Impact of aerobic granular sludge sizes and dissolved oxygen concentration on greenhouse gas N2O emission.

Aerobic granular sludge (AGS) at wastewater treatment plants (WWTPs) are known to produce nitrous oxide (N2O), a greenhouse gas which has a ∼300 times higher global warming potential than carbon dioxide. In this research, we studied N2O emissions from different sizes of AGS developed at a dissolved oxygen (DO) level of 2 mgO2/L while exposing them to disturbances at various DO concentrations ranging from 1 to 4 mgO2/L. Five different AGS size classes were studied: 212-600 µm, 600-1000 µm, 1000-1400 µm, 1400-2000 µm, and > 2000 µm. Metagenomic data showed N2O reductase genes (nosZ) were more abundant in the smaller AGS sizes which aligned with the observation of higher N2O reduction rates in small AGS under anaerobic conditions. However, when oxygen was present, the activity measurements of N2O emission showed an opposite trend compared to metagenomic data, smaller AGS (212 to 1000 µm) emitted significantly higher N2O (p < 0.05) than larger AGS (1000 µm to >2000 µm) at DO of 2, 3, and 4 mgO2/L. The N2O emission rate showed positive correlation with both oxygen levels and nitrification rate. This pattern indicates a connection between N2O emission and nitrification. In addition, the data suggested the penetration of oxygen into the anoxic zone of granules might have hindered nitrous oxide reduction, resulting in incomplete denitrification stopping at N2O and consequently contributing to an increase in N2O emissions. This work sets the stage to better understand the impacts of AGS size on N2O emissions in WWTPs under different disturbance of DO conditions, and thus ensure that wastewater treatment will comply with possible future regulations demanding lowering greenhouse gas emissions in an effort to combat climate change.

Case study: Bioaugmenting the comammox dominated biomass from B-stage to enhance nitrification in A-stage at Blue Plains AWWTP.

A comprehensive case study was undertaken at the Blue Plains wastewater treatment plant (WWTP) to explore the bioaugmentation technique of introducing nitrifying sludge into the non-nitrifying stage over the course of two operational years. This innovative approach involved the return of waste activated sludge (WAS) from the biological nutrient removal (BNR) system to enhance the nitrification in the high carbon removal rate system. The complete ammonia oxidizer (comammox) Nitrospira Nitrosa was identified as the main nitrifier in the system. Bioaugmentation was shown to be successful as nitrifiers returned from BNR were able to increase the nitrifying activity of the high carbon removal rate system. There was a positive correlation between returned sludge from the BNR stage and the specific total kjeldahl nitrogen (TKN) removal rate in A stage. The bioaugmentation process resulted in a remarkable threefold increase in the specific TKN removal rate within the A stage. Result suggested that recycling of WAS is a simple technique to bio-augment a low SRT system with nitrifiers and add ammonia oxidation to a previously non-nitrifying stage. The results from this case study hold the potential for applicable implications for other WWTPs that have a similar operational scheme to Blue Plains, allowing them to reuse WAS from the B stage, previously considered waste, to enhance nitrification and thus improving overall nitrogen removal performance. PRACTITIONER POINTS: Comammox identifying as main nitrifier in the B stage. Comammox enriched sludge from B stage successfully bio-augmented the East side of A stage up to threefold. Bioaugmentation of comammox in the West side of A stage was potentially inhibited by the gravity thickened overflow. Sludge returned from B stage to A stage can improve nitrification with a very minor retrofits and short startup times.

A 55-Year-Old Male With Systemic Gout Complicated by Septic Shock.

Tophaceous gout is the systemic deposition of uric acid which can induce cutaneous ulceration. We present the case of a 55-year-old male with chronic tophaceous gout whose initial presentation was complicated by septic shock due to methicillin-sensitive Streptococcus aureus bacteremia and superinfection of many of his affected joints. The case and discussion will focus on the extent of his infections and approaches to preventative care.

Wastewater surveillance of SARS-CoV-2 at intra-city level demonstrated high resolution in tracking COVID-19 and calibration using chemical indicators.

Wastewater-based epidemiology has proven to be a supportive tool to better comprehend the dynamics of the COVID-19 pandemic. As the disease moves into endemic stage, the surveillance at wastewater sub-catchments such as pump station and manholes is providing a novel mechanism to examine the reemergence and to take measures that can prevent the spread. However, there is still a lack of understanding when it comes to wastewater-based epidemiology implementation at the smaller intra-city level for better granularity in data, and dilution effect of rain precipitation at pump stations. For this study, grab samples were collected from six areas of Seattle between March-October 2021. These sampling sites comprised five manholes and one pump station with population ranging from 2580 to 39,502 per manhole/pump station. The wastewater samples were analyzed for SARS-CoV-2 RNA concentrations, and we also obtained the daily COVID-19 cases (from individual clinical testing) for each corresponding sewershed, which ranged from 1 to 12 and the daily incidence varied between 3 and 64 per 100,000 of population. Rain precipitation lowered viral RNA levels and sensitivity of viral detection but wastewater total ammonia (NH4+-N) and phosphate (PO43--P) were shown as potential chemical indicators to calibrate/level out the dilution effect. These chemicals showed the potential in improving the wastewater surveillance capacity of COVID-19.

Retrospective Analysis of a Modern Cohort of Dermatofibrosarcoma Protuberans From 2000 to 2018.

BACKGROUND: There is limited data on how demographics, tumor characteristics, and treatment methods affect overall survival in patients with dermatofibrosarcoma protuberans (DFSP). OBJECTIVE: To summarize characteristics of patients with DFSP, assess prognostic factors, and evaluate the impact of treatment modality on their overall survival. METHODS: We investigated DFSP using data for 4451 patients with histologically confirmed cases of DFSP diagnosed between 2000 and 2018 from the 18 US regional registries of the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program. RESULTS: Older age (P < .001) and large tumor size (P = .006) were significantly associated with worse overall survival in controlled analysis. Older age (P < .050), males (P < .001), non-white race (P < .001), and lower median household income (P < .010) were more likely to present with larger tumor size. Different treatments were associated with patient characteristics. Older age (P < .001), non-white race (P < .032), larger tumor size (P < .001), and head/neck location (P < .001) were associated with patients receiving surgery and radiation instead of surgery only. Additionally, men (P < .021), non-whites (P < .001), lower median household income (P < .001), and larger tumor size (P = .003) were less likely to have Mohs micrographic surgery performed over excision. CONCLUSIONS: Age at presentation and tumor size appeared to be notable prognostic factors. Although treatment modality did not significantly influence patient survival, certain patient characteristics are associated with different treatment modalities.

Insect repellents: An updated review for the clinician.

Malaria, Zika virus, West Nile virus, Dengue fever, and Lyme disease are common causes of morbidity and mortality around the world. While arthropod bites may cause local inflammation and discomfort, a greater concern is the potential to develop deadly systemic infection. The use of insect repellents (IRs) to prevent systemic infections constitutes a fundamental public health effort. Cost effectiveness, availability, and high efficacy against arthropod vectors are key characteristics of an ideal IR. Currently, numerous IRs are available on the market, with N,N-diethyl-3-methylbenzamide (DEET) being the most widely used. DEET has an excellent safety profile and remarkable protection against mosquitoes and various other arthropods. Other Environmental Protection Agency-registered IR ingredients (eg, permethrin, picaridin, IR3535, oil of lemon eucalyptus, oil of citronella, catnip oil, and 2-undecanone) are alternative IRs of great interest because some of these ingredients have efficacies comparable to that of DEET. These alternative IRs possess low toxicity and favorable customer experiences in use (eg, cosmetically pleasant, naturally occurring). This review summarizes the currently available Environmental Protection Agency-registered IRs, including their origins, mechanisms of action, side effect profiles, and available formulations. This review will enable the clinician to select the best IR option to meet a patient's needs and provide the greatest protection from arthropod bites and their sequelae.

Digital photography for the dermatologist.

Dermatology is a specialty reliant on presenting detailed and accurate visual observations. Digital photography is a highly prevalent and accessible technology that can be easily incorporated into a dermatology practice to facilitate documentation and communication of clinical findings. Dermatologists will benefit from being comfortable with digital photography and techniques to improve their photography skills. This review presents the fundamentals of photography and techniques helpful in capturing an adequate image. We explore the application of photography in the setting of microscopy, dermatopathology, dermatoscopy, and Wood's lamp. Lastly, new imaging technologies, such as multispectral and infrared imaging, are discussed.

Surgical Intervention of Dysphagia Caused by Ossification of Anterior Longitudinal Ligament: A Case Report.

Ossification of the anterior longitudinal ligament (OALL) in the cervical spine is a common entity but rarely causes dysphagia, dyspnea, and dysphonia. We report an OALL case which causes such symptoms. A 47-year-old female patient had a complaint of progressive difficulty swallowing for 2 months. A cervical X-ray and computerized tomography scan were taken afterward, which showed OALL at the C3-7 level. She then had esophageal endoscopy to rule out other dysphagia-related disorders. The patient underwent anterior osteotomy via anterior cervical approach with significant relief of dysphagia postoperatively. Surgical management in symptomatic OALL improves dysphagia and prevents its secondary complications.

Impact of nitrite and oxygen on nitrous oxide emissions from a granular sludge sequencing batch reactor.

Maximizing nutrient removal and minimizing greenhouse gas (GHG) emissions is imperative for the future of wastewater treatment. As municipalities focus on minimizing their carbon footprints, future permits could regulate GHG emissions from wastewater treatment plants. This study investigates how nitrous oxide (N2O) emissions are affected by dissolved oxygen and nitrite concentrations, providing potential strategies to meet possible gaseous emission permits. A lab-scale sequencing batch reactor (SBR) was enriched with aerobic granular sludge (AGS) capable of phosphate removal and simultaneous nitrification-denitrification (SND). N2O emissions were tracked at varying dissolved oxygen (DO) and nitrite (NO2-) concentrations, with >99% SND efficiency and 93%-100% phosphate removal efficiency. Higher DO and NO2- concentrations were associated with higher N2O emissions. Emissions were minimized at a DO concentration of 1 mg L-1, with an average emission factor of 0.18% of oxidized NH3-N emitted as N2O-N, which is lower than factors from many full-scale treatment plants (Vasilaki et al., 2019) and similar to a Nereda® full-scale AGS SBR (van Dijk et al., 2021). This challenges assertions that AGS emits more N2O than conventional activated sludge, although more research at full-scale with influent quality variations is required to confirm this trend. Molecular analyses revealed that the efficient SND was likely achieved with shortcut nitrogen removal facilitated by a low presence of nitrite oxidizing bacteria and a large population of denitrifying phosphate accumulating organisms, which far outnumbered denitrifying glycogen accumulating organisms.

Adverse Events of Non-Invasive Body Contouring: Analysis of the Food and Drug Administration Manufacturer and User Facility Device Experience Database.

BACKGROUND: Multiple non-invasive modalities have become popular alternatives to surgical procedures for body contouring. OBJECTIVE: To analyze adverse events (AEs) associated with non-invasive body contouring devices reported through the Manufacturer and User Facility Device Experience (MAUDE) database. METHODS AND MATERIALS: The MAUDE database were queried for AEs associated with non-invasive body contouring devices between January 2011 and June 2021. An extensive list of keywords and brand and manufacturer names was used. RESULTS: A total of 1,325 reports with 1,590 AEs were identified among 6 modalities. More than 70% were reported in the past 5 years. Cryolipolysis made up 38.3% reports, which mostly pertained to paradoxical hyperplasia and hernias. Radiofrequency had the most reports (41.9%). Like laser devices, most of their reports described burns. Focused ultrasound was commonly associated with unintentional fat loss and surface irregularities. Focused electromagnetic field resulted in only 7 reports. CONCLUSION: The analysis of present study supports previous studies concerning common local symptoms caused by these devices, but it also reveals complications not reported in previous device studies. This study highlights the importance of proper technique and adherence to device guidelines. Practitioners should be knowledgeable of potential complications from each device to both prevent and manage them accordingly.

Polidocanol: A Review of Off-Label Dermatologic Uses.

BACKGROUND: Polidocanol is an FDA-approved treatment of incompetent great saphenous veins, accessory saphenous veins, and visible varicosities of the great saphenous vein system, but numerous other off-label dermatological applications have been reported. OBJECTIVE: To describe the various off-label dermatological clinical uses of polidocanol, as well as efficacy and adverse effects. METHODS: The review of studies searchable on PubMed from 2004 to 2021 describing clinical uses of polidocanol to determine efficacy and adverse effects associated with various dermatologic applications. RESULTS: Polidocanol has shown efficacy in the treatment of mucocele of minor salivary gland, hemangioma, upper extremity veins, reticular veins of the chest, facial veins, pyogenic granuloma, lymphangioma circumscriptum, digital mucous cyst, mixed skin ulcers, cutaneous focal mucinosis, seromas, glomuvenous malformations, acne cysts, lymphocele, and dissecting cellulitis. Commonly reported side effects include pain, erythema, swelling, ecchymosis, and ulceration. Most sources were case reports and small prospective studies, as such the strength of data supporting many uses is limited by small sample sizes and lack of controls. CONCLUSION: Although polidocanol is currently only FDA approved for incompetent great saphenous veins, accessory saphenous veins, and visible varicosities of the great saphenous vein system, the use of polidocanol has been selected for a variety of off-label clinical applications.

Online dermatology curriculum experiences among US dermatology residents and faculty.

Many dermatology residency programs adapted to the COVID-19 pandemic by transitioning to online teaching methods. This may impact the quality of education and the satisfaction of residents. Dermatology faculty and residents nationwide were surveyed regarding their experiences with the novel online curricula. A total of 65 individuals representing at least 20 ACGME-accredited dermatology programs responded. Many programs implemented a predominantly online curriculum (78%). Most participants reported that both clinical dermatology and dermatopathology were online during the pandemic's peak (90%). Among those who had experienced a live curriculum prior to the pandemic, 49% reported that a virtual curriculum had similar effectiveness, whereas 36% deemed it less effective. Open-ended questions suggested that disadvantages of a virtual curricula included too many distractions, lack of human features, and less spontaneous feedback. They also suggested advantages to an online curriculum included flexibility and more opportunities to hear from guest speakers. Dissatisfaction before the curriculum change was the same as after (7%), suggesting that the educational experience was not worsened. Failing to adjust the curriculum to residents' needs can contribute to lower satisfaction and inadequate education. The variation of responses signifies the importance of seeking sufficient feedback from residents to meet their educational needs.

Advances in Cutaneous Squamous Cell Carcinoma Management.

cSCC is increasing in prevalence due to increased lifespans and improvements in survival for conditions that increase the risk of cSCC. The absolute mortality of cSCC exceeds melanoma in the United States and approaches that of melanoma worldwide. This review presents significant changes in the management of cSCC, focusing on improvements in risk stratification, new treatment options, optimization of existing treatments, and prevention strategies. One major breakthrough in cSCC treatment is the advent of immune checkpoint inhibitors (ICIs) targeting programmed cell death protein 1 (PD-1) and programmed death-ligand 1 (PD-L1), which have ushered in a renaissance in the treatment of patients with locally advanced and metastatic disease. These agents have offered patients with advanced disease decreased therapeutic toxicity compared to traditional chemotherapy agents, a more durable response after discontinuation, and improved survival. cSCC is an active field of research, and this review will highlight some of the novel and more developed clinical trials that are likely to impact cSCC management in the near future.

Acroangiodermatitis presenting as unilateral hypertrophic verrucous plaques.

Acroangiodermatitis (AAD)[KL1] is a rare vasoproliferative disorder often involving the extremities that has been classified into two variants. Mali-type AAD is more common and associated with chronic venous stasis. Stewart-Bluefarb syndrome[KL2], the other variant, is associated with underlying arteriovenous abnormalities. Mali-type AAD is a relatively benign diagnosis but it may mimic more harmful etiologies such as Kaposi sarcoma both clinically and histologically. A 67-year-old woman with a history of varicose veins, deep vein thrombosis, stroke, and obesity presented to our outpatient clinic with verrucous red-brown papules and plaques on her right lower extremity worsening for three years. Biopsy was consistent with a diagnosis of Mali-type AAD. Providers should be aware of AAD and its variants to accurately differentiate it from more harmful entities.