species of wild felids; the developed stereomicroscope-aided retrograde flushing technique has the potential to become the gold standard method for harvesting spermatozoa of endangered species that have a small ductus deferens.

Coupling electrokinetic remediation with flushing using green tea synthesized nano zero-valent iron/nickel to remediate Cr (VI)

This study focuses on a flushing-electrokinetic remediation technology of hexavalent chromium from the chromium slag dump site. A suspension of nanoscale zero-valent iron/nickel fabricated from green tea (GT-nZVI/Ni), was employed as an eluent to degrade Cr (VI) and enhance the remediation effectiveness of a single EK. The removal efficiency of Cr (VI) was compared under different voltages, electrode spacings and pH values of the anolyte. The results demonstrated that the combined flushing and EK achieved a removal rate of Cr (VI) in the soil throughout all the experiments ranging from 83.08 to 96.97% after 120 h. The optimal result was obtained when the voltage was 28 V, the pH value of anolyte was 3 and the electrode spacing was 15 cm. The removal of Cr (VI) reached 91.49% and the energy consumption was 0.32606 kW·h·g-1. The underlying mechanisms responsible for the removal of Cr (VI) by GT-nZVI/Ni flushing-EK primarily involved electromigration, reduction and adsorption co-precipitation processes. The fractionation analysis of Cr (VI) concentration in the soil after remediation showed that the presence of GT-nZVI/Ni facilitated the conversion of Cr (VI) into oxidizable and residual states with low mobility and toxicity. The results of toxicity characteristic leaching procedure (TCLP) indicated that the leaching concentration of Cr (VI) was below 1 mg·L-1, complying with the standards set by the Environmental Protection Agency. Additionally, the phytotoxicity testing revealed that the germination index (GI) of the remediated soil reached 54.75%, indicating no potential harm to plants.

Impact of fixture purging on water age and excess water usage, considering stochastic water demands

Higher water ages are linked with water quality decline as chlorine dissipates, temperatures become more favorable for microbial growth, and metals and organic matter leach from the pipes. Water fixtures with automated purging devices can limit water age in premise plumbing systems, but also increase water use. To develop purging strategies that lower age while also minimizing water use, the stochastic nature of water demands must be considered. In this research, a hydraulic plumbing network model, with stochastic demands at fixtures, was used to compare water age and water use for five purging conditions: purging at regular intervals, "smart" purging (considering the time of last use), purging with different volumes of water, purging at different fixtures, and the purging with different levels of home occupancy. Higher purging frequency and volume resulted in lower water ages, but higher water use. Purging greatly reduced the variability in water ages, avoiding extreme ages entirely. Water age was minimized by scheduling the purging around occupancy behavior, such as before the occupants wake up or return from work. Scheduled purging used more water than smart purging. Purging after 12 h of nonuse used only 55% of the additional water required for purging every 12 h. Purging after 24 h of nonuse at the kitchen tap and shower used only 38% of the additional water required for purging every 24 h, while maintaining lower water ages and removing the variability in water ages. While larger purging volumes had a greater impact on water age, there were diminishing returns. Purging has a larger impact on low-occupancy homes because fixtures have less frequent use. Overall, this research provides a methodology to compare purging strategies that minimize both water age and water use. While the numerical results presented here are only valid for the specific layout and usage habits, they provide insights and trends applicable to other cases.

A Monocentric Randomized Controlled Clinical Trial to Compare Single- and Double-Lumen Needles in Oocyte Retrieval Procedure in Assisted Reproductive Technologies

The purpose was to determine any difference in outcomes, primarily in terms of number of retrieved oocytes per procedure, between two different needles used for oocytes retrieval procedure in Assisted Reproductive Technologies: the single-lumen needle (SLN) versus the double-lumen needle (DLN) with follicle flushing after aspiration. This randomized controlled trial included oocyte retrieval (OR) cycles for IVF and ICSI performed in 18 to 42-year-old women between March 2019 and January 2021 at a tertiary-care Fertility Center. A total of 200 ORs were randomized, 100 in each group. The mean number of retrieved oocytes was not different between groups (10.2 ± 6.5 for DLNs vs. 10.7 ± 7.0 for SLNs, p = 0.810). No significant differences were observed also in terms of number of retrieved oocytes/punctured follicles (83.0% ± 27.0% vs. 81.0% ± 22.0%, p = 0.916), number of retrieved oocytes/follicles at trigger (78.0% ± 29.0% vs. 78.0% ± 27.0%, p = 0.881), number of mature oocytes (7.6 ± 5.3 vs. 8.0 ± 5.1, p = 0.519), and pregnancy rate (27% vs. 23%, p = 0.514). However, the time required to retrieve each oocyte was longer using the DLN (1.5 ± 1.3 vs. 1.1 ± 0.9 minutes, p = 0.002). The present study confirmed the new perspectives on the sole use of SLNs in terms of saving time, without affecting the number of retrieved oocytes. Trial registration number and date of registration NCT03611907; July 26, 2018.

Comparison of Heparin and Saline for Prevention of Central Venous Catheter Occlusion in Pediatric Oncology: A Systematic Review and Meta-Analysis

OBJECTIVE

The management of central venous catheter (CVC) occlusion remains an area without clear evidence-based guidelines. Studies have been conducted that compare the use of heparin and normal saline for reducing thrombosis, but the evidence is not strong enough to suggest a significant advantage of one over the other. Therefore, the study aimed to assess the effectiveness of heparin and normal saline flushing in preventing CVC occlusion in pediatric patients with cancer.

DATA SOURCES

A comprehensive search was conducted in PubMed, Web of Science, Cochrane, MEDLINE, CINAHL, Embase, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov platform using specific keywords. The search was conducted until March 2022. Five randomized controlled trials are included in this study.

CONCLUSION

Five studies with a total of 316 pediatric cancer patients met the inclusion criteria. The studies were found to be heterogeneous due to variations in the types of cancer, heparin concentration, flushing frequency of CVCs, and methods used to measure occlusion. Despite these differences, there was no significant difference in the effect of flushing with heparin and normal saline in preventing CVC occlusion. The analysis revealed that normal saline is as effective as heparin in preventing CVC occlusion among pediatric cancer patients.

IMPLICATIONS FOR NURSING PRACTICE

This systematic review and meta-analysis demonstrated that there is no significant difference between the use of heparin and normal saline flushing in preventing CVC occlusion among pediatric cancer patients. Considering the potential risks of heparin, the use of normal saline flushing may be recommended to prevent CVC obstruction.

Current Status of Korean Alcohol Drinking in Accordance with the Korean Alcohol Guidelines for Moderate Drinking Based on Facial Flushing

Since each person has a different ability to break down alcohol, it is inappropriate to apply a uniform standard to everyone when evaluating drinking status. In Korea, there has been a guideline for moderate drinking based not only on sex and age but Koreans' alcohol metabolism capabilities that can be predicted by presence of facial flushing response. So far, there have been no studies that have investigated drinking habits of Koreans in accordance with the guideline. This study tried to identify the current drinking status of Koreans according to the guideline. As a result, it was confirmed that about 1/3 of the total population was accompanied by facial flushing when drinking alcohol, and it was found that different drinking habits were shown even in the same age and gender groups according to the presence of facial flushing. It is difficult to accurately evaluate drinking habits because facial flushing has not yet been investigated in some large data or various medical examinations. In the future, it is necessary to ensure that the presence of facial flushing can be confirmed at the medical treatment or examination site so that accurate drinking habit evaluation and prevention and resolution of drinking problems can be achieved.

Flushing After Lumbar Epidural Steroid Injection with Dexamethasone

PURPOSE OF REVIEW

Epidural steroid injections are an accepted treatment for low back pain and radicular symptoms. While epidural steroid injections are routinely performed without complications, side effects can be seen, including flushing. Flushing has been studied using various steroid preparations, including dexamethasone, but at significantly higher doses. This was a prospective cohort study that examines the rate of flushing in ESIs with a lower dose (4 mg) of dexamethasone. Subjects undergoing lumbar epidural steroid injection were asked about the presence of flushing following the procedure prior to discharge and again at 48 h after. A total of 80 participants received fluoroscopically guided interlaminar and transforaminal epidural injections. All participants received 4 mg of dexamethasone. Of the 80 subjects, 52 were female, and 28 were male. Seventy-one underwent a transforaminal epidural injection and 9 underwent an interlaminar epidural injection. Four (5%) subjects experienced flushing-1 subject experienced immediate post-procedural flushing and 3 experienced flushing within 48 h. All 4 subjects (100%) were female. All 4 subjects received transforaminal injections (100%).

RECENT FINDINGS

There is a gap of knowledge about the flushing after lumbar epidural steroid injection with dexamethasone. Flushing is a known and common side effect of epidural steroid injections, varying in frequency based on type of steroid as well as dose. We found 5% incidence in flushing reaction with 4 mg of dexamethasone.

Extreme eutrophication and salinisation in the Coorong estuarine-lagoon ecosystem of Australia's largest river basin (Murray-Darling)

Estuaries in rainfall poor regions are highly susceptible to climatic and hydrological changes. The Coorong, a Ramsar-listed estuarine-coastal lagoon at the end of the Murray-Darling Basin (Australia), has experienced declining ecological health over recent decades. Twenty years of environmental data were analysed to assess patterns and drivers of water quality changes. Large areas of the Coorong are now persistently hyper-saline (salinity >80 psu) and hypereutrophic (total nitrogen, TN > 4 mg L^-1, total phosphorus, TP > 0.2 mg L^-1, chlorophyll a > 50 μg L^-1) which coincided with reduced flushing due to diminished freshwater inflows and increasing evapo-concentration. Sediment quality also was related to flushing, with higher concentrations of organic carbon, TN, TP and sulfides as salinity increased. While total nutrient levels are very high, dissolved inorganic nutrients are generally low. Increased lagoonal flushing would be beneficial to reduce the hypersalinisation and hypereutrophication and improve ecosystem health.

Relationship between Alcohol Consumption and Testosterone Deficiency according to Facial Flushes among Middle-Aged and Older Korean Men

BACKGROUND

This study examined the relationship between alcohol consumption and total testosterone deficiency based on facial flushing among Korean men.

METHODS

A total of 314 men were included in this study and divided into non-drinkers (n=78) and drinkers (n=236). Drinkers were also divided into flushers (n=96) and non-flushers (n=140). Flushers and non-flushers were separated into two groups based on the amount of alcohol consumed: moderate drinkers (≤8 standard drinks per week) and heavy drinkers (>8 standard drinks per week). Total testosterone <3.5 ng/mL was defined as testosterone deficiency.

RESULTS

The risk of testosterone deficiency was significantly higher in heavy drinkers who flushed than in nondrinkers (odds ratio, 4.37; 95% confidence interval, 1.20-15.88; P=0.025). However, no significant difference was observed in the risk of testosterone deficiency in non-flushers, regardless of the amount of alcohol consumed.

CONCLUSION

This study suggests that the risk of testosterone deficiency increases in heavy drinkers (>8 drinks per week) who flush compared to that in non-drinkers.

Botulinum Toxin A Alleviates Persistent Erythema and Flushing in Patients with Erythema Telangiectasia Rosacea

Introduction

The persistent erythema and flushing seen in some cases of rosacea do not respond effectively to, or may easily relapse after, oral medication or light-based therapies (laser or intense pulsed light). Intradermal botulinum toxin A (BTX-A) injection can be used to treat intractable erythema and flushing, but studies with large samples and long-term observation have not been conducted to determine its effectiveness and safety. The aim of this study is thus to investigate the effective duration and safety of intradermal BTX-A injection for intractable erythema and flushing.

Methods

Sixteen patients with rosacea with erythema telangiectasia were injected with BTX-A at 1-cm intervals between each point. Clinician Erythema Assessment (CEA) scores were obtained at baseline and 1 month after injection. Flushing assessment and survey using the Dermatological Quality of Life Index (DLQI) questionnaire were conducted at baseline and at 1, 3, and 6 months after injection.

Results

At 1 month after injection, CEA scores revealed significant improvements in erythema and flushing; the results of the questionnaire on flushing and DLQI indicated that the improvement of flushing usually lasted for 3–6 months, but the effect decreased significantly at 6 months, and individual patients needed another treatment.

Conclusions

BTX-A significantly improves the symptoms and quality of life of patients with refractory rosacea with few adverse effects.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00784-0.

Assessment of flow ramping in water bodies impacted by hydropower operation in Norway - Is hydropower with environmental restrictions more sustainable?

Hydropower production is a key electricity generation technology in many parts of the world which can play a significant role in the transition towards a green and clean energy system. Hydropower can mobilize flexible energy on demand (hydropeaking) to balance out intermittent electricity from wind and photovoltaics. Adoption of hydropower as a peaking power source could lead to increased frequency of flow ramping in rivers downstream hydropower tailraces, which is one of the main stressors for riverine biota in alpine rivers. Both planned and accidental shutdowns of hydropower turbines need ecological mitigation. Our survey revealed that >3000 km of rivers downstream ca 800 hydropower plants in Norway may be ecologically impacted by non-natural flow fluctuations, and few have appropriate mitigation thresholds. A considerable eco-friendly peaking service may come from the Norwegian hydropower portfolio of over 19 GW installed capacity, with outlets into fjords, reservoirs or other large water bodies which normally dampen the ecological impacts of flow ramping. Intensive flow ramping occurs with irregular intervals from most types of hydropower. Although the highest frequency of stops were revealed in hydropower turbines not impacting river flow from storage hydropower, a significant number of turbine flow stops lasting over half a day in most types and categories of diversion hydropower. We suggest that further emerging ecosystem-based mitigations need to be adapted in hydropower licenses. This includes operational thresholds for both up and down ramping, constructional measures like by-pass valves, retention basins and increased base-flow or flow cap to ensure sustainability for hydropower operations. Our data reveal some of the most intensive hydropeaking operations from hydropower impacting longer rivers. Hence, our data underpins the potential for restoring downstream modified flow by ecosystem based measures related to both up and down ramping events in many regulated rivers.

Design and operational considerations in response to Legionella occurrence in Las Vegas Valley groundwater

Legionella occurrence monitoring is not required by United States Environmental Protection Agency (USEPA) drinking water regulations, and few occurrence studies exist for Legionella in source water or distribution systems. Legionella occurrence was monitored in Las Vegas Valley (Las Vegas, Nevada, USA) drinking water sources, including non-treated surface water, seasonal groundwater (61 wells, before and after chlorination), finished water (after treatment at water treatment facilities), and chlorinated distribution system water (at 9 reservoirs and 75 sample locations throughout the network). Legionella pneumophila was detected at least once at each of the wells sampled before chlorination, with an overall positivity rate of 38% (343/908). During well start-up (time<2 hours; turbidity>3 NTU), L. pneumophila concentrations averaged 2,792±353 MPN/100 mL, with a median of 105 MPN/100 mL, and range of <1 to 90,490 MPN/100 mL across 61 seasonally operated (typically April-October) groundwater wells. After initial flushing (turbidity<3 NTU), the average concentration decreased by more than two orders of magnitude to 24±3 MPN/100 mL but ranged from <1 to >2,273 MPN/100 mL. This trend indicates that stagnation (up to 391 days) contributed to greater initial concentrations, and flushing alone was incapable of complete L. pneumophila elimination. L. pneumophila concentration was significantly, positively correlated with total aqueous adenosine triphosphate (ATP) (p<0.00001, r=0.41-0.71), turbidity (p<0.00001, r=0.27-0.51), orthophosphate (p=0.35-0.076, r=0.51-0.59), and pump depth (p=0.032, r=0.40). During a full-scale assessment of chlorination (Ct=0.7 to 10.5 mg-min/L; T=26.6-28.1°C), substantial reduction of Legionella spp. (up to 2.5 logs) was observed; although, detectable concentrations were still measured. Extrapolating from a Chick-Watson model (log inactivation=0.28*(Ct); R²=0.87) constructed from the full-scale chlorination results, 3- and 4-log inactivation in Las Vegas Valley groundwater would require 10.8 and 14.3 mg-min/L, respectively; at least 3-log inactivation was required to bring Legionella spp. to below detection at the studied well. Chlorine exposure (Ct=0.1 to 10.9 mg-min/L) at most wells discharging directly to the distribution system was insufficient to fully inactivate Legionella spp. After discussing these findings with the state regulatory agency, direct-to-distribution wells (38 of 61 wells) remained out of operation; the distribution system, wells, and reservoirs were monitored for Legionella and chlorine residual, and additional treatment scenarios were identified for further evaluation. Legionella was either not detected or was well controlled in surface water, finished effluent from the drinking water treatment plant, chlorinated reservoirs, and the chlorinated distribution system. This study emphasizes the importance of utility-driven, non-regulatory research in order to protect public health and also identifies the need for greater occurrence monitoring and guidance for Legionella in groundwater supplies.

Annual water residence time effects on thermal structure: A potential lake restoration measure?

Innovative methods to combat internal loading issues in eutrophic lakes are urgently needed to speed recovery and restore systems within legislative deadlines. In stratifying lakes, internal phosphorus loading is particularly problematic during the summer stratified period when anoxia persists in the hypolimnion, promoting phosphorus release from the sediment. A novel method to inhibit stratification by reducing residence times is proposed as a way of controlling the length of the hypolimnetic anoxic period, thus reducing the loading of nutrients from the sediments into the water column. However, residence time effects on stratification length in natural lakes are not well understood. We used a systematic modelling approach to investigate the viability of changes to annual water residence time in affecting lake stratification and thermal dynamics in Elterwater, a small stratifying eutrophic lake in the northwest of England. We found that reducing annual water residence times shortened and weakened summer stratification. Based on finer-scale dynamics of lake heat fluxes and water column stability we propose seasonal or sub-seasonal management of water residence time is needed for the method to be most effective at reducing stratification as a means of controlling internal nutrient loading.

Larval flushing alters malaria endemicity patterns in regions with similar habitat abundance

A model of Anopheles gambiae populations dynamics coupled with Plasmodium falciparum transmission dynamics is extended to include mechanisms of larval flushing which are known to occur. Flushing dynamics are modeled using a simulation that incorporates seasonal, autocorrelated, and random components based on 30 years of rainfall data for the Kakamega District of the western Kenya highlands. The model demonstrates that flushing phenomena can account for differences between regions with the same annual larval habitat pattern, changing the World Health Organization endemicity classification from either hyperendemic or holoendemic to hypoendemic disease patterns. Mesoendemic patterns of infection occur at the boundary of the holoendemic to hypoendemic transition. For some levels of flushing the entomological inoculation rate drops to an insignificant amount and disease disappears, while the annual indoor resting density remains well above zero. In these scenarios, the disease is hypoendemic, yet the model shows that outbreaks can occur when disease is introduced at particular time points.

Clinical Features and Prognosis of Patients with Carcinoid Syndrome and Carcinoid Heart Disease: A Retrospective Multicentric Study of 276 Patients

INTRODUCTION

Carcinoid syndrome is the most frequent functional syndrome of neuroendocrine neoplasia. It is characterized by flushing, diarrhea, wheezing, hypotension, and exanthema and may cause carcinoid heart disease.

METHODS

We assessed clinical characteristics and prognosis of patients with carcinoid syndrome and carcinoid heart disease in 276 patients from 3 referral centers.

RESULTS

Carcinoid syndrome patients had a mean age of 57 years (range 21-84) and a normal BMI of 24.9 (SD 4.5; range 13.8-39.6). Most primaries were of small bowel or unknown primaries with distant metastasis in 94.6%. Flushing was the most frequent symptom in 74.3% of patients, followed by diarrhea in 68.8%, and wheezing in 40.9%. Pain was described by 45.3%, weakness by 23.5%, and weight loss of >10% in 6 months by 30.1% of patients. Carcinoid heart disease was diagnosed in 37.3% of patients (n = 104) by echocardiography and involved predominantly in the tricuspid valve. Combinations with other valve defects were common. Somatostatin analogs were taken by 80.4% of patients and 17% needed additional loperamide/opium tincture. Surgery and peptide receptor radiotherapy were most frequent treatments. The median survival of patients with carcinoid syndrome after diagnosis was 9 years. Prognosis was significantly impaired by male sex and diagnosis of carcinoid heart disease but surprisingly significantly increased by the presence of symptoms flushing and weakness.

DISCUSSION/CONCLUSION

Carcinoid syndrome is associated with extensive disease and primaries in small bowels or of unknown primary. Weight loss, weakness, and pain are frequent, and carcinoid heart disease is diagnosed in more than one-third of patients.

Rosacea: Treatment targets based on new physiopathology data

Over the past 15 years, numerous clinical, epidemiological and physiopathological articles have been published on rosacea. There is now increasing evidence that rosacea is an inflammatory disease characterised by abnormal innate immune response, major vascular changes, and increased colonisation by Demodex mites, along with a genetic predisposition and multiple external aggravating factors. It is thus possible to define treatment targets and possible treatments: 1) permanent vascular changes (medical and instrumental treatments); 2) flushing (betablockers, botulinum toxin); 3) innate immunity (antibiotics, nonspecific antioxidants and anti-inflammatory molecules); 4) a neurovascular component (analgesics, antidepressants); 5) Demodex (antiparasitic drugs); 6) microbiome; 7) skin barrier impairment (cosmetics and certain systemic drugs); 8) sebaceous glands (isotretinoin, surgery); 9) environmental factors (alcohol, coffee, UV exposure). Treatment recommendations are now available in many countries and benefit from the new phenotypic approach to rosacea, in which every sign or symptom is considered separately rather than having to deal with overlapping subtypes. Since the 2000s, many good quality clinical trials have been published in the field of rosacea and many others are still ongoing. Rosacea is a complex disease involving many different mechanisms and with numerous possible treatments, but there are still some important unmet needs with regard to optimal care.

Citizen science chlorine surveillance during the Flint, Michigan federal water emergency

Rising incidence of waterborne diseases including Legionellosis linked to low chlorine residuals in buildings and the availability of inexpensive testing options, create an opportunity for citizen science chorine monitoring to complement sampling done by water utilities. University researchers and Flint residents coordinated a citizen science chlorine surveillance campaign in Flint, Michigan in 2015-19, that helped expose the nature of two deadly Legionnaires Disease outbreaks in 2014-2015 during the Flint Water Crisis and progress of system recovery during the Federal emergency. Results obtained with an inexpensive color wheel were in agreement with a digital colorimeter (R² =0.99; p = 2.81 × 10^-21) at 15 sites geographically distributed across Flint. Blinded tests revealed good agreement between official (n = 2051) and citizen (n = 654) data in terms of determining whether regulatory guidelines for chlorine were met, but a discovery that the citizen data were statistically lower than the city's (p<0.00001) especially in warm summer months led to recommendations for increased flushing of service lines before measurements. This work suggests that expanded citizen surveillance of chlorine, site specific flushing advice, and guidance on decisions about water heater set point could help consumers reduce Legionella risks in their homes. Citizen science initiatives for chlorine monitoring offer a unique opportunity for mutually beneficial collaborations between consumers and utilities to reduce the main source of waterborne disease in developed countries.

Flushing rates and hydrodynamical characteristics of Mosquito Lagoon (Florida, USA)

A hydrodynamic model is applied to a domain encompassing Mosquito Lagoon and a segment of north Indian River Lagoon on the east coast of Florida with the goals of (1) describing the hydrodynamic regime of the area according to existing conditions and (2) to determine the flushing rates of the system after introducing a hypothetical pollutant (numerical dye tracer). Results from the 1-year simulation agree with observations and show that the Mosquito Lagoon (ML) and North Indian River Lagoon (NIRL) are dominated by the nontidal (low frequency) water level oscillations except at the northernmost part of the ML where the influence of tidal renewal dominates. The global tracer application results reveal that only the two northernmost segments of Mosquito Lagoon (ML-ac and ML-df) reach 50% of tracer concentrations (R50) within the year of simulation (day 19 and day 176 respectively). The five (discrete) segments tracer study resulted in lower R50 values and the hypothetical pollutant is removed (flushed) from each of the segments within the year and with an averaged renewal time value for the Mosquito Lagoon basin of 98 days. Observed throughout the simulation period is the interaction across the different segments and a predominantly two-layered water mass exchange through the Haulover Canal. Most significant is that the resulting renewal times (R50) indicate the existence of three dynamically distinct sections within Mosquito Lagoon. These findings aid in the identification of poorly flushed zones and serve as a baseline for the duration and possible propagation of detrimental conditions such as a harmful algal bloom (HAB) event or a contaminant spill.

Single-well injection-withdrawal tests as a contaminant transport characterisation tool for landfilled waste

A new single well injection withdrawal (SWIW) test was trialled at four landfills using the tracers lithium and deuterium, and by injecting clean water and measuring electrical conductivity. The aim of the research was to develop a practical test for measuring lateral contaminant transport to aid in the design of landfill flushing. Borehole dilution tests using dyes were undertaken prior to each SWIW test to determine background flow velocities. SWIW tests were performed at different scales by varying the volume of tracer injected (1 to 5,800 m³) and the test duration (2 to 266 days). Tracers were used individually, simultaneously or sequentially to examine repeatability and scaling. Mobile porosities, estimated from first arrival times in observation wells and from model fitting ranged from 0.02 to 0.14. The low mobile porosities measured rule out a purely advective-dispersive system and support a conceptual model of a highly preferential dual-porosity flow system with localised heterogeneity. A dual-porosity model was used to interpret the results. The model gave a good fit to the test data in 7 out of 11 tests (where R² ≥ 0.98), and the parameters derived are compatible with previous experiments in MSW. Block diffusion times were estimated to range from 12 to 6,630 h, with a scaling relationship apparent between the size of the test (volume of tracer used and/or the duration) and the observed block diffusion time. This scaling relationship means affordable small-scale tests can inform larger-scale flushing operations.

Comparing the Effects of Pulsatile and Continuous Flushing on Time and Type of Peripheral Intravenous Catheters Patency: A Randomized Clinical Trial

Introduction: Peripheral intravenous catheters (PICs) patency techniques such as flushing are being developed. According to some studies, flushing can be used continuously or in pulsatile forms. This study aimed to compare the effects of pulsatile flushing (PF) and continuous flushing (CF) on time and type of PICs patency. Methods: In this double-blind randomized clinical trial, 71 patients were randomly assigned into two groups of PF (n=35) and CF (n=36). The PF protocol was performed as successive injections of 1 mL normal saline (N/S) per second (sec) with a delay of less than 1 sec until the completion of 5 mL of solution. However, CF protocol was performed by injecting 5 mL N/S within 5 sec without any delay before and after each medicine administration. Data related to the time and type of PICs patency were collected using a patency checklist every 12 hours (h) up to 96 h. The statistical analysis was done by R statistical software (Version 3.5.1). Results: The results showed that the number of PICs remaining open was not significantly different between PF and CF groups during 96 h. The highest number of PICs excluded from the study was related to the time of 96 h as a result of partial patency in the two groups. Conclusion: There was no difference between CF and PF regarding the time and type of PICs patency. Thus, both techniques can be used to maintain the catheter patency.

Efficacy and safety of non-surgical short-wave radiofrequency treatment of mild-to-moderate erythematotelangiectatic rosacea: a prospective, open-label pilot study

Although various treatments have been proposed for the management of rosacea, achieving complete remission of persistent erythema remains challenging. Short-wave radiofrequency (SWRF) treatment has been shown to repair skin barriers and reduce chronic inflammation. However, limited studies have evaluated the effectiveness of SWRF treatment for erythematotelangiectatic rosacea (ETR). A prospective, open-label pilot study using SWRF therapy was conducted on 30 patients with mild-to-moderate ETR. During the first stage, the patients underwent a single, full-face treatment and were evaluated before and after the session, as well as on the 7th and 15th day post-treatment. During the second stage, ten treatment sessions were administered, and the patients were evaluated before and after the tenth session, as well as 1 month after the treatment. Adverse events were recorded during each treatment session, and the patients were followed up for 3 months after the last session. Twenty-eight patients completed the entire trial. On the 7th day after the single treatment, the global score (total score of flushing, persistent erythema, and telangiectasia) of ETR improved from 5.23 ± 1.09 to 4.00 ± 0.76 relative to the baseline value (p < 0.05); moreover, the overall treatment satisfaction improved from 7.27 ± 0.89 to 4.90 ± 0.91 (p < 0.05). 1 month after the tenth treatment session, the global score improved from 5.30 ± 1.01 to 3.85 ± 0.93 (p < 0.05), and the overall treatment satisfaction improved from 7.13 ± 0.85 to 5.17 ± 1.19 (p < 0.05). During the 3 month follow-up period, there were two cases of recurrence. Therefore, this report indicates that SWRF might be an effective auxiliary treatment for mild-to-moderate ETR.

Novel housing designs for nanofiltration and ultrafiltration gravity-driven recycled membrane-based systems

Ultra-low pressure gravity-driven membrane (GDM) systems have the potential to be significantly less costly and complex than conventional membranes for water treatment applications. To build upon this inherent advantage, this study assesses the reuse of recycled membranes in GDM systems for producing drinking water. Two reverse osmosis spiral-wound modules were recycled into nanofiltration (NF)-like and ultrafiltration (UF)-like membranes via controlled exposure to free chlorine. To operate the recycled membranes, two housing devices, based on a simple fitting and an advanced end-caps design, were developed. The recycled membrane systems were tested under a range of conditions (submerged vs. external system configuration and continuous vs. intermittent filtration mode). Synthetic river water feed solutions were used in the tests where performance, fouling, and clogging were measured. NF-like recycled membranes resulted in poor salt rejection and low permeability (~1.7 L m^-2 h^-1 bar^-1), but also in high rejection (>81%) of dissolved organic carbon. UF-like recycled membranes maintained their capacity to reject biopolymers (BP) (>74%) and featured up to 18-fold higher permeate rate than NF-like recycled membranes. The optimized operating conditions were found when the recycled membranes were housed in the end-caps device and operated intermittently (relaxation time plus forward flushing). Flushing reduced the fouling accumulation inside the membrane (only 12% and 40% of BP accumulation was observed in the NF-like and UF-like, respectively). However, the end-caps-based device was estimated to be more expensive during the economic analysis. To address this techno-economic trade-off, a decision-making tree was developed to select the appropriate configuration based upon the implementation context. Overall, this study concludes that these designs can serve as robust, low-cost (water production cost <1 USD ct. yr. L^-1), and light-weight GDM alternatives. This study is beneficial for developing compact GDM systems based on recycled spiral-wound membranes for both rural areas and emergency response.

Severe mesenteric traction syndrome is associated with increased systemic inflammatory response, endothelial dysfunction, and major postoperative morbidity

This study aimed to determine if mesenteric traction syndrome (MTS) triggers increased systemic inflammation and endothelial cell dysfunction. Patients developing severe MTS had pronounced early IL6 elevations followed by endothelial cell damage. Furthermore, these processes were associated with increased postoperative morbidity.

OBJECTIVE

To determine whether mesenteric traction syndrome (MTS) leads to increased systemic inflammation and dysfunction of the glycocalyx and endothelial cell and whether this correlates with the degree of postoperative morbidity.

INTRODUCTION

Severe MTS is associated with increased postoperative morbidity following major gastrointestinal surgery, but the pathophysiological mechanism has not been previously explored. Systemic inflammatory response and impaired glycocalyx and endothelial cells may be responsible for the development of symptoms.

METHODS

The study analyzed prospectively collected data from two cohorts (n = 67). The severity of the MTS response was graded intraoperatively and blood samples for PGI₂, catecholamines, IL6, and endothelial biomarkers obtained at predefined time points.

RESULTS

Patients undergoing either esophagectomy (n = 45) or gastrectomy (n = 22) were included. Surgery led to significantly increased plasma concentrations of all biomarkers. Yet, patients who developed severe MTS had higher baseline epinephrine levels (p < 0.05) and higher levels of PGI₂ (p < 0.05), Syndecan-1 (p < 0.001), and sVEGFR1 (p < 0.001). Peak values of IL6, Syndecan-1, sVEGFR1, and sTM all correlated to peak PGI₂. Lastly, patients with high postoperative morbidity had higher baseline epinephrine (p = 0.009) and developed higher plasma IL6 (p = 0.007) and sTM (p = 0.022).

CONCLUSION

The development of severe MTS during upper gastrointestinal surgery is associated with preoperative elevated plasma epinephrine and further a more pronounced proinflammatory response and damage to the vascular endothelium. The increased postoperative morbidity seen in patients with severe MTS may thus, in part, be explained by an inherent susceptibility towards an inappropriate secretion of PGI₂, which leads to an increased surgical stress response and endothelial damage. These findings must be confirmed in a new prospective cohort.

Subtype-Specific Off-Label Treatment of Rosacea

We present 2 cases of rosacea that were successfully managed with off-label treatment. The first is a case of painful, exuding papulopustular lesions of the nose treated with rifaximin, and the other is a case of severe, debilitating and painful flushing treated with sumatriptan. The cases support previous notions that gastrointestinal comorbidities may be related to papulopustular lesions and that flushing may be related to neurogenic inflammation and migraine. The cases also imply that a new approach to rosacea management, based on endotypes and comorbidities, may be warranted.

How to perform appropriate flushing after lipid emulsion administration using totally implantable venous access devices in long-term total parenteral nutrition and home parenteral nutrition

BACKGROUND & AIMS

There has been no clear evidence regarding the appropriate method of flushing catheters and totally implantable venous access devices (TIVADs) after lipid emulsion (LE) administration. Therefore, the aim of the study was to identify appropriate methods of flushing to minimize residual LE when using TIVADs to ensure the safety of long-term total parenteral nutrition (TPN) and home parenteral nutrition (HPN).

METHODS

A soybean oil LE containing indocyanine green (ICG) was administered from the injection site of the primary infusion set for flowing TPN, and LE dynamics were evaluated by a fluorescence imaging system. TIVADs were connected to the end of the infusion sets. After LE administration, the tubes and chambers were flushed from the injection site using saline at various speeds (20, 40, 60 mL/min), with and without pulsation. The washout effect of TPN solution after LE administration followed by flushing was examined, as was the washout effect of size differences in the infusion sets.

RESULTS

When the LE was flushed with 20 mL of saline immediately after administering the LE using a standard infusion set (inner diameter 2.5 mm), the LE still remained in the tubes and chambers under any flushing condition. Flushing the LE from the injection site with 10 mL of saline and then flowing >240 mL of TPN solution were effective for minimizing residual LE inside the tubes and chambers. When using an infusion set with a small inner diameter (1.0 mm), the LE inside the tubes and chambers was almost discharged with ≥20 mL of saline immediately after administering the LE. In all settings, flushing with/without pulsation did not affect LE washout efficacy.

CONCLUSIONS

Flushing immediately with saline ≥10 mL and then flowing >240 mL of primary PN solution after soybean oil LE administration using the standard infusion set or flushing with 20 mL saline immediately after administering the soybean oil LE using the infusion set with a small inner diameter are effective for minimizing the residual LE in the catheter and TIVAD, ensuring the safety of long-term TPN and HPN.

Lack of Efect of Short-term Lupin Grain Feeding on Ovulation Rate in Non-prolific Polish Mountain Ewes during the Breeding Season: Ultrasonographic and Endoscopic Assessment of Ovarian Activity

The specific changes in antral follicle numbers and wave-like development have remained unrevealed in cyclic ewes fed high-protein, high-energy lupin grain for 6 days during the luteal phase of the estrous cycle (i.e., short-term nutritional flushing). This study was mainly conducted to determine ovarian effects of the 6-day lupin grain feeding in non-prolific Polish Mountain ewes, using transrectal ovarian ultrasonography and abdominal videoendoscopy. Estrus and ovulations were synchronized in 24 ewes with progestin-releasing intravaginal sponges for 12 days during the middle portion of the breeding season (September-October; 50.0458&amp;deg;N, 19.8406&amp;deg;E). Twenty-four ewes were assigned to three equal groups (n=8 each), including the Control group being fed the maintenance diet (i.e., hay-only), Treatment 1 receiving 500 g of lupin grain once a day, and Treatment 2 receiving 250 g of lupin grain twice a day, from days 9-14 of the synchronized estrous cycle (day 0=first ovulation of the interovulatory period studied). No differences were observed in the mean ovulation rate among the three groups of Polish Mountain ewes (P&amp;gt;0.05). Ovarian antral follicles emerging in the penultimate wave of the estrous cycle in Treatment 2 ewes had a longer growth phase (p &amp;lt;0.05) and attained a greater diameter (p &amp;lt;0.05) before ovulation, in comparison to those in the other two groups. A final wave of the interovulatory interval emerged ~1 day earlier in Treatment 2 than in Treatment 1 ewes (p &amp;lt;0.05). Nutritional supplementation with lupin grain increased the number of 3-mm follicles in Treatment 2 ewes (p &amp;lt;0.05). The results of this study indicated that short-term nutritional flushing with lupin grain from mid- to late luteal phase did not consistently enhance ovulatory responses in non-prolific genotypes of ewes. Although the administration of lupins altered the timing of wave emergence, ovulatory follicle diameter, or duration of different stages of the follicular lifespan, it failed to increase the number of ovulatory follicles emerging in the penultimate and final waves of the estrous cycle in non-prolific Polish Mountain sheep.

Association between the incidence of hypertension and alcohol consumption pattern and the alcohol flushing response: A 12-year follow-up study

BACKGROUND

Alcohol consumption is associated with hypertension, and this association depends on the alcohol consumption pattern and alcohol flushing response. In this 12-year follow-up study, we investigated the relationship between the alcohol consumption pattern and incidence of hypertension in the Korean population.

METHODS

We analyzed 1,366 Korean participants in the Ansung-Ansan cohort study without hypertension at baseline. The subjects were classified into four alcohol consumption patterns: never-drinking, light alcohol consumption, moderate alcohol consumption, and heavy alcohol consumption, and as flushers or non-flushers in response to alcohol.

RESULTS

In flushers, moderate and heavy alcohol consumption patterns increased the risk of incident hypertension compared with never-drinkers [moderate: HR 1.811 (95% CI 1.084-3.028); heavy: HR 2.494 (95% CI 1.185-5.247)], but non-flushers were not associated with increased risk of incident hypertension according to the alcohol consumption pattern. In addition, a heavy alcohol consumption pattern increased the risk of hypertension among flushers compared with non-flushers [HR 2.232 (95% CI 1.054-4.728)].

CONCLUSION

In this 12-year follow-up study, we observed that moderate and heavy alcohol consumption was associated with an increased risk of hypertension in flushers. Especially, a heavy alcohol consumption pattern in flushers markedly increased the risk of hypertension.

Implementation and evaluation of short peripheral intravenous catheter flushing guidelines: a stepped wedge cluster randomised trial

BACKGROUND

Peripheral intravenous catheters (PIVCs) are ubiquitous medical devices, crucial to providing essential fluids and drugs. However, post-insertion PIVC failure occurs frequently, likely due to inconsistent maintenance practice such as flushing. The aim of this implementation study was to evaluate the impact a multifaceted intervention centred on short PIVC maintenance had on patient outcomes.

METHODS

This single-centre, incomplete, stepped wedge, cluster randomised trial with an implementation period was undertaken at a quaternary hospital in Queensland, Australia. Eligible patients were from general medical and surgical wards, aged ≥ 18 years, and requiring a PIVC for > 24 h. Wards were the unit of randomisation and allocation was concealed until the time of crossover to the implementation phase. Patients, clinicians, and researchers were not masked but infections were adjudicated by a physician masked to allocation. Practice during the control period was standard care (variable practice with manually prepared flushes of 0.9% sodium chloride). The intervention group received education reinforcing practice guidelines (including administration with manufacturer-prepared pre-filled flush syringes). The primary outcome was all-cause PIVC failure (as a composite of occlusion, infiltration, dislodgement, phlebitis, and primary bloodstream or local infection). Analysis was by intention-to-treat.

RESULTS

Between July 2016 and February 2017, 619 patients from 9 clusters (wards) were enrolled (control n = 306, intervention n = 313), with 617 patients comprising the intention-to-treat population. PIVC failure was 91 (30%) in the control and 69 (22%) in the intervention group (risk difference - 8%, 95% CI - 14 to - 1, p = 0.032). Total costs were lower in the intervention group. No serious adverse events related to study intervention occurred.

CONCLUSIONS

This study demonstrated the effectiveness of post-insertion PIVC flushing according to recommended guidelines. Evidence-based education, surveillance and products for post-insertion PIVC management are vital to improve patient outcomes.

TRIAL REGISTRATION

Trial submitted for registration on 25 January 2016. Approved and retrospectively registered on 4 August 2016. Ref: ACTRN12616001035415 .

The flushing procedure in nursing practices: A cross-sectional study with Portuguese and Brazilian nurses

BACKGROUND

In patients with peripheral intravenous catheters (PIVCs), performing flushing is an essential procedure to maintain catheter patency and prevent complications. These PIVC related complications can lead to premature removal and therapeutics interruption, which implies the need of a new catheterization thus increasing patient discomfort and pain.

AIMS

To identify nursing practices related to the flushing procedure, namely: moment(s) of the flushing; the syringe size used; the flush solution, volume and technique; the knowledge and accomplishment of the recommended standards on flushing by nurses.

METHODS

A cross-sectional study was conducted between July and December 2017, with Brazilian and Portuguese nurses. An online questionnaire was developed based on the international recommendations on flushing procedure. Descriptive analysis was performed.

RESULTS

A total of 76 nurses answered the questionnaire. The majority of nurses (84.2%) performed flushing: the most common technique used was continuous syringe pressure (31.2%), with the push-pause technique being performed by 23.4% of the nurses. Despite the majority performs flushing at four distinct moments (after the PIVC insertion, before, between and after drug delivery), there are inconsistencies in flush solution, volume, and syringe size. The most used volume to perform flushing was 5 mL, filled using normal saline. Despite this, they also recognized the omission of this procedure due to time constrains, no familiarity with the procedure and unavailable material.

CONCLUSIONS

This study identified that flushing procedure isn't always performed by nurses in their clinical practice. Also, several inconsistencies were observed between nurses that performed flushing, reflecting the lack of empirical evidence in this area of research.

Influence of Facial Flushing on Pre- or Type 2 Diabetes Risk according to Alcohol Consumption in Korean Male

Background

This study aims to examine the association between alcohol consumption and the risk of pre- or type 2 diabetes mellitus (T2DM) by alcohol-induced flushing response in Korean male adults, particularly based on their body mass index (BMI).

Methods

This study selected 1,030 (158 non-drinkers, 364 flushers, and 508 non-flushers) male adults who had medical checkups. A logistic regression analysis was used to compare the association between alcohol consumption and the risk of pre- or T2DM.

Results

In both the normal-weight group (BMI <23 kg/m²) and the overweight group (BMI ≥23 kg/m² and <25 kg/ m²), the flushers had a higher risk of pre- or T2DM (odds ratio, 95% confidence interval) when consuming more than 8 drinks of alcohol per week than the non-drinkers (normal-weight group: 3.43, 1.06–11.07; overweight group: 4.94, 1.56–15.67). But in the non-flushers among the normal-weight group and the overweight group, there was no significant difference compared to non-drinkers regarding the risk of pre- or T2DM. Obese flushers had a significantly higher risk of pre- or T2DM when consuming more than 4 drinks of alcohol per week than the non-drinkers (>4 and ≤8 drinks: 2.64, 1.10–6.36; >8 drinks: 2.42, 1.11–5.27). However, obese non-flushers had only a significant higher risk of pre- or T2DM when consuming more than 8 drinks of alcohol per week than the non-drinkers (2.72, 1.39–5.30)

Conclusion

These results suggest that obese flushers have an increased risk of developing pre- or T2DM even with less alcohol consumption.

Relationship between alcohol consumption and rheumatoid factor (RF) with alcohol-induced facial flushing response

This study investigated the relationship between alcohol consumption with alcohol-induced facial flushing response and rheumatoid factor (RF) in adult men. The cohort comprised 1675 men who underwent a general medical check-up between July 2016 and June 2017, including 355 non-drinkers, 498 flushers, and 822 non-flushers. One drink was defined as 14 g of alcohol. RF was considered negative if the level was less than 18 IU/mL and positive if the level was greater than 18 IU/mL. Logistic regression analyses were used. Compared to non-drinkers, the odds ratio for a positive RF among non-flushers was 0.92 (95% confidence interval [CI], 0.37-2.29) for those with an average alcohol consumption of ≤4 drinks per week, 1.64 (95% CI, 0.67-3.98) for those consuming more than 4 drinks per week but fewer than or equal to 8 drinks per week, and 1.17 (95% CI, 0.55-2.50) for those consuming more than 8 drinks per week; the differences were not statistically significant. Compared to non-drinkers, flushers also had a non-significant odds ratio for positive RF of 1.26 (95% CI, 0.54-2.90) among those with an average alcohol consumption of ≤4 drinks per week. However, flushers showed a significantly higher odds ratio for a positive RF of 3.12 (95% CI, 1.18-8.24) among those consuming more than 4 but fewer than or equal to 8 drinks per week, and 3.27 (95% CI, 1.42-7.52) among those consuming more than 8 drinks per week. Additionally, flushers consuming more than 8 drinks per week were associated with significantly higher rates of positive RF than non-flushers (odds ratio, 2.38; 95% CI, 1.05-5.17). Our study revealed that flushers consuming more than 4 drinks per week showed a higher probability of positive RF than non-drinkers. Furthermore, flushers consuming more than 8 drinks per week had a higher probability of positive RF than non-flushers. Our results strongly indicate that the average weekly alcohol consumption level and the presence or absence of flushing should be considered when interpreting the results of RF examinations in healthy men.

Residential water heater cleaning and occurrence of Legionella in Flint, MI

After the Federal emergency in Flint, MI was declared in early 2016 in response to elevated lead-in-water and incidence of Legionnaires' disease, concerns arose that contaminants in residential water heaters could continue to contribute to poor quality tap water. Here, a comprehensive field survey of residential water heaters (n = 30) and associated water quality was conducted and the subsequent effects of an aggressive manual water heater clean-out was determined, including draining the tank and removing sediments via brushing and flushing. Before cleaning, inorganics accumulated in the tank sediments did not serve as a source of metals measured at hot water outlets. After cleaning, hardness- (calcium, magnesium, silica) and corrosion-associated inorganics (lead, iron, copper, aluminum, zinc) decreased by 64% in samples from sediment cleanout drain valves. Culturable L. pneumophila was only detected in 1 home (3.3%) prior to cleaning and 2 homes (6.7%) after cleaning, thus quantitative polymerase chain reaction was used to quantify potential effects on unculturable strains despite the limitation of differentiating live and dead cells. After the cleaning protocol, Legionella spp. and L. pneumophila gene numbers decreased or remained non-detectable in 83% and 98% of samples, respectively. Homes with less than 0.4 mg/L influent free chlorine tended to have quantifiable Legionella spp. gene numbers in water entering the home and had elevated L. pneumophila and Legionella spp. gene numbers throughout the home plumbing. Also, Legionella spp. and L. pneumophila gene numbers were highest for water heaters set at or below ∼42 °C and significantly decreased >51 °C, consistent with Legionella's preferred temperature range. Examination of the only home that had culturable L. pneumophila both before and after the cleaning protocol revealed that the organism was culturable from several sample locations throughout the home, including in water representative of the water main. Notably, the home was located in close proximity to McLaren Hospital, where an outbreak of Legionnaires disease was reported, and the water heater had a setpoint within the Legionella growth range of 44.2 °C. Considering that other factors were more strongly associated with Legionella occurrence and water heater sediment was not detectably mobilizing to tap water, it was concluded that water heater cleaning had some benefits, but was not an overarching factor contributing to possible human health risks.

The effect of Salvia officinalis extract on symptoms of flushing, night sweat, sleep disorders, and score of forgetfulness in postmenopausal women

Background:

Complications of hormone therapy (as replacement) during menopause prompted us to research on alternative therapies including herbal therapy in this regard.

Objectives:

The effect of Salvia officinalis extract on symptoms of flushing, night sweat, sleep disorders, and score of forgetfulness in postmenopausal women on Namazi Hospital Bone Density Center in Shiraz 2015.

Methods:

In a double-blind randomized controlled clinical trial, 66 postmenopausal women complaining of menopausal symptoms were divided into two groups of intervention and control, respectively. The intervention group received S. officinalis tablets (containing 100 mg S. officinalis extract), with a dose of three tablets a day for 3 months, while the control group received placebo tablets with the same prescription order. MRS (Menopause Rating Scale) and PSQI (Pittsburgh Sleep Quality Index) questionnaires were completed at the beginning and end of the study. The checklists of hot flushing and night sweating were completed a week before the intervention and at weeks 2, 4, 6, 8, 10, 12 during the intervention. Finally, the data were analyzed through SPSS₁₈ software, using paired t-test, ANOVA. A significant level of 5% was considered.

Results:

According to the paired t-test, the mean score of flushing, palpitation, sleeping disorders, muscle and joint aches, depression, nervousness, anxiety, and sexual desire and satisfaction significantly decreased by 1.6, 0.4, 1.6, 2.1, 1.4, 1.2, 1.6, and 0.8 units, respectively, in the intervention group compared to the control group (P < 0.001). Therefore, the mean score of PSQI significantly decreased by 3.8 units in the intervention group after the intervention (9.4 ± 3.7 vs 5.6 ± 1.9 (P < 0.05).

Conclusions:

Salvia extract improved menopausal symptoms such as flushing, night sweat, heart palpitations, muscle and joint pain, depression, anxiety, sleep disorders, and sexual desire.

Association between Alcohol Consumption and Metabolic Syndrome Determined by Facial Flushing in Korean Women

Background

This study aimed to examine the relationship between alcohol consumption and metabolic syndrome in Korean women as determined by facial flushing.

Methods

Of the female patients aged <65 years who visited the health promotion center at Chungnam National University Hospital from January 2016 to March 2017, 1,344 women were included. After adjusting for confounding factors such as age, body mass index, smoking, exercise, and menopausal status, multiple logistic regression analysis was performed to assess the association between alcohol consumption and the risk of metabolic syndrome in the facial flushing and non-facial flushing groups compared with the non-drinkers.

Results

Even after adjusting for confounding factors, the risk of metabolic syndrome was significantly high in all drinking subgroups (≤2 standard drinks: odds ratio [OR], 1.68; 95% confidence interval [CI], 1.10–2.68; 2<, ≤4 standard drinks: OR, 2.48; 95% CI, 1.29–4.74; and >4 standard drinks: OR, 4.16; 95% CI, 2.03–8.30) of the facial flushing group. The risk of metabolic syndrome was significantly high only in the subgroup of weekly alcohol consumption >4 standard drinks (OR, 2.20; 95% CI, 1.07–4.52) in the non-facial flushing group.

Conclusion

This study suggests that Korean women experiencing facial flushing when drinking have a higher risk of developing metabolic syndrome even with a low weekly drinking amount than those who do not experience face flushing.

Adrenocortical carcinoma masquerading as pheochromocytoma: a histopathologic dilemma

SUMMARY

Adrenocortical carcinoma (ACC) is an aggressive cancer that originates in the cortex of the adrenal gland and generally has a poor prognosis. ACC is rare but can be more commonly seen in those with cancer predisposition syndromes (e.g. Li-Fraumeni and Lynch Syndrome). The diagnosis of ACC is sometimes uncertain and it requires the use of precise molecular pathology; the differential diagnosis includes pheochromocytoma, adrenal adenoma, renal carcinoma, or hepatocellular carcinoma. We describe a case of a 57-year-old woman with Lynch Syndrome and metastatic ACC who was initially diagnosed as having pheochromocytoma. The tumor was first identified at 51 years of age by ultrasound followed by a CT scan. She underwent a left adrenalectomy, and the histopathology identified pheochromocytoma. Two years later, she had tumor recurrence with imaging studies showing multiple lung nodules. Following a wedge resection by video-assisted thoracoscopic surgery (VATS), histopathology was read as metastatic pheochromocytoma at one institution and metastatic ACC at another institution. She later presented to the National Institutes of Health (NIH) where the diagnosis of ACC was confirmed. Following her ACC diagnosis, she was treated with mitotane and pembrolizumab which were stopped due to side effects and progression of disease. She is currently receiving etoposide, doxorubicin, and cisplatin (EDP). This case highlights the importance of using a multi-disciplinary approach in patient care. Thorough evaluation of the tumor's pathology and analysis of the patient's genetic profile are necessary to obtain the correct diagnosis for the patient and can significantly influence the course of treatment.

LEARNING POINTS

Making the diagnosis of ACC can be difficult as the differential diagnosis includes pheochromocytoma, adrenal adenoma, renal carcinoma, or hepatocellular carcinoma. Patients with Lynch Syndrome should undergo surveillance for ACC as there is evidence of an association between Lynch Syndrome and ACC. Conducting a complete tumor immunoprofile and obtaining a second opinion is very important in cases of suspected ACC in order to confirm the proper diagnosis. A multi-disciplinary approach including genetic testing and a thorough evaluation of the tumor's pathology is imperative to ensuring that the patient receives an accurate diagnosis and the appropriate treatment.

Development of a severe mesenteric traction syndrome during major abdominal surgery is associated with increased postoperative morbidity: Secondary data analysis on prospective cohorts

PURPOSE

MTS is elicited during open abdominal surgery and is characterized by facial flushing, hypotension, and tachycardia in response to the release of prostacyclin (PGI₂) to plasma. MTS seems to affect postoperative morbidity, but data from larger cohorts are lacking. We aimed to determine the impact of severe mesenteric traction syndrome (MTS) on postoperative morbidity in patients undergoing open upper gastrointestinal surgery.

METHODS

The study was a secondary analysis of data from three cohorts (n = 137). The patients were graded for severity of MTS intraoperatively, and hemodynamic variables and blood samples for plasma 6-keto-PGF_1α, a stable metabolite of PGI₂, were obtained at defined time points. Postoperative morbidity was evaluated by the comprehensive complication index (CCI) and the Dindo-Clavien classification (DC).

RESULTS

Patients undergoing either esophagectomy (n = 70), gastrectomy (n = 22), liver- (n = 23), or pancreatic resection (n = 22) were included. Severe MTS was significantly associated with increased postoperative morbidity, i.e., CCI ≥ 26.2 (OR 3.06 [95% CI 1.1-6.6]; p = 0.03) and risk of severe complications, i.e., DC ≥3b (OR 3.1 [95% CI 1.2-8.2]; p = 0.023). Furthermore, patients with severe MTS had increased length of stay (OR 10.1 [95% CI 1.9-54.3]; p = 0.007) and were more likely to be admitted to the intensive care unit (OR = 7.3 [95% CI 1.3-41.9]; p = 0.027), but there was no difference in 1-year mortality.

CONCLUSION

Occurrence of severe MTS during upper gastrointestinal surgery is associated with increased postoperative morbidity as indicated by an increased rate of severe complications, length of stay, and admission to the ICU. It remains to be determined whether inhibition of MTS enhances postoperative recovery.

Relationship between Alcohol Consumption and Ocular Pressure according to Facial Flushing in Korean Men with Obesity

Background

This study aimed to examine the relationship between alcohol consumption and intraocular pressure (IOP) according to facial flushing in Korean men with obesity.

Methods

The study included 479 Korean men with a body mass index of ≥25 kg/m² (75 non-drinkers, 174 with drinking-related facial flushing, and 230 without facial flushing) who underwent health check-ups between October 1, 2016 and March 31, 2017. Multivariate logistic regression was used to assess the relationship between alcohol consumption and high IOP (≥21 mm Hg).

Results

Flushers consuming ≤16 drinks per week had a significantly higher risk of high IOP than non-drinkers, depending on alcohol consumption (≤8 standard drinks: odds ratio [OR], 4.49; 95% confidence interval [CI], 1.05– 19.25; >8 but ≤16 standard drinks: OR, 8.14; 95% CI, 1.37–48.45). However, when the consumption was >16 drinks per week, the high IOP risk did not significantly increase (OR, 0.71; 95% CI, 0.05–10.69). In addition, there was no significant relationship between alcohol consumption and high IOP among non-flushers consuming ≤8 drinks per week (OR, 2.07; 95% CI, 0.52–8.19). However, a significantly increased risk of high IOP was observed among non-flushers consuming >8 drinks per week, depending on alcohol consumption (>8 but ≤16 standard drinks: OR, 4.84; 95% CI, 1.14–20.61; >16 standard drinks: OR, 4.08; 95% CI, 1.02–16.26).

Conclusion

This study suggests that obese men with alcohol flush reactions may have an increased risk of high IOP with the consumption of smaller amounts of alcohol than non-flushers.

Effects of prolonged flushing interval in totally implantable venous access devices (TIVADs)

Totally implantable venous access device (TIVAD) lumen occlusion is a long-term complication of central venous catheters, associated with risks of infection, therapy interruptions and increased healthcare costs. The role of flushing and locking in maintaining TIVAD patency is paramount. Most flushing protocols are based on manufacturers' recommendations, which indicate that 4 weeks is the safest interval between two consecutive flushing procedures during periods when TIVADs are not in use. Conversely, results of several studies suggest that extended flushing intervals (FIs) do not increase the rate of obstructive or infective complications. The study aimed to describe the effects of prolonged FIs in a cohort of 317 patients with cancer. The authors found no significant difference in terms of TIVAD problems between long (>45 days) and short (≤45 days) FI groups, which raises questions over the validity of current practice.

Assessment of nosocomial bacterial contamination in dental unit waterlines: Impact of flushing

Purpose

This study evaluated the extent of bacterial contamination in water from dental unit waterlines (DUWLs).

Methodology

Water samples were collected (before flushing, 1 min post-flushing, and 3 min post-flushing) from 24 clinics (Group A: no disinfection, Group B: citric acid disinfectant) of a Government Dental College. Bacterial counts, identification, antibiotic sensitivity tests, determination of endotoxin levels, and scanning electron microscopy (to confirm the presence of biofilm) were performed.

Results

The most common opportunistic bacteria were P. aeruginosa (95%), S. aureus (58%), S. auricularis (49%), P. fluorescens (44%), and A. baumannii (20%). Approximately 50% of the bacterial isolates were resistant to two or more antibiotics. Flushing for 3 min did not reduce the contamination of water from Group A clinics which exceeded the recommendation of ≤500 CFU/ml. No bacterial growth was seen in Group B samples. Endotoxin levels were >5.00 endotoxin units (EU)/ml in Group A and ranged from 1.33 to 5.00 EU/ml in Group B clinics. Scanning electron microscopy images showed bacterial biofilms on the surfaces of the tubes.

Conclusions

DUWL contamination is a serious issue in dentistry, and the microbiological quality of the water must be monitored regularly. Further studies on endotoxin exposure and prevention are therefore necessary.

Korean Alcohol Guidelines for Moderate Drinking Based on Facial Flushing

This study investigated advantages and potential risks associated with drinking alcohol in Koreans based on the alcohol flush reaction. Our investigation reviewed published studies and examined moderate-drinking levels for Koreans based on modified National Institute on Alcohol Abuse and Alcoholism guidelines. Fourteen articles out of a total 198 publications were searched using PubMed, EMBASE, KoreaMed, and RISS (Research Information Sharing Service) databases and selected for review. Individuals without alcohol flush reaction (non-flushers) exhibited lower risks associated with insulin resistance, metabolic syndrome, and hyperhomocysteinemia and their 10-year cardiovascular disease risk when alcohol consumption was ≤8 drinks/wk. Conversely, risks associated with insulin resistance, metabolic syndrome, high blood pressure, prediabetes or type-2 diabetes, and high intraocular pressure and increases in carbohydrate-deficient transferrin, gamma glutamyl transferase, and blood glucose levels were present when >8 drinks were consumed. For individuals with flushing reaction (flushers), advantages were reported in relation to risks of hyperhomocysteinemia when alcohol consumption was ≤4 drinks/wk, whereas consumption of >4 drinks/wk increased the risk of insulin resistance, metabolic syndrome, high blood pressure, pre-diabetes or type-2 diabetes, high-risk colorectal adenoma, and high intraocular pressure and increased carbohydrate-deficient transferrin, gamma glutamyl transferase, and blood glucose levels. The moderate drinking level for Koreans is ≤8 drinks/wk for men aged ≤65 years and ≤4 drinks/wk for men aged over 65. For women, these limits should be half of those for men. Furthermore, individuals with flushing reaction should maintain an alcohol consumption level half of that for non-flushers.

Summer is in winter: Disturbance-driven shifts in macroinvertebrate communities following hydroelectric power exploitation

In Alpine streams, humans have strongly modified the interactions between hydraulic processes, geomorphology and aquatic life through dams, flow abstraction at water intakes and river channel engineering. To mitigate these impacts, research has addressed both minimum flows and flow variability to sustain aquatic ecosystems. Whilst such environmental flows might work downstream of dams, this may not be the case for water intakes. Intakes, generally much smaller than dams, are designed to abstract water and to leave sediment behind. Sediment accumulation then results in the need to flush intakes periodically, often more frequently than daily in some highly glaciated basins. Sediment delivery downstream is then maintained through short duration floods with very high sediment loads. Here we tested the hypothesis that sediment flushing, and the associated high frequency of bed disturbance, controls in-stream habitat and macroinvertebrate assemblages. We collected macroinvertebrates over a 17-month period from an Alpine stream as well as a set of lateral unperturbed tributaries that served as controls. In contrast to established conceptual models, our results showed that the stream is largely void of life during summer, but that populations recover rapidly as the frequency of intake flushing falls in early autumn, producing richer and larger populations in winter and early spring. The recovery in autumn may be due to the recruitment of individuals from tributaries. We conclude that intake flushing in summer inverts expected summer-winter macroinvertebrate abundances, and questions the extent to which environmental flows in intake-impacted Alpine streams will lead to improvements in instream macrofauna unless sediment also is managed.

Octreotide reverses shock due to vasoactive intestinal peptide-secreting adrenal pheochromocytoma: A case report and review of literature

Vasoactive intestinal peptide-producing tumors (VIPoma) usually originate in the pancreas and are characterized by diarrhea, hypokalemia, and achlorhydria (WDHA syndrome). In adults, nonpancreatic VIPoma is very rare. Herein, we report an unusual case of VIP-producing pheochromocytoma marked by persistent shock, flushing, and watery diarrhea and high sensitivity to octreotide. A 53-year-old woman was hospitalized for sudden-onset hypertension with convulsions, which then rapidly evolved to persistent shock, flushing, and watery diarrhea. Abdominal computed tomography indicated a left adrenal mass, accompanied by bleeding; and marked elevations of both plasma catecholamine and VIP concentrations were documented via laboratory testing. Surprisingly, all clinical symptoms responded swiftly to octreotide treatment. Once surgically treated, hormonal levels normalized in this patient, and the clinical symptoms dissipated. Postoperative pathological and immunohistopathological studies confirmed a VIP-secreting pheochromocytoma with strong, diffuse positivity for somatostatin receptor type 2. During a 6-mo follow-up period, she seemed in good health and was symptom-free.

Performance evaluation of 1-D numerical model HEC-RAS towards modeling sediment depositions and sediment flushing operations for the reservoirs

Sediment inflow to the reservoir is a key factor to calculate life of the reservoir. Flushing is a very useful technique in order to enhance the life of reservoir. From the literature review, 14 reservoirs were considered where flushing has already been practiced and only 6 reservoirs were found successful in flushing. The others were found partially flushed. In this research, data of three successfully flushed reservoirs namely Baira reservoir (India), Gebidem reservoir (Switzerland), and Gmund reservoir (Austria) were used to run 1-D numerical model HEC-RAS. In the first phase, the longitudinal profiles of delta were modeled and calibrated with observed sediment depositions. In the presence of available data of discharges and respective reservoir levels, the modeled deltas were used for flushing the deltas. With the help of modeled delta and corresponding flushing discharges, sediment deposition and flushing durations were computed. The simulated flushed durations were 31, 102, and 180 h for Baira, Gebidem, and Gmund reservoirs, respectively. The simulated flushed durations were found close to observed durations. Hence, the use of 1-D numerical model HEC-RAS is encouraged for modeling of sediment deposits and flushing operations.

Nonclonal Mast Cell Activation Syndrome: A Growing Body of Evidence

Patients who present with typical features of mast cell activation with laboratory confirmation and without evidence of a clonal mast cell disorder or other medical condition should be initiated on medical treatment to block mast cells and their mediators. If a major response is achieved, a diagnosis of nonclonal mast cell activation syndrome (NC-MCAS) is likely and treatment should be optimized, including management of any associated conditions. In this review, the latest evidence with regard to the diagnosis and treatment of NC-MCAS is presented.