Anterior spinal fusion (ALIF/OLIF/LLIF) with lumbosacral transitional vertebra: A systematic review and proposed treatment algorithm.

•Key anterior approaches differences in LSTV include vascular (aortic bifurcation/iliocaval confluence), muscular (psoas) and osseus anatomy (inter-crestal tangent/pubic symphysis), when compared to non-LSTV.•There are increased surgical deviations but not significantly greater complications for anterior approaches in LSTV.•Vascular awareness while accessing L45 will be in the presence of a more cephalad ABF and ICC with sacralized L5, and access to the deeper L56 level will be in the presence of a more caudal ABF and ICC in lumbarized S1.

Antidepressants Trial in Parkinson's Disease (ADepT-PD): protocol for a randomised placebo-controlled trial on the effectiveness of escitalopram and nortriptyline on depressive symptoms in Parkinson's disease.

BACKGROUND: Depressive symptoms are common in patients with Parkinson's disease and depression is a significant predictor of functional impairment, reduced quality of life and general well-being in Parkinson's disease. Despite the high prevalence of depression, evidence on the effectiveness and tolerability of antidepressants in this population is limited. The primary aim of this trial is to establish the clinical and cost effectiveness of escitalopram and nortriptyline for the treatment of depression in Parkinson's disease. METHODS: This is a multi-centre, double-blind, randomised placebo-controlled trial in 408 people with Parkinson's disease with subsyndromal depression, major depressive disorder or persistent depressive disorder and a Beck Depression Inventory-II (BDI-II) score of 14 or above. Participants will be randomised into one of three groups, receiving either escitalopram, nortriptyline or placebo for 12 months. Trial participation is face-to-face, hybrid or remote. The primary outcome measure is the BDI-II score following 8 weeks of treatment. Secondary outcomes will be collected at baseline, 8, 26 and 52 weeks and following withdrawal, including severity of anxiety and depression scores as well as Parkinson's disease motor severity, and ratings of non-motor symptoms, cognitive function, health-related quality of life, levodopa-equivalence dose, changes in medication, overall clinical effectiveness, capability, health and social care resource use, carer health-related quality of life, adverse effects and number of dropouts. DISCUSSION: This trial aims to determine the effectiveness of escitalopram and nortriptyline for reducing depressive symptoms in Parkinson's disease over 8 weeks, to provide information on the effect of these medications on anxiety and other non-motor symptoms in PD and on impact on patients and caregivers, and to examine their effect on change in motor severity. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03652870 Date of registration - 29th August 2018.

Impulse control disorders are associated with lower ventral striatum dopamine D3 receptor availability in Parkinson's disease: A [11C]-PHNO PET study.

INTRODUCTION: Reduced postsynaptic D3 dopaminergic receptor availability has been reported in the ventral striatum of pathological gamblers without Parkinson's disease (PD) and in patients with PD and impulse control disorders (ICD). However, a direct relationship between ventral striatum D3 dopaminergic receptors and the severity of ICD in PD patients has not yet been proven using a validated tool for ICD in PD, such as the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's disease-Rating Scale (QUIP-RS). In this pilot study, we investigated the relationship between ventral striatum D3 dopamine receptor availability and severity of impulse control disorder (ICD) in Parkinson's disease (PD). METHODS: Twelve patients were assessed with PET and the high affinity dopamine D3 receptor radioligand [11C]-PHNO. Severity of ICD was assessed with the QUIP-RS. RESULTS: We found that lower ventral striatum D3 receptor availability measured with [11C]-PHNO PET was associated with greater severity of ICD, as measured by the QUIP-RS score (rho = -0.625, p = 0.03). CONCLUSION: These findings suggest that the occurrence and severity of ICD in Parkinson's disease may be linked to reductions in ventral striatum dopamine D3 receptor availability. Further studies in larger cohort of patients need to be performed in order to confirm our findings and clarify whether lower ventral striatum D3 receptor may reflect a pharmacological downregulation to higher dopamine release in ventral striatum of patients with ICD or a patients' predisposition to ICD.

A novel use of cement as a salvage procedure in patients with complex spinal injuries with proximal junctional failure.

Long-construct fixations can be complicated by proximal junctional kyphosis. In elderly, high-risk patients with numerous comorbidities, lengthy surgical times and increased blood loss associated with revision osteotomies and extension of fusions are not often tolerated and pose serious life-threatening risks. We present a salvage technique used in a patient with proximal junctional failure and demonstrate its role in improving symptoms and functionality in those not deemed fit for major surgery. Pre- and postoperative pain scores in accordance with the visual analogue scale, walking distances and radiographs were reviewed in a patient who underwent the salvage technique to ascertain the subjective and objective difference in pain and functionality. The patient showed marked improvement in pain scores and walking distances postoperatively. Additionally, the degree of proximal junctional kyphosis was lower on postoperative radiographs. While holding risks of its own, our described technique can be performed in select cases and is a good salvage procedure in high-risk patients. It prevents their exposure to the risks that accompany large revision operations and fusion models with further potential to fail. We recommend that our technique is performed only at specialist centres.

Assessment of corrosion in retrieved spine implants.

Recently the use of dissimilar metals in spine instrumentation has increased, especially in the case of adult deformities, where rods made from Cobalt Chrome alloys (CoCr) are used with Titanium (Ti) screws. The use of dissimilar metals increases the risk of galvanic corrosion and patients have required revision spine surgery due to severe metallosis that may have been caused by corrosion. We aimed to assess the presence of corrosion in spine implant retrievals from constructs with two types of material combinations: similar (Ti/Ti) and dissimilar (CoCr/Ti). First, we devised a grading score for corrosion of the rod-fixture junctions. Then, we applied this score to a collection of retrieved spine implants. Our proposed corrosion grading score was proven reliable (kappa > 0.7). We found no significant difference in the scores between 4 CoCr and 11 Ti rods (p = 0.0642). There was no indication that time of implantation had an effect on the corrosion score (p = 0.9361). We recommend surgeons avoid using implants designs with dissimilar metals to reduce the risk of corrosion whilst a larger scale study of retrieved spine implants is conducted. Future studies can now use our scoring system for spine implant corrosion. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 632-638, 2018.

Roaming behaviour of dogs in four remote Aboriginal communities in the Northern Territory, Australia: preliminary investigations.

OBJECTIVE: To estimate the home range (HR) and investigate the potential predictors for roaming of 58 dogs in four Aboriginal communities in the Northern Territory. DESIGN: Prospective study. PROCEDURE: Global positioning system (GPS) collars were attached to the dogs for 1-4 days, recording location fixes every 1-3 min. Utilisation distributions (UDs) and extended (95% isopleth) and core (50% isopleth) HRs of dogs were determined. Potential predictors of roaming were assessed. RESULTS: Estimated core (median, 0.27 ha) and extended (median, 3.1 ha) HRs differed significantly (P = 0.0225 and 0.0345, respectively) between the four communities; dogs in the coastal community travelled significantly (P < 0.0001) more per day than dogs in the three inland communities studied. Significant associations were found between extended HR size and sex (P = 0.0050) and sex + neuter (P = 0.0218), and between core HR size and sex (P = 0.0010), neuter status (P = 0.0255) and sex + neuter (P = 0.0025). Entire males roamed more than neutered females. The core HR of dogs with poor/fair body condition scores (BCSs) was larger than dogs with ideal/obese BCSs (P = 0.0394). Neutered male dogs also travelled more per day than entire female dogs (P = 0.0475). CONCLUSIONS: Roaming information can be used to inform the management of dogs in remote communities and to design disease control programs. Widespread data collection across the Northern Territory should be undertaken to further investigate the associations found in this study, considering that data were collected during relatively short periods of time in one season.

What influences the home range size of free-roaming domestic dogs?

In many regions of the world domestic dogs are free roaming and live in close relationship with humans. These free-roaming domestic dogs (FRDD) can cause public health problems such as dog bites and transmission of infectious diseases. To effectively control diseases transmitted by FRDD, knowledge on the dogs' behaviour is required. To identify predictors of home range (HR) size, we collected global positioning system data from 135 FRDD living in eight Aboriginal and Torres Strait Islander communities in Northern Australia. The core HR size ranged from 0·17 to 2·33 ha and the extended HR size from 0·86 to 40·46 ha. Using a linear mixed effect model with a Restricted Maximum Likelihood approach, the dog's sex and reproductive status were identified as predictors of roaming. Non-castrated males had the largest HRs, followed by neutered females. Also, FRDDs were found to roam further during the pre- than the post-wet season. These findings have implications for infectious disease spread. Identification of risk groups for disease spread within a population allows for more targeted disease response and surveillance. Further investigation of predictors of roaming in other FRDD populations worldwide would increase the external validity of such studies.

Spatial and temporal microbial pollution patterns in a tropical estuary during high and low river flow conditions.

Spatial and temporal patterns of coastal microbial pollution are not well documented. Our study examined these patterns through measurements of fecal indicator bacteria (FIB), nutrients, and physiochemical parameters in Hilo Bay, Hawai'i, during high and low river flow. >40% of samples tested positive for the human-associated Bacteroides marker, with highest percentages near rivers. Other FIB were also higher near rivers, but only Clostridium perfringens concentrations were related to discharge. During storms, FIB concentrations were three times to an order of magnitude higher, and increased with decreasing salinity and water temperature, and increasing turbidity. These relationships and high spatial resolution data for these parameters were used to create Enterococcus spp. and C. perfringens maps that predicted exceedances with 64% and 95% accuracy, respectively. Mapping microbial pollution patterns and predicting exceedances is a valuable tool that can improve water quality monitoring and aid in visualizing FIB hotspots for management actions.

The relationship between spinopelvic measurements and patient-reported outcome scores in patients with multiple myeloma of the spine.

AIMS: Patients with multiple myeloma (MM) develop deposits in the spine which may lead to vertebral compression fractures (VCFs). Our aim was to establish which spinopelvic parameters are associated with the greatest disability in patients with spinal myeloma and VCFs. PATIENTS AND METHODS: We performed a retrospective cross-sectional review of 148 consecutive patients (87 male, 61 female) with spinal myeloma and analysed correlations between spinopelvic parameters and patient-reported outcome scores. The mean age of the patients was 65.5 years (37 to 91) and the mean number of vertebrae involved was 3.7 (1 to 15). RESULTS: The thoracolumbar region was most commonly affected (109 patients, 73.6%), and was the site of most posterior vertebral wall defects (47 patients, 31.8%). Poorer Oswestry Disability Index scores correlated with an increased sagittal vertical axis (p = 0.006), an increased number of VCFs (p = 0.035) and sternal involvement (p = 0.012). Poorer EuroQol visual analogue scale scores correlated with posterior vertebral wall defects in the thoracolumbar region (p = 0.012). The sagittal vertical axis increased with the number of fractures and kyphosis in the thoracolumbar (p = 0.009) and lumbar (p < 0.001) regions. CONCLUSIONS: In MM, patients with VCFs have poorer clinical scores at presentation in the presence of sagittal imbalance. Outcome is particularly affected by multiple fractures in the thoracolumbar and lumbar regions and by failure to prevent kyphosis. Patients with MM should be screened for spinal lesions early. Cite this article: Bone Joint J 2016;98-B:1234-9.

Cortical Lewy bodies and Aß burden are associated with prevalence and timing of dementia in Lewy body diseases.

AIMS: Our main objective was to determine the neuropathological correlates of dementia in patients with Lewy body disease (LBD). Furthermore, we used data derived from clinical, neuropathological and genetic studies to investigate boundary issues between Dementia with Lewy bodies (DLB) and Parkinson's disease with (PDD) and without (PDND) dementia. METHODS: One hundred and twenty-one cases with a neuropathological diagnosis of LBD and clinical information on dementia status were included in the analysis (55 PDD, 17 DLB and 49 PDND). We carried out topographical and semi-quantitative assessment of Lewy bodies (LB), Aß plaques and tau-positive neuropil threads (NT). The APOE genotype and MAPT haplotype status were also determined. RESULTS: The cortical LB (CLB) burden was the only independent predictor of dementia (OR: 4.12, P < 0.001). The total cortical Aß plaque burden was an independent predictor of a shorter latency to dementia from onset of motor signs (P = 0.001). DLB cases had a higher LB burden in the parietal and temporal cortex, compared to PDD. Carrying at least one APOE ϵ4 allele was associated with a higher cortical LB burden (P = 0.02), particularly in the neocortical frontal, parietal and temporal regions. CONCLUSIONS: High CLB burden is a key neuropathological substrate of dementia in LBD. Elevated cortical LB pathology and Aß plaque deposition are both correlated with a faster progression to dementia. The higher CLB load in the temporal and parietal regions, which seems to be a distinguishing feature of DLB, may account for the shorter latency to dementia and could be mediated by the APOE ϵ4 allele.

Factors controlling volatile organic compounds in dwellings in Melbourne, Australia.

This study characterized indoor volatile organic compounds (VOCs) and investigated the effects of the dwelling characteristics, building materials, occupant activities, and environmental conditions on indoor VOC concentrations in 40 dwellings located in Melbourne, Australia, in 2008 and 2009. A total of 97 VOCs were identified. Nine VOCs, n-butane, 2-methylbutane, toluene, formaldehyde, acetaldehyde, d-limonene, ethanol, 2-propanol, and acetic acid, accounted for 68% of the sum of all VOCs. The median indoor concentrations of all VOCs were greater than those measured outdoors. The occupant density was positively associated with indoor VOC concentrations via occupant activities, including respiration and combustion. Terpenes were associated with the use of household cleaning and laundry products. A petroleum-like indoor VOC signature of alkanes and aromatics was associated with the proximity of major roads. The indoor VOC concentrations were negatively correlated (P < 0.05) with ventilation. Levels of VOCs in these Australian dwellings were lower than those from previous studies in North America and Europe, probably due to a combination of an ongoing temporal decrease in indoor VOC concentrations and the leakier nature of Australian dwellings.

Patient-reported outcomes in routine cancer clinical practice: a scoping review of use, impact on health outcomes, and implementation factors.

BACKGROUND: This review focused on the identification of patient-reported outcome measures (PROMs) used in routine cancer clinical practice, the impact on patient, provider, and system outcomes, and the implementation factors influencing uptake. METHODS: A scoping review of the published health literature was conducted using empirical databases, namely, Ovid Medline (2003 to September 2013), CINAHL (2003-2013) and PsycINFO (2003-2013). Scoping reviews are systematic literature reviews in a broad topic area that provide relevant and quantified results about the knowledge available on a particular topic and aim to rapidly map and synthesize the evidence to emphasize what is known. RESULTS: From a total of 2447 unique publications, 30 articles that met eligibility criteria were reviewed. PRO use appears to be acceptable to patients, enables earlier detection of symptoms and may improve communication between clinicians and patients. However, the impact of routine PROMs collection on health outcomes is less clear and high-quality research is still warranted. CONCLUSION: PROMs use in routine cancer clinical practice is growing with improvements on essential care processes shown but a number of implementation barriers must still be addressed. The lack of standardization in PROMs used in cancer organizations may make it difficult to use these data for quality monitoring in the future.

Neurological, visual, and MRI brain scan findings in 87 South African patients with HIV-associated cryptococcal meningoencephalitis.

BACKGROUND: HIV-associated cryptococcal meningoencephalitis (CM) is a leading cause of adult meningitis in sub-Saharan Africa. Neuroradiological data is however limited to case reports and small case series from developed countries and/or immunocompetent patients. METHODS: Eighty seven patients aged ≥18 hospitalized with a first episode of CM had magnetic resonance (MRI) imaging during the first two weeks of admission. A subset of eleven patients had follow-up scans approximately one month from their initial MRI scan. All had prospectively-recorded detailed neurological and visual examinations. RESULTS: An abnormal finding on neurological examination was detected in 33 (39%) patients. 38 (48%) patients experienced some visual loss. Neuroradiological lesions presumed to be cryptococcosis-related, as defined by the presence of dilated Virchow Robin spaces, pseudocysts or cryptococcomas, enhancing nodules, hydrocephalus, meningitis, focal perilesional oedema and infarcts, were detected in 55 (63%) patients. MRI findings suggestive of a second diagnosis were found in 18 (21%) patients. Visual loss was associated with the presence of cryptococcal-related lesions (p = 0.02). Blindness was associated with raised intracranial pressure (ICP) (p = 0.02). Of eleven patients with paired scans, brain swelling was identified on the initial scan in only one patient. CONCLUSION: The majority of patients had MRI brain scan abnormalities presumed secondary to CM. Dilated Virchow Robin spaces were the commonest neuroradiological lesion. Visual loss was associated with the degree of cerebral involvement as reflected by the presence of MRI abnormalities. Blindness was associated with the presence of raised ICP. Initial generalised brain swelling does not appear to be common, but further studies with paired scans are needed.

A review of the surgical management of sacral chordoma.

BACKGROUND: Sacral chordomas are rare low-to-intermediate grade malignant tumours, which arise from remnants of the embryonic notochord. This review explores prognostic factors in the management of sacral chordomas and provides guidance on the optimal treatment regimens based on the current literature. PATIENTS AND METHODS: Electronic searches were performed using MEDLINE, Embase and the Cochrane library to identify studies on prognostic factors in the management of sacral chordomas published between January 1970 and December 2013. The literature search and review process identified 100 articles that were included in the review article. This included both surgical and non-surgical studies on the management of sacral chordomas. RESULTS: Sacrectomy with wide resection margins forms the mainstay of treatment but is associated with high risk of disease recurrence and reduced long-term survival. Adequate resection margins may require sacrifice of adjacent nerve roots, musculature and ligaments leading to functional compromise and mechanical instability. Large tumour size (greater than 5-10 cm in diameter), dedifferentiation and greater cephalad tumour extension are associated with increased risk of disease recurrence and reduced survival. Chordomas are poorly responsive to conventional radiotherapy and chemotherapy. CONCLUSION: Operative resection with wide resection margins offers the best long-term prognosis. Inadequate resection margins, large tumour size, dedifferentiation, and greater cephalad chordoma extension are associated with poor oncological outcomes. Routine long-term follow-up is essential to enable early detection and treatment of recurrent disease.

Enhanced detection of infectious salmon anaemia virus using a low-speed centrifugation technique in three fish cell lines.

Infectious salmon anaemia (ISA), caused by ISA virus (ISAV), is a serious disease of farmed Atlantic salmon, Salmo salar L. Recently, molecular- and immunofluorescent-based techniques have become powerful diagnostic tools for ISAV detection, but culture-based techniques remain the gold standard. A disadvantage of ISAV culture is that the incubation time required before cytopathic effect (CPE) is observed in cell monolayers. To decrease time until CPE is observed, a low-speed centrifugation technique was applied to existing standard operating procedures for ISAV culture in three fish cell lines. Time until CPE observation was compared in CHSE, SHK and ASK cells, treated or not treated with low-speed centrifugation after inoculation with ISAV. Low-speed centrifugation treatment significantly enhanced observable cell infection. Compared to control cells, the length of time until ISAV CPE observation decreased in centrifuged ASK and CHSE cells. Low-speed centrifugation was also incorporated into a modified clinical shell vial assay. At 48 h post-inoculation with approximately 20 viral particles, ISAV was detected by an immunofluorescence antibody test in treated ASK and SHK1 cells but not in control cells. Finally, this enhanced viral adsorption assay performed in ASK cells demonstrated higher sensitivity than a real-time RT-PCR assay performed on RNA isolated from ISAV-spiked salmon kidney homogenates.

Sporadic Cryptosporidium infection in Nigerian children: risk factors with species identification.

A cross-sectional study was conducted to investigate risk factors for sporadic Cryptosporidium infection in a paediatric population in Nigeria. Of 692 children, 134 (19·4%) were infected with Cryptosporidium oocysts. Cryptosporidium spp. were identified in 49 positive samples using PCR-restriction fragment length polymorphism and direct sequencing of the glycoprotein60 (GP60) gene. Generalized linear mixed-effects models were used to identify risk factors for all Cryptosporidium infections, as well as for C. hominis and C. parvum both together and separately. Risk factors identified for all Cryptosporidium infections included malaria infection and a lack of Ascaris infection. For C. hominis infections, stunting and younger age were highlighted as risk factors, while stunting and malaria infection were identified as risk factors for C. parvum infection.

Depressive symptoms in PD correlate with higher 5-HTT binding in raphe and limbic structures.

BACKGROUND: Depression associated with Parkinson disease (PD) has a different symptom profile to endogenous depression. The etiology of depression in PD remains uncertain though abnormal serotonergic neurotransmission could play a role. OBJECTIVE: To assess with PET serotonergic function via in vivo serotonin transporter (5-HTT) availability in antidepressant-naive patients with PD. METHODS: Thirty-four patients with PD and 10 healthy matched control subjects had a clinical battery of tests including the patient-report Beck Depression Inventory-II (BDI-II), the clinician-report Hamilton Rating Scale for Depression (HRSD), and the structured clinical interview for DSM-IV Axis I Disorders (SCID-I). They underwent ¹¹C-DASB PET, a selective in vivo marker of 5-HTT binding in humans. RESULTS: BDI-II scores correlated with HRSD scores. Ten of 34 patients with PD (29.4%) had BDI-II and HRSD scores above the discriminative cutoff for PD depression though only half of these patients could be classed on SCID-I criteria as having an anxiety/mood disorder. Patients with PD with the highest scores for depression symptoms showed significantly raised ¹¹C-DASB binding in amygdala, hypothalamus, caudal raphe nuclei, and posterior cingulate cortex compared to low score cases, while ¹¹C-DASB binding values in other regions were similarly decreased in depressed and nondepressed patients with PD compared to healthy controls. CONCLUSION: Depressive symptoms in antidepressant-naive patients with PD correlate with relatively higher 5-HTT binding in raphe nuclei and limbic structures possibly reflecting lower extracellular serotonin levels. Our data are compatible with a key role of abnormal serotonergic neurotransmission contributing to the pathophysiology of PD depression and justify the use of agents acting on 5-HTT.

The contralateral lamina: a reliable guide in subaxial, cervical pedicle screw placement.

We have assessed the clinical observation that the angle of the contralateral lamina matches the angle required from the sagital plane for the placement of pedicle screws in the subaxial cervical spine. Fifty-four randomly chosen axial CT scans taken between December 2003 and December 2004 were examined. Subjects were excluded if the scan showed signs of fracture, tumour or gross abnormality. The digitised images were analysed on the Philips PACS system using SECTRA software. One hundred and sixty-eight individual vertebrae were assessed between C3 and C7. The following were measured; the angle of the pedicle relative to the sagital plane, the smallest internal and external diameter of the pedicles and the angle of the lamina. Angular measures had a CV% of 3.9%. The re-measurement error for distance was 0.5 mm. Three hundred and thirty-six pedicles were assessed in 25 females and 29 males. Average age was 48.2 years (range 17-85). Our morphologic data from live subjects was comparable to previous cadaveric data. Mean pedicle external diameter was 4.9 mm at C3 and 6.6 mm at C7. Females were marginally smaller than males. Left and right did not significantly differ. In no case was the pedicle narrower than 3.2 mm. Mean pedicle angle was 130 degrees at C3 and 140 degrees at C7. The contralateral laminar angle correlated well at C3, 4, 5 (R (2) = 0.9, C3 P = 0.002, C4 P = 0.06, C5 P = 0.0004) and was within 1 degrees of pedicle angle. At C6, 7 it was within 11 degrees . In all cases a line parallel to the lamina provided a safe corridor of 3 mm for a pedicle implant. The contralateral lamina provides a reliable intraoperative guide to the angle from the sagital plane for subaxial cervical pedicle instrumentation in adults.

The use of copper and silver in carbon point-of-use filters for the suppression of Legionella throughput in domestic water systems.

AIMS: To evaluate throughput of seeded Legionella pneumophila bacteria in domestic point-of-use filters. METHODS AND RESULTS: The filters were challenged with tap water seeded with Leg. pneumophila. After multiple challenge events (4.25 x 10(11) CFU per filter), the levels of Legionella were lower in the effluent from the filter containing both copper and silver (mean 4.48 x 10(3) CFU ml(-1)) than in the effluent from the filter containing copper only (1.26 x 10(4) CFU ml(-1); P < 0.001). After a single challenge event of approx. 5 x 10(9) CFU L. pneumophila per filter, there was no significant difference between the levels of Legionella in the effluents from a carbon filter containing copper and a carbon filter with no metals (mean 6.87 x 10(2) and 6.89 x 10(2) CFU ml(-1), respectively; P = 0.985). CONCLUSIONS: Legionella was detected in filter effluent up to 6 weeks after being challenged, indicating that while filters may reduce the levels during an initial contamination event, the exposure is extended as the accumulated bacteria slough off over time. SIGNIFICANCE AND IMPACT OF THE STUDY: This study has provided an understanding of the response of Legionella to the use of silver and copper in domestic point-of-use carbon filters.