Removal of microfiber in vertical flow constructed wetlands treating greywater.

Nature-based solutions such as constructed wetlands (CW) are considered as a sustainable, green technology for greywater treatment. However, their efficiency to remove microplastics is not well-known even though greywater is considered as a significant source of microfiber pollution. In this study, the removal of fiber microplastics from greywater using a vertical flow constructed wetland (VFCW) was investigated. For the purposes of this study, an experimental wetland was constructed, planted with the flowering plant Zantedeschia aethiopica and filled with a substrate made of sand/gravel of several sizes. The system's performance was monitored for five months during which it received real laundry wastewater. Promising results were obtained showing the significant removal of microfibers from the influent (> 95 %). Moreover, the ability of the system to remove microfibers from laundry wastewater was not significantly affected from the hydraulic loading rate (HLR) applied. The average microfibers concentration decreased from 71 ± 25 microparticles/L in the influent to 1 ± 1 microparticles/L in the effluent of VFCW when an HLR of 63.7 mm/d was applied. High removal efficiencies were also observed for COD and turbidity (93 % and 94 %, respectively). Thus, the results indicate a significant improvement in the overall quality of laundry wastewater due to the use of the VFCW.

Small airways' function in Obstructive Sleep Apnea-Hypopnea Syndrome.

INTRODUCTION AND OBJECTIVES: Most of the studies of the pathophysiology of Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS) focus on the collapsibility and obstruction of the upper airways. The aim of our study was the investigation of small airways' function in patients with OSAHS. MATERIALS AND METHODS: We studied 23 patients (mean age, 51.6 years) diagnosed with mild to severe OSAHS, without comorbidities and 8 controls (mean age, 45.9 years). All subjects underwent full polysomnography sleep study; spirometry and maximum flow/volume curves while breathing room air and a mixture of 80%He-20%O2. The volume of equal flows (VisoV⋅) of the two curves and the difference of flows at 50% of FVC (ΔV˙max50) were calculated, as indicates of small airways' function. RESULTS: The results showed that VisoV⋅ was significantly increased in patients with OSAHS compared with controls (18.79±9.39 vs. 4.72±4.68, p=0.004). No statistically significantly difference was found in ΔV˙max50% (p=0.551); or the maximum Expiratory flow at 25-75% of FVC (p=0.067) and the maximum expiratory flow at 50% of FVC (p=0.174) breathing air. CONCLUSIONS: We conclude that at the time of the diagnosis of OSAHS, the function of the small airways is affected. This could be due to breathing at low lung volumes and the cyclic closure/opening of the small airways and may affect the natural history of OSAHS. The findings could lead to new therapeutic implications, targeting directly the small airways.

The role of compliance with PAP use on blood pressure in patients with obstructive sleep apnea: is longer use a key-factor?

Scientific data about the effects of positive airway pressure (PAP) treatment on blood pressure (BP) control are continuously increasing; however, they are controversial. We aimed to determine the long-term effects of compliance with PAP therapy on BP in both hypertensive and normotensive patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). One thousand one hundred sixty eight consecutive patients with newly diagnosed OSAHS, who had been recommended PAP therapy, were followed up for a minimum of 2 years. Patients with previous cardiovascular disease were excluded. BP was measured at baseline and after 2 years of PAP treatment. In addition, the correlation between the changes in BP with different levels of PAP compliance was assessed. At the end of the follow-up period, in the hypertensive group of patients (n=586), a significant decrease was shown in systolic (-11.2 mm Hg, P<0.001) and diastolic BP (-4.2 mm Hg, P<0.001). Furthermore, in the patients without hypertension (n=528), a significant decrease was noted both in systolic and diastolic BP (-3.6, P<0.001 and -2.4, P<0.001, respectively). A correlation between the magnitude of change in systolic and diastolic BP and hours of use of PAP (r=0.14, P=0.002 and r=0.1, P=0.025, respectively) was observed in all patients. Long-term use of PAP treatment, as well as increased hours of PAP in patients with OSAHS use showed significant reductions in BP not only in patients with hypertension, but also in normotensive patients. Therefore a significant potential reduction in cardiovascular mortality and morbidity should be expected in these patients.

Management of pregnancy and delivery of a patient with malfunctioning ventriculoperitoneal shunt.

The use of ventriculoperitoneal shunts increased the life expectancy of many women with hydrocephalus who are able to reach childbearing age. It is believed that pregnancy may be associated with shunt malfunction and the management of pregnant women with a malfunctioning ventriculoperitoneal shunt is a challenging medical condition for the anaesthetist, the obstetrician and the neurosurgeon. We report on a case of a 35-year-old primiparous woman who underwent a scheduled caesarean delivery at 30 weeks' gestation due to deteriorating neurological condition during pregnancy. The patient had a history of astrocytoma resection in the past and placement of a ventriculoperitoneal shunt due to obstructive hydrocephalus. She had a normal life without neurological deficits until the 18th week of gestation, when the first neurological symptoms appeared. An MRI was done that showed significant dilatation of the fourth ventricle and it was believed that the shunt was not functioning properly so the patient's symptoms were present because of raised intracranial pressure. In the 30th week of gestation, she had a caesarean delivery under epidural anaesthesia and she gave birth to a live female infant. Her neurological condition started improving 48 h after delivery and the symptoms gradually regressed. At 20 days after surgery she was discharged from hospital. The presence of a ventriculoperitoneal shunt is not a contraindication for pregnancy. Maternal shunt dependency carries a relatively high incidence of complications for some patients, e.g. shunt malfunction due to raised intraabdominal pressure caused by the gravid uterus. The results of pregnancies and deliveries in women with pre-existing ventriculoperitoneal shunts are favourable if there is proper management.

Microsatellite DNA analysis does not distinguish malignant from benign pleural effusions.

Distinguishing malignant from benign pleural effusions using routine cytology is a common diagnostic problem. Recently, genetic alterations, including microsatellite instability (MSI) and loss of heterozygosity (LOH), have been described in malignant pleural effusions and proposed as methods improving diagnostics. The purpose of this study was to evaluate a panel of molecular markers for the detection of genetic alterations of cells in pleural effusions and to determine their diagnostic value as an additional test to cytologic examination. Pleural fluid and peripheral blood from 48 patients (36 male and 12 female, median age 71 years) were analyzed. Twenty-six patients had malignant pleural effusion, including 23 lung cancer and three metastatic non-pulmonary carcinoma. The control group consisted of 22 patients with benign pleural effusions. Only 14 malignancy-associated pleural effusions were cytology-positive for malignant cells (54%), whereas all benign pleural effusions were negative. DNA was extracted from all the samples and analysed for MSI and/or LOH using the following microsatellite markers: D3S1234, D9S171, D12S363, D17S250, D5S346 and TP53Alu, located at five chromosomal regions: 3p, 9p, 12q, 17q, 5q. Microsatellite analysis of the pleural fluid pellet exhibited genetic alterations in two neoplastic pleural fluid cases and in one inflammatory case. Two out of 26 (7.6%) patients with malignant pleural effusion showed genetic alterations. One exhibited MSI in three different microsatellite markers (D17S250, D9S171, D3S134) and the other showed LOH in marker D3S134. One out of 22 (4.5%) patients with benign pleural effusion showed LOH in marker D3S134. In conclusion, genetic alterations at the level of microsatellite DNA, were detected only in very few cases of malignant pleural effusions, and in one case of benign pleural effusion. Thus, our data suggest that microsatellite DNA analysis does not facilitate the diagnosis of malignant pleural effusion.

Health-related quality of life in patients with obstructive sleep apnoea and chronic obstructive pulmonary disease (overlap syndrome).

The association of obstructive sleep apnoea (OSA) and chronic obstructive pulmonary disease (COPD) is not rare as COPD and OSA are both frequent diseases. The aim of this study was to determine the effect of OSA on quality of life (QOL) in patients with overlap syndrome (OVS). Thirty subjects with OVS and 15 control subjects participated. The St George's Respiratory Questionnaire (SGRQ) was used to determine QOL. The control group included subjects with COPD and no evidence of OSA by overnight polysomnography. All subjects were habitual snorers with normal Epworth Sleepiness Scale scores. Significant differences were found between the groups for the total score and each of the three components of the SGRQ suggesting worse QOL in OVS patients (symptoms 54.9 +/- 18.9 vs. 38.2 +/- 19.3, p = 0.008; activity 59.2 +/- 16.2 vs. 44.4 +/- 11.3, p = 0.003; impacts 35.2 +/- 23 vs. 20.8 +/- 8.7, p = 0.025 and total 45.7 +/- 17.7 vs. 30.9 +/- 8.7, p = 0.004 in OVS patients and control group, respectively). Obstructive sleep apnoea has a major impact on QOL in patients with OVS and can exist in COPD patients with habitual snoring even in the absence of daytime sleepiness. Further studies are needed to determine the impact of OSA treatment on QOL and morbidity in this population.

Assessing the knowledge of bronchial asthma among primary health care physicians in Crete: a pre- and post-test following an educational course.

AIM: To assess the level of knowledge for bronchial asthma of the primary healthcare physicians serving a rural population on the island of Crete, both before and immediately after a one-day educational course. METHODS: Twenty-one primary health care physicians, randomly selected from a list of 14 Health Care Centres on the island of Crete were invited to participate in the study and attended an educational course. Nine of the 21 physicians were fully qualified general practitioners, while the remainder were non-specialized (NSs) physicians who had recently graduated from the University of Crete, Medical School. A questionnaire of 20 items based on current bronchial asthma clinical guidelines was used. Three scores, the mean total, knowledge subscore and attitudes subscore, were calculated for each group of physicians, both before and after the course. RESULTS: At baseline mean total score and knowledge and attitudes subscores were higher for non-specialized physicians than for the general practitioners, but the differences were not statistically significant (p > 0.05). The knowledge subscore was improved in both groups, however the difference was statistically significant only for the non-specialized physicians (t = 2.628, d.f. = 11, p < 0.05). The mean total score after the course was significantly higher for the non-specialized physicians in comparison to that of the general practitioners (t=-2.688, d.f. = 19, p < 0.05). CONCLUSIONS: This study adds to the information about the success of continuing medical education, and also demonstrates that the recent graduates in the studied population, could be educated with more positive results than the fully qualified practitioners

Fibrinolytics in the treatment of parapneumonic effusions.

Intrapleural instillation of fibrinolytic agents has been shown, in a number of studies, to be an effective and safe mode of treatment in complicated parapneumonic effusions and empyema, minimizing the need for surgical intervention. Streptokinase and urokinase are the fibrinolytics used, but the technique of instillation is not yet standardized. The usual dose of streptokinase is 250,000 IU, 100,000 IU for urokinase. Fibrinolytics are diluted in 30-100 mL normal saline and the success rate ranges 50-100%, depending on the stage of pleural effusion. Generally, fibrinolytics are more successful if used early in the process of pleural infection (in complicated parapneumonic effusions rather than in empyemas). Adverse reactions are rare, of the allergic type and more frequent for streptokinase. Urokinase is safer but more expensive.

Utility of fibrinolytic agents for draining intrapleural infections.

Multiple studies have shown that the intrapleural instillation of fibrinolytic agents provides an effective and safe mode of treatment for complicated parapneumonic effusions and empyemas that decrease the need for surgical interventions. Although most investigators use streptokinase and urokinase, the technique of instillation is not standardized. The usual dose of streptokinase is 250,000 IU, but doses range from 50,000 to 220,000 IU for urokinase. Reported success rates range from 38% to 100%, but outcomes depend on the stage of progression of the parapneumonic effusion when fibrinolytics are employed. Fibrinolytics are more effective in complicated parapneumonic effusions than in established empyemas. Although complications of fibrinolytic therapy rarely occur, they result most often from allergic reactions to streptokinase. Urokinase is safer but more expensive. More randomized, comparative, controlled studies are needed to further define the most effective mode of fibrinolytic therapy for subgroups of patients with pleural infection.

Concurrent twice-a-week docetaxel and radiotherapy: a dose escalation trial with immunological toxicity evaluation.

PURPOSE: In vitro studies show that docetaxel (Taxotere) is potent radiosensitizer. In a previous study we observed a 27% complete response rate after radiotherapy and weekly docetaxel for non-small-cell lung cancer. In this dose escalation study we investigated the feasibility of a twice-a-week docetaxel regimen together with conventionally fractionated radiotherapy for brain, chest, and pelvic tumors. METHODS AND MATERIALS: Nine patients with stage IIIb lung cancer, 9 with stage IVa pelvic tumors, and 9 with brain glioblastoma were recruited. The starting dose was 15 mg/m2 (twice a week) and was escalated by 4 mg/m2 increments every 3 patients with chest, pelvic, and brain tumors. RESULTS: The maximum tolerated dose of docetaxel was 15 mg/m2 (twice a week) for chest and pelvic cancer patients. The dose-limiting toxicity (DLT) was asthenia and mucosal toxicity (esophagitis or diarrhea in chest and pelvic tumors, respectively). Patients with glioblastomas received 23 mg/m2 (twice a week) without toxicity. Complete response of the chest disease was observed in 3/9 (33%) patients and partial response in 4/9 (44%). Three patients with glioblastoma had a partial response. In pelvic malignancies a high complete response rate was observed (4/9; 45%). Severe monocytopenia and lymphocytopenia were observed during the fourth week of treatment. IgG and IgA immunoglobulins were also reduced. This coincided with the onset of asthenia and severe mucosal toxicity. Asthenia was absent in patients treated for brain tumors, and lymphocyte toxicity was less pronounced. CONCLUSIONS: Docetaxel radiochemotherapy is a promising therapeutic approach for locally advanced cancer. The recommended dose of docetaxel for chest and pelvic cancer patients is 15 mg/m2 twice a week. Patients with brain tumors can be safely treated with higher doses of docetaxel (23 mg/m2 twice a week) without toxicity. The severe immunologic toxicity observed suggests that granulocyte-macrophage colony-stimulating factor (GM-CSF) and immunoglobulin administration may be important in the efficacy and tolerance of taxane-based radiochemotherapy. Randomized trials are required to assess whether the efficacy of docetaxel radiochemotherapy depends on the frequency of docetaxel administration during radiation treatment.

Intrapleural urokinase versus normal saline in the treatment of complicated parapneumonic effusions and empyema. A randomized, double-blind study.

Intrapleural administration of fibrinolytic agents has been shown to be effective and safe in the treatment of loculated parapneumonic pleural effusions. However, controlled studies of the possible role of the activity of urokinase (UK) through the volume effect are lacking. We therefore investigated the hypothesis that UK is effective through the lysis of pleural adhesions and not through the volume effect. Thirty-one consecutive patients with multiloculated pleural effusions were randomly assigned to receive either intrapleural UK (15 patients) or normal saline (NS) (16 patients) for 3 d, in a double-blind manner. All patients had inadequate drainage through a chest tube (< 70 ml/24 h). UK was given daily through the chest tube in a dose of 100.000 IU diluted in 100 ml of NS. Controls were given the same volume of NS intrapleurally. Response was assessed by clinical outcome, fluid drainage, chest radiography, pleural ultrasonography (US) and/or computed tomography (CT). Clinical and radiographic improvement was noted in all but two patients in the UK group but in only four in the control group. The net mean volume drained during the 3-d treatment period was significantly greater in the UK group (970 +/- 75 ml versus 280 +/- 55 ml, p < 0.001). Pleural fluid drainage was complete in 13 (86.5%) patients in the UK group (two patients were treated through video-assisted thoracoscopy) but in only four (25%) in the control group. Twelve patients in the control group were subsequently treated with UK and six of them had complete drainage; the remaining six patients had complete drainage after video-assisted thoracoscopy. Our results suggest that UK is effective in the treatment of loculated pleural effusions through the lysis of pleural adhesions and not through the volume effect.

Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions: a prospective, double-blind study.

Intrapleural administration of fibrinolytics has been shown in small numbers of patients with complicated parapneumonic effusions (CPE) and pleural empyema to be effective and relatively safe. Although streptokinase (SK) is recommended as the fibrinolytic of choice, there are no comparative studies among fibrinolytics. We therefore compared the efficacy, safety, and the cost of treatment two of the most used thrombolytics, SK and urokinase (UK). Fifty consecutive patients with CPE or empyema were randomly allocated to receive either SK (25 patients) or UK, in a double-blind fashion. All patients had inadequate drainage through chest tube (< 70 ml/24 h). Both drugs were diluted in 100 ml normal saline and were infused intrapleurally through the chest tube in a daily dose of 250,000 IU of SK or 100,000 IU of UK. The chest tube was clamped for 3 h after instillation. Response was assessed by clinical outcome, fluid drainage, chest radiography, pleural ultrasound, and/or computed tomography. Clinical and radiologic improvement was noted in all but two patients in each group, who required surgical intervention. The mean volume drained during the first 24 h after instillation was significantly increased; 380 +/- 99 ml for the SK group (p < 0.001) and 420.8 +/- 110 ml for the UK group (p < 0.001). The total volume (mean +/- SD) of fluid drained after treatment was 1,596 +/- 68 ml for the SK group, and 1,510 +/- 55 ml for the UK group (p > 0.05). The SK instillations (mean +/- SD) were 6 +/- 2.16 (range, 3 to 10) and those of UK 5.92 +/- 2.05 (range, 3 to 8). High fever as adverse reaction to SK was observed in two patients. The total cost of the drug in the UK group was two times higher than that of SK ($180 +/- 47 for SK and $320 +/- 123 for UK). The mean total hospital stay after beginning fibrinolytic therapy was 11.28 +/- 2.44 d (range, 7 to 15) for the SK group and 10.48 +/- 2.53 d (range, 6 to 18) for the UK group (p = 0.32). We conclude that intrapleural SK or UK is an effective adjunct in the management of parapneumonic effusions and may reduce the need for surgery. UK could be the thrombolytic of choice given the potentially dangerous allergic reactions to SK and relatively little higher cost of UK.

Intrapleural urokinase in the treatment of complicated parapneumonic pleural effusions and empyema.

Intrapleural urokinase has not been evaluated systemically in terms of efficacy, safety, and cost of treatment in a large series of patients with complicated (parapneumonic) pleural effusions (CPE) and pleural empyemas (PE). Furthermore, the optimal dose and duration of treatment is not known. Twenty consecutive patients with multiloculated parapneumonic effusions (13 with CPE and 7 with PE), in whom a single chest tube failed to drain the fluid, were studied prospectively. The age of the patients ranged 15-92 yrs (median 51 yrs). Urokinase was administered intrapleurally, in a low single daily dose of 50,000 U in 100 mL normal saline via the chest tube. Previous intrapleural instillation of 100 mL normal saline failed to promote drainage in all patients. Urokinase enhanced drainage in all patients. Clinical and radiological improvement was noted in all but one patient. The mean (SD) volume of fluid significantly increased in the first 24 h post-urokinase (p<0.001). The number of urokinase instillations ranged 3-7 (median 5). Radiological evaluation showed excellent improvement in 13 of the 20 (65%) patients. Urokinase was well-tolerated in all patients. The clinical course of patients was uneventful at a mean follow-up of 15 months (range 6-30 months) later. Mean total cost of treatment was $530 +/- 34.6. Our results show that intrapleural instillation of small doses of urokinase is a cost-effective and safe mode of treatment of complicated pleural effusions and pleural empyema and could be the fibrinolytic of choice.

Role of streptokinase in the treatment of acute loculated parapneumonic pleural effusions and empyema.

BACKGROUND: Intrapleural administration of streptokinase has been shown in a few small series to be effective treatment for complicated parapneumonic effusions and pleural empyemas, but techniques of instillation of streptokinase differ. The role of streptokinase in promoting drainage was investigated prospectively in a larger series of patients with complicated parapneumonic effusions and pleural empyemas. METHODS: Twenty consecutive patients with parapneumonic effusions, 15 with complicated parapneumonic effusions and five with pleural empyemas, drawn from 160 patients presenting with pleural effusions were studied. The age of the patients ranged from 15 to 92 years. Initial thoracocentesis showed mean (SD) values of pH 7.1 (0.15), glucose 45.9 (17.5) mg/dl, white blood cell count 12,000 (6627)/mm3. Streptokinase was administered intrapleurally in a single daily dose of 250,000 units in 100 ml normal saline via the chest tube once the drainage was < 100 ml/24 hours. Patients were treated for 3-10 (mean 6) days. RESULTS: Following administration of streptokinase a clinical and radiological improvement was noted in all but one patient who died on the fourth day of hospitalisation due to widespread adenocarcinoma. Another patient with clinical but minimal radiological improvement underwent thoracotomy, but a clear pleural space with only fibrotic changes was found. The mean (SD) volume of fluid drained 24 hours before streptokinase was 42.5 (39) ml, which increased in the first 24 hours after streptokinase to 334 (130) ml. Radiological evaluation showed an excellent improvement in 14 of the 20 patients, a moderate improvement in three, and minimal improvement in the remaining three patients. One patient developed a high fever as an adverse reaction to streptokinase. All 19 patients who completed the treatment were well at follow up 6-30 months (mean 15 months) later. CONCLUSIONS: Intrapleural instillation of streptokinase is an effective and safe mode of treatment for complicated parapneumonic effusions and pleural empyemas and alleviates the need for thoracotomy.