The water we would like

Water is needed for our health: it maintains the health and integrity of every cell in the body, keeps the bloodstream liquid enough to flow through blood vessels, helps eliminate the by-products of the body’s metabolism, aids digestion, and other exceptional properties. High-quality water is needed to preserve health. Unfortunately, the environment and all its sectors are differently contaminated. This dangerous state is closely linked to increased anthropic activities (industrial and agricultural) and the use of harmful substances released without control. Old contaminants (pesticides and substances deriving from industrial activities) and new contaminants, called "emerging" (drugs, phytotoxins, body care products), can arrive in rivers, in surface and deep water, and the sea if they are not removed from the wastewater. These substances are harmful to human health because they enter the environment in quantities exceeding the natural self capacity purification of the ecosystems. We can be exposed to water-derived contaminants in different ways. For example, people can ingest small amounts of pollutants by drinking water; they can absorb pollutants through the skin while bathing or showering and during recreational activities, such as swimming, windsurfing, and water skiing; they can inhale droplets suspended in the air or vapors while taking a shower. They can also ingest foods that have been contaminated with water-borne pollutants.Wastewater treatment plants (WWTPs) cannot altogether remove most of these substances, which can easily reach the drinking water supplies, causing health problems for adults and children. Although drinking water quality is regulated and monitored in many countries, today’s increased knowledge suggests reviewing standards and guidelines on a near-permanent basis for both held and newly identified contaminants and adopting technologies as tertiary treatment processes, which could promote the easy degradation of recalcitrant compounds. It will be necessary to verify that the degradation products are less dangerous than the original molecules and that no dangerous aggregation products are formed. This communication reports some of the degradation studies carried out by our Research Teams in collaboration with foreign researchers using Advanced Oxidation Processes (AOPs) on pesticides and pharmaceuticals present in actual water samples. Photolysis and heterogeneous photocatalysis under simulated solar irradiation using two forms of TiO2 (suspended or immobilized on the surface of thin glass plates) have been investigated to assess the suitability of different oxidation processes to promote mineralization of recalcitrant substances. Transformation products (TPs) have been identified by an LC system coupled to a hybrid LTQ-FTICR (7-T) mass spectrometer (MS). To evaluate the treatment methods' effectiveness, the treated solutions' measurements have been performed using the “Microtox® Toxicity Test” that reports the luminescence inhibition of the marine bacteria Vibrio fischeri. During the degradation process, the temporary formation of toxic fragments was observed, which rapidly degraded to complete mineralization. Samples collected during the degradation process showed the temporary toxicity of the water. The rate of decomposition was highly dependent on the method used. Advanced oxidation processes such as TiO2/Xe-arc system, lead to a rapid decrease of the biorecalcitrant chemical concentrations in aqueous solutions, while photolysis and TiO2-coated glass are less effective. These promising results push us to continue and improver experimental trials. What is the future prospect? The creation of prototypes to be used by farmers and artisans to start with the virtuous path of water recycle

Removal of imidacloprid from polluted water using adsorption and membrane separation technologies

In this work, the stability of imidacloprid in fresh water and sludge was studied. The results revealed that the pesticide is unstable in both media. In freshwater, it underwent hydrolysis whereas a degradation to several metabolites has been observed in sludge. The rate constants for the hydrolysis and degradation at 25°C were 0.0.0067 and 0.0.0099 d–1, respectively. Monitoring the degradation of imidacloprid in sludge by high-pressure liquid chromatography-mass spectrometry (HPLC-MS) revealed that five metabolites have emerged during the study. These metabolites include imidacloprid urea, imidacloprid-guanidine, 6-hydroxynicotinic acid, an olefin, and 5-hydroxy, 1-(6-chloro-3-pyridylmethyl)-2-(nitroimino)-imidazolidin-5-ol. The efficiency of Al-Quds University Wastewater Treatment Plant towards the removal of imidacloprid indicates that the ultrafiltration-hollow fiber unit was insufficient, whereas the ultrafiltration-spiral wound, activated carbon, and reverse osmosis units were efficient for complete removal of the pesticide. Adsorption experiments of imidacloprid using either activated charcoal or micelle-clay complex were found to fit Langmuir isotherms better than Freundlich isotherm. The data demonstrate a higher Langmuir Qmax value for the activated charcoal (126.6 mg g–1) when compared to the micelle-clay complex (11.76 mg g–1). Filtration column experiments, conducted with mixed micelle-clay complex and sand (using a ratio of 1/50 by mass) at a flow rate of 2 mL min–1 and influent concentration of 50 mg L–1, revealed that a sufficient removal of imidacloprid was achieved in the first fraction of 100 mL elution. These findings indicate that the adsorption technology using the micelle-clay complex provides efficient removal of imidacloprid in continuous flow mode

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

REMOVAL OF ORGANIC POLLUTANTS FROM TREATED WASTEWATER USING MICELLE-CLAY FILTERS

In countries where fresh water is abundant; treatment of wastewater is performed to sustain and protect the environment from pollution. In dry regions treatment of wastewater enables to find alternative sources for fresh water, thus overcoming in part the increased scarcity of this precious supply. Removing contaminants from wastewater can be performed using physical and chemical methods for primary treatment while, secondary wastewater treatment is accomplished by biological activity, which is designed to remove the biodegradable portion of organic constituents. Removal of recalcitrant substances as pesticides often needs advanced treatments, such as ultrafiltration, ion exchange, adsorption and reverse osmosis. In this work we evaluated how a filter based on a micelle-clay complex can be incorporated in a multi-stage procedure of wastewater cleaning to remove organic persistent pollutants. Al-Quds University plant for wastewater treatment includes biological decontamination, two ultra-filtration (UF) hollow fibre modules with cut-off of 100 and 20 kDa, respectively, an activated carbon filter, and finally a reverse osmosis membrane (RO) as reported by Kamis et al. (2009). The treated water is suitable for non-restricted irrigation. The current study investigated the purification capability of two filters (20 x 5 cm) prepared mixing a clay-micelle complex (CMC) with different excess of quartz sand (1:100, or 1:50, w/w). The filtration capacity of 1:100 and 1:50 CMC-sand columns was tested using water passed through the first UF filter (cut-off 100 kDa) forgoing the 20 kDa membrane, the activated carbon filter, and the RO stage. The micelle-clay complex was prepared as suggested by Polubesova et al. (2005; 2006) using montmorillonite and octadecyltrimetylammonium bromide (ODTMA). The CMC-sand columns were saturated with the solution permeated from the UF filter and spiked with 5 mg l-1 of tribenuron-methyl (TM – m/z 395 Da) and 5 mg l-1 of its degradation product 2-methoxy-4-methylamino-6-methyl-1,3,5-triazine (MMMT - m/z 155 Da), used as system efficiency markers for pesticide removal. After saturation the columns were eluted with the same effluent (not containing the two chemicals). Total suspended solids (TSS), total dissolved solids (TDS), turbidity, chemical oxygen demand (COD) and biological oxygen demand (BOD) were determined before and after elution in each collected 100 ml fraction using APHA standard procedures (American Public Health Association, 2006). Pesticide residues were determined by LC/MS as Chiola et al. (2010). The values of COD and BOD were reduced by an order of magnitude and 5-fold in 1:50 and 1:100 sand excess filters, respectively. In both cases, TSS and turbidity were completely removed and TDS was slightly detectable after filtration. Figure 1 shows the effect of filtration on the values of COD and BOD using the 1:50 CMC-sand filter. Tribenuron-methyl (Figure 2) was retained at 95% of added amount on the 1:100 CMC-sand filter and totally retained on the 1:50 CMC-sand column. Due to its lower molecular weigh and higher charge availability for the adsorption process, the pesticide degradation product (Figure 2) was completely removed in both cases. Table 1 reports the amounts of TM and MMMT found during the filtration process in the 100 ml fractions collected using the 1:50 CMC-sand filter. In conclusion, results indicate that the introduction in the waste water treatment system of a filter filled with a mixture of a micelle-clay complex in a sequence of purification steps could be able to achieve a high quality water avoiding further treatment stages also in the presence of pesticide residues

Removal of Diclofenac Potassium from Wastewater Using Clay-Micelle Complex

In countries where fresh water is abundant treatment of wastewater is performed to sustain and protect the environment from pollution but in dry regions treatment of wastewater is essential to find alternative sources for fresh water thus overcoming in part the increased scarcity of this precious supply. Removing contaminants from wastewater can be performed using physical and chemical methods for primary treatment while, secondary wastewater treatment is accomplished by biological activity, which is designed to remove the biodegradable portion of organic constituents. Removal of recalcitrant substances often needs advanced treatments, such as ultrafiltration, ion exchange, adsorption and reverse osmosis. In this work we reported how a filter based on a micelle-clay complex can be incorporated in a multi-stage procedure of wastewater cleaning to remove organic persistent pollutants. Al-Quds University plant for wastewater treatment includes biological decontamination, two ultra-filtration (UF) hollow fibre modules with cut-off of 100 and 20 kDa, respectively, an activated carbon filter, and finally a reverse osmosis membrane (RO) [1]. The treated water is suitable for non-restricted irrigation. In this paper we report a relatively novel method for the removal diclofenac potassium (2-[(2,6-dichlorophenyl) amino]benzeneacetic acid) a polar acidic pharmaceuticals compound presents in river waters and wastewater plants, by using filters which include micelle-clay complexes. The micelle-clay composites, which we used, are positively charged, have large surface area and include large hydrophobic domains. It was shown by X-ray diffraction, electron microscopy and adsorption experiments that the characteristics of the micelle-clay complexes are different from those of organo-clay complexes, which are formed by adsorption of the same organic cation ODTMA (Octadecyl-trimethylammonium) as monomers [2]. The current study investigated the purification capability of two filters (20 x 5 cm) prepared mixing a clay-micelle complex (CMC) with different excess of quartz sand (1:100, or 1:50, w/w). The filtration capacity of 1:100 and 1:50 CMC-sand columns was tested using water passed through the first UF filter (cut-off 100 kDa) forgoing the 20 kDa membrane, the activated carbon filter, and the RO stage. The micelle-clay complex was prepared as suggested by Polubesova et al. (2005; 2006) using SWY-2 Wyoming Na-montmorillonite and octadecyltrimetylammonium bromide (ODTMA). Diclofenac potassium was obtained as a gift from Beit Jalah Pharmaceutical Company (Palestine). The CMC-sand columns were saturated with the solution permeated from the UF filter and spiked with varying concentration of diclofenac. Fractions were collected for assay of diclofenac potassium content and analyzed by LC/MS. Analysis of the Langmuir isotherms revealed that GAC had a somewhat larger number of adsorption sites than the composite, but the latter had a significantly stronger binding affinity for diclofenac. Filtration experiments of a solution that included 300 ppm diclofenac demonstrated a very efficient removal by clay-micelle filters. Filtration of diclofenac solutions at concentrations of 8 or 80 ppb yielded almost complete removal at flow rates of 30 and 60 mL/min. The estimate is that one kg of ODTMA in clay-micelle filter can remove more than 99% of diclofenac during a passage of more than 100 m3 of a solution having a concentration of 100 ppb of diclofena

Inland treatment of the brine generated from reverse osmosis advanced membrane wastewater treatment plant using epuvalisation system

The reverse osmosis (RO) brine generated from the Al-Quds University wastewater treatment plant was treated using an epuvalisation system. The advanced integrated wastewater treatment plant included an activated sludge unit, two consecutive ultrafiltration (UF) membrane filters (20 kD and 100 kD cutoffs) followed by an activated carbon filter and a reverse osmosis membrane. The epuvalisation system consisted of salt tolerant plants grown in hydroponic channels under continuous water flowing in a closed loop system, and placed in a greenhouse at Al-Quds University. Sweet basil (Ocimum basilicum) plants were selected, and underwent two consecutive hydroponic flowing stages using different brine-concentrations: an adaptation stage, in which a 1:1 mixture of brine and fresh water was used; followed by a functioning stage, with 100% brine. A control treatment using fresh water was included as well. The experiment started in April and ended in June (2012). At the end of the experiment, analysis of the effluent brine showed a remarkable decrease of electroconductivity (EC), PO43-, chemical oxygen demand (COD) and K+ with a reduction of 60%, 74%, 70%, and 60%, respectively, as compared to the influent. The effluent of the control treatment showed 50%, 63%, 46%, and 90% reduction for the same parameters as compared to the influent. Plant growth parameters (plant height, fresh and dry weight) showed no significant difference between fresh water and brine treatments. Obtained results suggest that the epuvalisation system is a promising technique for inland brine treatment with added benefits. The increasing of channel number or closed loop time is estimated for enhancing the treatment process and increasing the nutrient uptake. Nevertheless, the epuvalisation technique is considered to be simple, efficient and low cost for inland RO brine treatment