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Concept: Plumbing


There have been an increasing number of reports implicating Gammaproteobacteria often carrying genes of drug resistance from colonized sink traps to vulnerable hospitalized patients. However, the mechanism of transmission from the wastewater of the sink P-trap to patients remains poorly understood. Herein we report the use of a designated hand washing sink lab gallery to model dispersion of green fluorescent protein (GFP)- expressing Escherichia coli from sink wastewater to the surrounding environment. We found no dispersion of GFP-E.coli directly from the P-trap to the sink basin or surrounding countertop with coincident water flow from a faucet. However, when the GFP-E.coli were allowed to mature in the P-trap under conditions similar to a hospital environment a GFP-E.coli containing putative biofilm extended upward over seven days to reach the strainer. This subsequently resulted in droplet dispersion to the surrounding areas (<30 inches) during faucet operation. We also demonstrated that P-trap colonization could occur by retrograde transmission along a common pipe. We postulate that the organisms mobilize up to the strainer from the P-trap resulting in droplet dispersion rather than directly from the P-trap. This work helps to further define the mode of transmission of bacteria from a P-trap reservoir to a vulnerable hospitalized patient.Importance Many recent reports demonstrate that sink drain pipes become colonized with highly consequential multidrug resistant bacteria, which then result in hospital acquired infections. However, the mechanism of dispersal of bacteria from the sink to patients has not been fully elucidated. Through establishment of a unique sink gallery this work found that a staged mode of transmission involving biofilm growth from the lower pipe to the sink strainer and subsequent splatter to the bowl and surrounding area occurs rather than splatter directly from the water in the lower pipe. We have also demonstrated that bacterial transmission can occur via connections in wastewater plumbing to neighboring sinks. This work helps to more clearly define the mechanism and risk of transmission from a wastewater source to hospitalized patients in a world with increasingly antibiotic resistant bacteria which can thrive in wastewater environments and cause infections in vulnerable patients.

Concepts: Protein, Gene, Bacteria, Antibiotic resistance, Escherichia coli, Pseudomonas aeruginosa, Plumbing, Sink


Opportunistic premise plumbing pathogens are responsible for a significant number of infections whose origin has been traced to drinking water. These opportunistic pathogens represent an emerging water borne disease problem with a major economic cost of at least $1 billion annually. The common features of this group of waterborne pathogens include: disinfectant-resistance, pipe surface adherence and biofilm formation, growth in amoebae, growth on low organic concentrations, and growth at low oxygen levels. Their emergence is due to the fact that conditions resulting from drinking water treatment select for them. As such, there is a need for novel approaches to reduce exposure to these pathogens. In addition to much-needed research, controls to reduce numbers and human exposure can be instituted independently by utilities and homeowners and hospital- and building-operators.

Concepts: Bacteria, Opportunistic infection, Water pollution, Pathogen, Plumbing, Drinking water, Waterborne diseases, Water treatment


Since chest tubes have been routinely used to drain the pleural space, particularly after lung surgery, the management of chest tubes is considered to be essential for the thoracic surgeon. The pleural drainage system requires effective drainage, suction, and water-sealing. Another key point of chest tube management is that a water seal is considered to be superior to suction for most air leaks. Nowadays, the most common pleural drainage device attached to the chest tube is the three-bottle system. An electronic chest drainage system has been developed that is effective in standardizing the postoperative management of chest tubes. More liberal use of digital drainage devices in the postoperative management of the pleural space is warranted. The removal of chest tubes is a common procedure occurring almost daily in hospitals throughout the world. Extraction of the tube is usually done at the end of full inspiration or at the end of full expiration. The tube removal technique is not as important as how it is done and the preparation for the procedure. The management of chest tubes must be based on careful observation, the patient’s characteristics, and the operative procedures that had been performed.

Concepts: Hospital, Surgery, Pneumothorax, Plumbing, Thoracic cavity, Chest tube, Drainage, Drainage system


Hot water plumbing is an important conduit of microbes into the indoor environment and can increase risk of opportunistic pathogens (for example, Legionella pneumophila). We examined the combined effects of water heater temperature (39, 42, 48, 51 and 58 °C), pipe orientation (upward/downward), and water use frequency (21, 3 and 1 flush per week) on the microbial composition at the tap using a pilot-scale pipe rig. 16S rRNA gene amplicon sequencing indicated that bulk water and corresponding biofilm typically had distinct taxonomic compositions (R(2)Adonis=0.246, PAdonis=0.001), yet similar predicted functions based on PICRUSt analysis (R(2)Adonis=0.087, PAdonis=0.001). Although a prior study had identified 51 °C under low water use frequency to enrich Legionella at the tap, here we reveal that 51 °C is also a threshold above which there are marked effects of the combined influences of temperature, pipe orientation, and use frequency on taxonomic and functional composition. A positive association was noted between relative abundances of Legionella and mitochondrial DNA of Vermamoeba, a genus of amoebae that can enhance virulence and facilitate replication of some pathogens. This study takes a step towards intentional control of the plumbing microbiome and highlights the importance of microbial ecology in governing pathogen proliferation.The ISME Journal advance online publication, 10 March 2017; doi:10.1038/ismej.2017.14.

Concepts: DNA, Bacteria, Opportunistic infection, Microbiology, Ribosomal RNA, 16S ribosomal RNA, Plumbing, Water heating


Flint, Michigan switched to the Flint River as a temporary drinking water source without implementing corrosion control in April 2014. Ten months later, water samples collected from a Flint residence revealed progressively rising water lead levels (104, 397, and 707 μg/L) coinciding with increasing water discoloration. An intensive follow-up monitoring event at this home investigated patterns of lead release by flow rate-all water samples contained lead above 15 μg/L and several exceeded hazardous waste levels (>5000 μg/L). Forensic evaluation of exhumed service line pipes compared to water contamination “fingerprint” analysis of trace elements, revealed that the immediate cause of the high water lead levels was the destabilization of lead-bearing corrosion rust layers that accumulated over decades on a galvanized iron pipe downstream of a lead pipe. After analysis of blood lead data revealed spiking lead in blood of Flint children in September 2015, a state of emergency was declared and public health interventions (distribution of filters and bottled water) likely averted an even worse exposure event due to rising water lead levels.

Concepts: Oxygen, Iron, Zinc, Bottled water, Plumbing, Drinking water, Water supply, Water crisis


This evaluation examined whether participation in a home-based environmental educational intervention would reduce exposure to health and safety hazards and asthma-related medical visits. The home intervention program focused on vulnerable, low-income households, where children had asthma, were at risk for lead poisoning, or faced multiple unsafe housing conditions. Home visitors conducted two home visits, two months apart, consisting of an environmental home assessment, Healthy Homes education, and distribution of Healthy Homes supplies. Measured outcomes included changes in participant knowledge and awareness of environmental home-based hazards, rate of children’s asthma-related medical use, and the presence of asthma triggers and safety hazards. Analysis of 2013-2014 baseline and post-intervention program data for a cohort of 150 families revealed a significantly lower three-month rate (p < 0.05) of children's asthma-related doctor visits and hospital admissions at program completion. In addition, there were significantly reduced reports of the presence of home-based hazards, including basement or roof leaks (p = 0.011), plumbing leaks (p = 0.019), and use of an oven to heat the home (p < 0.001). Participants' pre- and post- test scores showed significant improvement (p < 0.05) in knowledge and awareness of home hazards. Comprehensive home interventions may effectively reduce environmental home hazards and improve the health of asthmatic children in the short term.

Concepts: Health care, Medicine, Health, Participation, Lead, Plumbing, Occupational safety and health, Home


A unique microbiome establishes in the portion of the potable water distribution system within homes and other buildings (i.e., building plumbing). To examine its composition and the factors that shape it, standardized cold water plumbing rigs were deployed at the treatment plant and in the distribution system of five water utilities across the U.S. Three pipe materials (copper with lead solder, CPVC with brass fittings or copper/lead combined pipe) were compared, with 8 hour flush cycles of 10 minutes to simulate typical daily use patterns. High throughput Illumina sequencing of 16S rRNA gene amplicons was employed to profile and compare the resident bulk water bacteria and archaea. The utility, location of the pipe rig, pipe material and stagnation all had a significant influence on the plumbing microbiome composition, but the utility source water and treatment practices were dominant factors. Examination of 21 water chemistry parameters suggested that the total chlorine concentration, pH, P, SO42- and Mg were associated with the most of the variation in bulk water microbiome composition. Disinfectant type exerted a notably low-magnitude impact on microbiome composition. At two utilities using the same source water, slight differences in treatment approaches were associated with differences in rare taxa in samples. For genera containing opportunistic pathogens, Utility C samples (highest pH of 9-10) had the highest frequency of detection for Legionella spp. and lowest relative abundance of Mycobacterium spp. Data were examined across utilities to identify a true universal core, special core, and peripheral organisms to deepen insight into the physical and chemical factors that shape the building plumbing microbiome.

Concepts: Bacteria, Ribosomal RNA, Pathogen, 16S ribosomal RNA, Lead, Plumbing, Drinking water, Water supply network


Partial replacement of lead service lines (LSLs) often results in the excessive long-term release of lead particulates due to the disturbance of pipe scale and galvanic corrosion. In this study, a modeling approach to simulate the release and transport of particulate and dissolved lead from full and partially replaced LSLs is developed. A mass transfer model is coupled with a stochastic residential water demand generator to investigate the effect of normal household usage (NHU) flow patterns on lead exposure. The model is calibrated by comparing simulation results against experimental measurements from pilot-scale setups where lead release under different flow rates and water chemistry scenarios was reported. Applying the model within a Monte-Carlo simulation framework, the partial replacement of the LSL was predicted to result in releasing spikes with significantly high concentrations of particulate lead (1011.9±290.3 µg/L) that were five times higher than those released from the full LSL. Sensitivity analysis revealed that the intensity of flow demands significantly affects particulate lead release, while dissolved lead levels were more dependent on the lengths of stagnation periods. Pre-flushing of the LSL prior to regulatory sampling was found to under-estimate the maximum monthly exposure of dissolved lead by 19%, while sampling at low flow rates (<5.2 LPM) was found to consistently suppress the high spikes induced by particulate lead mobilization.

Concepts: Simulation, Operations research, Plumbing, Release, Corrosion, Lead poisoning, Galvanic series, Galvanic corrosion


Bioprostheses are prone to structural valve degeneration, resulting in limited long-term durability. A significant challenge when comparing the durability of different types of bioprostheses is the lack of a standardized terminology for the definition of a degenerated valve. This issue becomes especially important when we try to compare the degeneration rate of surgically inserted and transcatheter bioprosthetic valves. This document, by the VIVID (Valve-in-Valve International Data), proposes practical and standardized definitions of valve degeneration and provides recommendations for the timing of clinical and imaging follow-up assessments accordingly. Its goal is to improve the quality of research and clinical care for patients with deteriorated bioprostheses by providing objective and strict criteria that can be utilized in future clinical trials. We hope that the adoption of these criteria by both the cardiological and surgical communities will lead to improved comparability and interpretation of durability analyses.

Concepts: Medicine, Comparison, Plumbing, Comparability


Green buildings are increasingly being plumbed with crosslinked polyethylene (PEX) potable water pipe. Tap water quality was investigated at a six month old plumbing system and chemical and odor quality impacts of six PEX pipe brands were examined. Eleven PEX related contaminants were found in the plumbing system; one regulated (toluene) and several unregulated: Antioxidant degradation products, resin solvents, initiator degradation products, or manufacturing aides. Water chemical and odor quality was monitored for new PEX-a, -b and -c pipes with (2 mg/L free chlorine) and without disinfectant over 30 days. Odor and total organic carbon (TOC) levels decreased for all pipes, but odor remained greater than the USA’s Environmental Protection Agency’s (USEPA) secondary maximum contaminant level. Odors were not attributed to known odorants ethyl-tert-butyl ether (ETBE) or methyl-tert-butyl ether (MTBE). Free chlorine caused odor levels for PEX-a1 pipe to increase from 26 to 75 threshold odor number (TON) on day 3 and affected the rate at which TOC changed for each brand over 30 days. As TOC decreased, the ultraviolet absorbance at 254 nm increased. Pipes consumed as much as 0.5 mg/L as Cl2 during each 3 day stagnation period. Sixteen organic chemicals were identified, including toluene, pyridine, methylene trichloroacetate and 2,4-di-tert-butylphenol. Some were also detected during the plumbing system field investigation. Six brands of PEX pipes sold in the USA and a PEX-a green building plumbing system impacted chemical and drinking water odor quality.

Concepts: Water pollution, United States Environmental Protection Agency, Plumbing, Water quality, Drinking water, Cross-linked polyethylene, Safe Drinking Water Act, Tap water