Exploring the correlations between epi indicators of COVID-19 and the concentration of pharmaceutical compounds in wastewater treatment plants in Northern Portugal

The COVID-19 pandemic caused by the SARS-CoV-2 virus led to changes in the lifestyle and human behaviour, which resulted in different consumption patterns of some classes of pharmaceuticals including curative, symptom-relieving, and psychotropic drugs. The trends in the consumption of these compounds are related to their concentrations in wastewater systems, since incompletely metabolised drugs (or their metabolites back transformed into the parental form) may be detected and quantified by analytical methods. Pharmaceuticals are highly recalcitrant compounds and conventional activated sludge processes implemented in wastewater treatment plants (WWTP) are ineffective at degrading these substances. As a results, these compounds end up in waterways or accumulate in the sludge, being a serious concern given their potential effects on ecosystems and public health. Therefore, it is crucial to evaluate the presence of pharmaceuticals in water and sludge to assist in the search for more effective processes. In this work, eight pharmaceuticals from five therapeutic classes were analysed in wastewater and sludge samples collected in two WWTP located in the Northern Portugal, during the third COVID-19 epidemic wave in Portugal. The two WWTP demonstrated a similar pattern with respect to the concentration levels in that period. However, the drugs loads reaching each WWTP were dissimilar when normalising the concentrations to the inlet flow rate. Acetaminophen (ACET) was the compound detected at highest concentrations in aqueous samples of both WWTP (98. 516 μg L ^- 1 in WWTP2 and 123. 506 μg L ^- 1in WWTP1), indicating that this drug is extensively used without the need of a prescription, known of general public knowledge as an antipyretic and analgesic agent to treat pain and fever. The concentrations determined in the sludge samples were below 1.65 µg g ^- 1 in both WWTP, the highest value being found for azithromycin (AZT). This result may be justified by the physico-chemical characteristics of the compound that favour its adsorption to the sludge surface through ionic interactions. It was not possible to establish a clear relationship between the incidence of COVID-19 cases in the sewer catchment and the concentration of drugs detected in the same period. However, looking at the data obtained, the high incidence of COVID-19 in January 2021 is in line with the high concentration of drugs detected in the aqueous and sludge samples but prediction of drug load from viral load data was unfeasible.

Discrimination and surveillance of infectious severe acute respiratory syndrome Coronavirus 2 in wastewater using cell culture and RT-qPCR

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA has been extensively detected in raw wastewater in studies exploring wastewater-based epidemiology (WBE) for early warning purposes. Nonetheless, only a few limited studies investigated the presence of SARS-CoV-2 in treated wastewaters to determine the potential health risks across the water cycle. The detection of SARS-CoV-2 has been done mostly by RT-qPCR and ddPCR, which only provides information on the presence of nucleic acids rather than information on potential infectivity. In this study, we set to develop and evaluate the use of viability RT-qPCR for the selective discrimination and surveillance of infectious SARS-CoV-2 in secondary-treated wastewater. Enzymatic (nuclease) and viability dye (Reagent D) pretreatments were applied to infer infectivity through RT-qPCR using porcine epidemic diarrhea virus (PEDV) as a CoV surrogate. Infectivity tests were first performed on PEDV purified RNA, then on infectious and heat-inactivated PEDV, and finally on heat inactivated PEDV spiked in concentrated secondary-treated wastewater. The two viability RT-qPCR methods were then applied to 27 secondary-treated wastewater samples positive for SARS-CoV-2 RNA at the outlet of five large urban wastewater treatment plants in Portugal. Reagent D pretreatment showed similar behavior to cell culture for heat-inactivated PEDV and both viability RT-qPCR methods performed comparably to VERO E6 cell culture for SARS-CoV-2 present in secondary-treated wastewater, eliminating completely the RT-qPCR signal. Our study demonstrated the lack of infectious SARS-CoV-2 viral particles on secondary-treated wastewater through the application of two pretreatment methods for the rapid inference of infectivity through RT-qPCR, showing their potential application in environmental screening. This study addressed a knowledge gap on the public health risks of SARS-CoV-2 across the water cycle.

Recovery of SARS-CoV-2 from large volumes of raw wastewater is enhanced with the inuvai R180 system

Wastewater-based epidemiology (WBE) for severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) is a powerful tool to complement syndromic surveillance. Although detection of SARS-CoV-2 in raw wastewater may be prompted with good recoveries during periods of high community prevalence, in the early stages of population outbreaks concentration procedures are required to overcome low viral concentrations. Several methods have become available for the recovery of SARS-CoV-2 from raw wastewater, generally involving filtration. However, these methods are limited to small sample volumes, possibly missing the early stages of virus circulation, and restrained applicability across different water matrices. The aim of this study was thus to evaluate the performance of three methods enabling the concentration of SARS-CoV-2 from large volumes of wastewater: i) hollow fiber filtration using the inuvai R180, with an enhanced elution protocol and polyethylene glycol (PEG) precipitation; ii) PEG precipitation; and iii) skimmed milk flocculation. The performance of the three approaches was evaluated in wastewater from multiple wastewater treatment plants (WWTP) with distinct singularities, according to: i) effective volume; ii) percentage of recovery; iii) extraction efficiency; iv) inhibitory effect; and v) the limits of detection and quantification. The inuvai R180 system had the best performance, with detection of spiked control across all samples, with average recovery percentages of 68% for porcine epidemic diarrhea virus (PEDV), with low variability. Mean recoveries for PEG precipitation and skimmed milk flocculation were 9% and 14%, respectively. The inuvai R180 enables the scalability of volumes without negative impact on the costs, time for analysis, and recovery/inhibition. Moreover, hollow fiber ultrafilters favor the concentration of different microbial taxonomic groups. Such combined features make this technology attractive for usage in environmental waters monitoring.

A wastewater-based epidemiology tool for COVID-19 surveillance in Portugal

The presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in wastewater produced interest in its use for sentinel surveillance at a community level and as a complementary approach to syndromic surveillance. With this work, we set the foundations for wastewater-based epidemiology (WBE) in Portugal by monitoring the trends of SARS-CoV-2 RNA circulation in the community, on a nationwide perspective during different epidemiological phases of the pandemic. The Charité assays (E_Sarbecco, RdRP, and N_Sarbecco) were applied to monitor, over 32-weeks (April to December 2020), the dynamics of SARS-CoV-2 RNA at the inlet of five wastewater treatment plants (WWTP), which together serve more than two million people in Portugal. Raw wastewater from three Coronavirus disease 2019 (COVID-19) reference hospitals was also analyzed during this period. In total, more than 600 samples were tested. For the first weeks, detection of SARS-CoV-2 RNA was sporadic, with concentrations varying from 10³ to 10⁵ genome copies per liter (GC/L). Prevalence of SARS-CoV-2 RNA increased steeply by the end of May into late June, mainly in Lisboa e Vale do Tejo region (LVT), during the reopening phase. After the summer, with the reopening of schools in mid-September and return to partial face-to-face work, a pronounced increase of SARS-CoV-2 RNA in wastewater was detected. In the LVT area, SARS-CoV-2 RNA load agreed with reported trends in hotspots of infection. Synchrony between trends of SARS-CoV-2 RNA in raw wastewater and daily new COVID-19 cases highlights the value of WBE as a surveillance tool, particularly after the phasing out of the epidemiological curve and when hotspots of disease re-emerge in the population which might be difficult to spot based solely on syndromic surveillance and contact tracing. This is the first study crossing several epidemiological stages highlighting the long-term use of WBE for SARS-CoV-2.

Endocarditis, Meningitis and Pneumocystis Pneumonia

Infective endocarditis (IE) is associated with high morbidity and mortality despite advances in antibiotic and surgical treatment. Systemic embolism occurs in up to 49% of IE patients and may involve the major arteries, limb arteries, viscera and the central nervous system. In this report we describe a 60-year-old female patient with a history of acute lymphoblastic leukaemia who presented with endocarditis manifesting as stroke, acute limb ischaemia and meningitis. Early diagnosis is essential since treatment lowers the risk of embolism, with most events occurring within 2 weeks of treatment initiation.

Systemic sclerosis sine scleroderma: a case report of anterior uveitis

Systemic sclerosis (SSc) sine scleroderma (ssSSc) is characterized by the absence of skin involvement, despite other manifestations of systemic sclerosis are present. It is not known whether sSSc represents a forme fruste of limited cutaneous SSc or a distinct entity, but the 2013 American College of Rheumatology/European League Against Rheumatism criteria for the classification of SSc have considered SSc without skin involvement to be a distinct subset. The authors present the case of a 70-year old female that was referred for a consultation for Raynaud's phenomenon and a chronic anterior uveitis (CAU). She had a history of dysphagia, diffuse pulmonary emphysema and a biopsy-documented fibrosis of the upper lobes, and an idiopathic non-ischemic dilated cardiomyopathy with severe left ventricle systolic dysfunction and left bundle branch block. Anti-nuclear and anti-centromere antibodies were positive, while manometry revealed distal esophageal hypomotility. After establishing the diagnosis of ssSSc and starting immunosuppression, the ocular disease improved, while the lung and heart diseases remained stable. This case underlines that it is very important to suspect SSc when CAU is present and/or skin thickening is absent. To our knowledge, this is the first report of CAU in a patient with ssSSc.

Predictors of natriuretic peptide non-response in patients hospitalized with acute heart failure

Increasing natriuretic peptide (NP) levels are associated with worse heart failure (HF) outcomes. Predictors of NP nonresponse have not been studied. The aim of this study was to identify predictors of nondecreasing NP levels during episodes of acute HF. A retrospective analysis was conducted in patients prospectively included in a registry of acute HF, with the primary diagnosis of acute HF. The objective under analysis was B-type NP (BNP) response, defined as a >30% decrease in BNP during hospitalization. Percentage of BNP variation was calculated as: % BNP variation = [(admission BNP - discharge BNP)/admission BNP] × 100. A logistic regression analysis was performed to study potential predictors of NP nonresponse. A multivariate model was built. A total of 496 patients were studied: 28.2% were considered nonresponders to the implemented HF treatment strategy. Identified predictors of nonresponse were older age, chronic HF, lower admission systolic blood pressure, anemia, renal dysfunction, and lower sodium on admission, as well as lower admission albumin and lower admission total cholesterol. Admission BNP was not a predictor of response. The only identified independent predictor of nonresponse was a low admission total cholesterol level (cutoff 125 mg/dl), with an odds ratio of 2.55 (95% confidence interval 1.59 to 4.11). This remained valid when the analysis was stratified according to admission BNP (cutoff 2,000 pg/ml) and according to statin use. In conclusion, a low admission total cholesterol level was a strong and independent predictor of BNP nonresponse in patients admitted with acute HF. The ability of cholesterol to predict BNP nonresponse was valid for patients with intrinsically low cholesterol and in those with statin-induced low cholesterol.

[Quality of life evaluation of the patients and parents satisfaction after Nuss procedure in the management of Pectus Excavatum]

Pectus Excavatum is the most common congenital deformity of the chest. Although Pectus Excavatum can be associated with heart or lung problems, the main indication for surgical correction of this congenital anomaly is the body image dissatisfaction. The Nuss technique is a minimally invasive procedure that allows the placement of an intrathoracic prosthetic convex bar, previously bended, which mobilize the sternum anteriorly. The aim of this study was to evaluate the degree of satisfaction of the patients and parents after the application of the Nuss technique using the Pectus Excavatum Evaluation Questionnaire. All parameters of psychosocial character - self-image, difficulties in exposing the chest, frustration, sadness, social isolation and ridicule - found a statistically significant improvement after surgical correction of Pectus Excavatum from the perspective of patients and their parents. There was not a marked improvement and consensus regarding the overall physical performance of patients. Which is understandable, since, theoretically, the physical deformity is not responsible for significant limitations on exertion. The current surgical correction of Pectus Excavatum by the Nuss technique allows obtaining aesthetic results of the chest with the resolution of the main problems with body image. Increase awareness of health issues for psychosocial and physical factors which might be involved in this kind of deformities is important, especially when there is a satisfactory solution.