Agronomic efficiency and heavy metal contamination of phosphorus (P) recycling products from old sewage sludge ash landfills

In einem modifizierten Neubauer-Gefäßversuch mit Roggen wurde die agronomische Effizienz von Recyclingprodukten untersucht, die aus einer für ca. 10 Jahre deponierten Klärschlammasche aus Monoverbrennung hergestellt wurden. Folgende Produkte wurden getestet: die deponierte Klärschlamm-Rohasche aus chemischer Fällung (SSA 1), ein Säureauszug ohne (SSA 2) und mit anschließender Ca-P-Fällung (SSA 3), und ein Produkt, welches nach dem Säureaufschluss einer Kationenaustauschprozedur unterworfen wurde (SSA 4). Zum Vergleich wurde eine thermochemisch behandelte Klärschlammasche (SSA-TC) mit untersucht, die den gegenwärtigen Stand der Technik repräsentiert. Als Referenz wurde ein kommer­zieller wasserlöslicher P-Mineraldünger (Superphosphat, SSP) eingesetzt. Die NAC-Löslichkeit von SSA 2–4 wurde durch den Säureaufschluss auf ein Niveau von 87–92% des Gesamt-P angehoben, im Vergleich zu 36,5% in der Rohasche (SSA 1) und 63% in SSA-TC. SSA 4 war das einzige Testprodukt mit einer hohen Wasserlöslichkeit (77% des Gesamt-P). Die auf den Trockenmasseertrag bezogene relative agronomische Effizienz (RAE-DMY) zeigte keine großen Unterschiede zwischen den Varianten, bei der optimalen P-Stufe (20 mg) variierte sie zwischen 84% des DMY-SSP für die Rohasche SSA 1 und 91% für SSA 2. Die Kalkulation der RAE bezogen auf die P-Aufnahme (RAE-PU) zeigte eine deutlichere Variation: Bei der P-Stufe 20 rangierte die RAE-PU zwischen 53,5% für SSA 1 und 99% für SSA 4. Somit unterschied sich SSA 4, das einzige wasserlösliche Testprodukt, deutlich von den nicht wasserlöslichen Varianten. Allerdings verzeichnete SSA 4 in der höchsten P-Stufe (40 mg) einen deutlichen Einbruch sowohl beim DMY als auch bei der P-Aufnahme. Dies war eine Folge von Na-Toxizität, die durch die behandlungsbedingt stark erhöhte Na-Konzentration dieses Testproduktes verursacht wurde.Mit der Säurebehandlung konnten die Schwermetallgehalte (As, Cd, Cr, Cu, Ni, Pb, Tl, Zn) der Rohasche signifikant reduziert werden, so dass die Grenzwerte der deutschen Düngemittelverordnung sicher eingehalten wurden. Die Urankonzentration war bereits im Ausgangs­material gering (2,9 mg/kg DM). Allerdings war auch die Ca-P-Fällung (SSA 3) nicht in der Lage, die hohen Fe- und Al-Konzentrationen des Ausgangsmaterials hinreichend zu reduzieren, um die (Re-)Formierung von unlöslichen Fe/Al-Phosphaten während des Experiments zu verhindern. Während durch einen Austausch der Kationen Al und Fe gegen Na (SSA 4) die Pflanzenverfügbarkeit und -aufnahme von P erhöht wurden, verursachte diese Behandlung andere, mit den ebenfalls erhöhten Na-Gehalten verbundene Schwierigkeiten.Das Experiment führte zu der Schlussfolgerung, dass weitere Versuchsansätze erforderlich sind, um P in einer Form aus der Klärschlammasche zu gewinnen, welche zugleich pflanzenverfügbar ist und möglichst geringe wachstumsreduzierende Kontaminanten wie Natrium oder Schwermetalle enthält, damit aschebasierte Recyclingdünger in Zukunft attraktiver werden.A modified Neubauer pot trial with rye was carried out to investigate the agronomic efficiency of different fertilizer products based on a sewage sludge monoincineration ash (SSA) which had been stored below ground for about ten years. Test products included the stored raw ash from chemically precipitated sewage sludge (SSA 1), an acid leaching treatment without (SSA 2) and with subsequent Ca-P precipitation (SSA 3), and a product subjected to an ion exchange process after acid leaching (SSA 4). For comparison, a thermo-chemically treated ash (SSA-TC) representing the currently available technology was also included. A commercial water soluble P fertilizer (SSP) was used as a reference. NAC-solubility of SSA 2–4 was increased by the acid leaching procedure up to a level around 87–92% of total P, compared to 36.5% in the raw ash (SSA 1) and 63% in SSA-TC. SSA 4 was the only test product with high water solubility (77% of total P). Relative agronomic efficiency related to dry matter yield (RAE-DMY) did not show large variation between products, ranging from 84% (SSA 1) to up to 91% (SSA 2) in comparison to the control (SSP) at the optimum P level (20 mg). A larger variation was displayed when relative agronomic efficiency regarding P uptake (RAE-PU) was calculated. At P level 20, RAE-PU ranged between 53.5% for SSA 1 up to 99% for SSA 4. Thus, the water soluble product clearly distinguished itself from the non-water soluble variants. However, at the highest P level (40 mg), there was a significant decrease in both DMY and PU for SSA 4, which could be explained by Na toxicity related to the high Na content of the product originating from the treatment procedure.The acid leaching treatment successfully reduced heavy metal contents (As, Cd, Cr, Cu, Ni, Pb, Tl, Zn) of the raw ash, so that the limit values of the German Fer­tilizer Ordinance were safely met. U concentration was already low (2.9 mg/kg DM) in the raw material. However, even the Ca-precipitation (SSA 3) was not able to reduce the initially high Fe and Al concentrations to a sufficiently low level to prevent the (re-)formation of insoluble Fe/Al-phosphates during the experiment. While the exchange of the cations Al and Fe by Na (SSA 4) was able to enhance the plant availability and uptake of P, it induced other difficulties related to the increase in Na content.It was concluded that, to make the ash-based recycling fertilizers more attractive, further research is needed to find a procedure which will make the ash-P plant available and at the same time result in a product which is low in growth-reducing contaminants such as sodium or heavy metals

Combined multidisciplinary in/outpatient rehabilitation delays definite nursing home admission in advanced Parkinson’s disease patients

IntroductionAdvanced Parkinson’s disease (aPD) patients have a high risk on definite nursing home admission. We analyzed the effectiveness of an in-and outpatient multidisciplinary rehabilitation, focusing on activities of daily living (ADL) and delaying definite nursing home admission.MethodsThis study included 24 aPD patients, who received a 6-week inpatient multidisciplinary rehabilitation program, including optimization of pharmacotherapy, which was followed by an individualized outpatient support program during 2 years (intervention group). A non-randomized matched control group (n = 19), received care as usual. Primary endpoints consisted of the Amsterdam Linear Disability Scale (ALDS) and percentage of patients being able to live independently at home after 2 years. Secondary endpoints included changes in medication (LEDD), motor performance (SCOPA-SPES), cognition (SCOPA-COG), hallucinations (NPI) and depression (BDI).ResultsOverall, 83% of patients were able to return home after the 6-week inpatient intervention, and 65% still lived at home at 2 years follow-up. Median ALDS scores after 2 years in the intervention group were significantly better, compared to the control group (p = 0.002). All secondary endpoints had improved significantly vs. baseline directly after the 6-week inpatient rehabilitation, which had disappeared at 2 years follow-up, with the exception of the daily dose of medication, which was significantly higher in the intervention group.ConclusionThis 2-year follow-up study showed that a combined multidisciplinary in/outpatient rehabilitation program for aPD patients, was able to stabilize ADL functions, and finally delayed definite nursing home admissions in 65% of treated patients.Trial registrationfilenumber M10.091051; ABR code NL32699.042.10

Cost-Effectiveness and Cost-Utility of Early Levodopa in Parkinson's Disease

Background: In the Levodopa in EArly Parkinson's disease (LEAP) study, 445 patients were randomized to levodopa/carbidopa 100/25 mg three times per day for 80 weeks (early-start) or placebo for 40 weeks followed by levodopa/carbidopa 100/25 mg three times per day for 40 weeks (delayed-start).Objective: This paper reports the results of the economic evaluation performed alongside the LEAP-study.Methods: Early-start treatment was evaluated versus delayed-start treatment, in which the cost-effectiveness analysis (CEA) and the cost-utility analysis (CUA) were performed from the societal perspective, including health care costs among providers, non-reimbursable out-of-pocket expenses of patients, employer costs of sick leave, and lowered productivity while at work. The outcome measure for the CEA was the extra cost per unit decrease on the Unified Parkinson's Disease Rating Scale 80 weeks after baseline. The outcome measure for the CUA was the extra costs per additional quality adjusted life year (QALY) during follow-up.Results: 212 patients in the early-start and 219 patients in the delayed-start group reported use of health care resources. With savings of D 59 per patient (BCa 95% CI: -829, 788) in the early-start compared to the delayed-start group, societal costs were balanced. The early-start group showed a mean of 1.30 QALYs (BCa 95% CI: 1.26, 1.33) versus 1.30 QALYs (BCa 95% CI: 1.27, 1.33) for the delayed-start group. Because of this negligible difference, incremental cost-effectiveness and cost-utility ratios were not calculated.Conclusion: From an economic point of view, this study suggests that early treatment with levodopa is not more expensive than delayed treatment with levodopa.Neurological Motor Disorder

Datasets for the Reporting of Primary Tumour in Bone: Recommendations From the International Collaboration on Cancer Reporting (ICCR)

BACKGROUND AND OBJECTIVES: Bone tumours are relatively rare and, as a consequence, treatment in a centre with expertise is required. Current treatment guidelines also recommend review by a specialised pathologist. Here we report on international consensus-based datasets for the pathology reporting of biopsy and resection specimens of bone sarcomas. The datasets were produced under the auspices of the International Collaboration on Cancer Reporting (ICCR), a global alliance of major (inter-)national pathology and cancer organisations. METHODS AND RESULTS: According to the ICCR\u27s process for dataset development, an international expert panel consisting of pathologists, an oncologic orthopaedic surgeon, a medical oncologist, and a radiologist produced a set of core and noncore data items for biopsy and resection specimens based on a critical review and discussion of current evidence. All professionals involved were bone tumour experts affiliated with tertiary referral centres. Commentary was provided for each data item to explain the rationale for selecting it as a core or noncore element, its clinical relevance, and to highlight potential areas of disagreement or lack of evidence, in which case a consensus position was formulated. Following international public consultation, the documents were finalised and ratified, and the datasets, including a synoptic reporting guide, were published on the ICCR website. CONCLUSION: These first international datasets for bone sarcomas are intended to promote high-quality, standardised pathology reporting. Their widespread adoption will improve the consistency of reporting, facilitate multidisciplinary communication, and enhance comparability of data, all of which will help to improve management of bone sarcoma patients

Durvalumab after chemoradiotherapy in patients with stage III non-small-cell lung cancer: real-world outcomes versus clinical trial results

Aim: We investigated the effectiveness of durvalumab post-concurrent CRT (cCRT) and post-sequential CRT (sCRT) versus cCRT and sCRT alone and compared these outcomes with the PACIFIC trial. Methods: Four cohorts of stage III NSCLC patients who received CRT were included: cCRT with and without durvalumab, sCRT with and without durvalumab. PFS and OS were analyzed using Cox regression. Results: Durvalumab improved PFS (cCRT: aHR = 0.69, sCRT: aHR = 0.71) and OS (cCRT: aHR = 0.71, sCRT: aHR = 0.32), although not all results were significant. PFS was longer in the real-world than in the trial, while OS did not differ. Conclusion: Durvalumab after CRT improved the survival outcomes. The difference between PFS in our study and the trial may be due to differences in follow-up methods. Plain language summary We assessed a medicine called durvalumab on patients with non-small cell lung cancer who received chemoradiotherapy in a real-world setting. We compared their outcomes with those from a clinical trial. Patients who received two types of chemoradiotherapy with or without durvalumab were included, and their progression-free survival (PFS) and overall survival (OS) outcomes were analyzed. We found that patients treated with durvalumab had better PFS and OS than those treated without durvalumab. PFS was longer in the real-world than in the clinical trial, but OS was similar. The difference in PFS may be due to differences in measuring PFS

Durvalumab after chemoradiotherapy in patients with stage III non-small-cell lung cancer: real-world outcomes versus clinical trial results

Aim: We investigated the effectiveness of durvalumab post-concurrent CRT (cCRT) and post-sequential CRT (sCRT) versus cCRT and sCRT alone and compared these outcomes with the PACIFIC trial. Methods: Four cohorts of stage III NSCLC patients who received CRT were included: cCRT with and without durvalumab, sCRT with and without durvalumab. PFS and OS were analyzed using Cox regression. Results: Durvalumab improved PFS (cCRT: aHR = 0.69, sCRT: aHR = 0.71) and OS (cCRT: aHR = 0.71, sCRT: aHR = 0.32), although not all results were significant. PFS was longer in the real-world than in the trial, while OS did not differ. Conclusion: Durvalumab after CRT improved the survival outcomes. The difference between PFS in our study and the trial may be due to differences in follow-up methods. Plain language summary We assessed a medicine called durvalumab on patients with non-small cell lung cancer who received chemoradiotherapy in a real-world setting. We compared their outcomes with those from a clinical trial. Patients who received two types of chemoradiotherapy with or without durvalumab were included, and their progression-free survival (PFS) and overall survival (OS) outcomes were analyzed. We found that patients treated with durvalumab had better PFS and OS than those treated without durvalumab. PFS was longer in the real-world than in the clinical trial, but OS was similar. The difference in PFS may be due to differences in measuring PFS

Enrichment of Sialylated IgG by Lectin Fractionation Does Not Enhance the Efficacy of Immunoglobulin G in a Murine Model of Immune Thrombocytopenia

Intravenous immunoglobulin G (IVIg) is widely used against a range of clinical symptoms. For its use in immune modulating therapies such as treatment of immune thrombocytopenic purpura high doses of IVIg are required. It has been suggested that only a fraction of IVIg causes this anti immune modulating effect. Recent studies indicated that this fraction is the Fc-sialylated IgG fraction. The aim of our study was to determine the efficacy of IVIg enriched for sialylated IgG (IVIg-SA (+)) in a murine model of passive immune thrombocytopenia (PIT). We enriched IVIg for sialylated IgG by Sambucus nigra agglutinin (SNA) lectin fractionation and determined the degree of sialylation. Analysis of IVIg-SA (+) using a lectin-based ELISA revealed that we enriched predominantly for Fab-sialylated IgG, whereas we did not find an increase in Fc-sialylated IgG. Mass spectrometric analysis confirmed that Fc sialylation did not change after SNA lectin fractionation. The efficacy of sialylated IgG was measured by administering IVIg or IVIg-SA (+) 24 hours prior to an injection of a rat anti-mouse platelet mAb. We found an 85% decrease in platelet count after injection of an anti-platelet mAb, which was reduced to a 70% decrease by injecting IVIg (p<0.01). In contrast, IVIg-SA (+) had no effect on the platelet count. Serum levels of IVIg and IVIg-SA (+) were similar, ruling out enhanced IgG clearance as a possible explanation. Our results indicate that SNA lectin fractionation is not a suitable method to enrich IVIg for Fc-sialylated IgG. The use of IVIg enriched for Fab-sialylated IgG abolishes the efficacy of IVIg in the murine PIT model