Sodium glucose co-transporter-2 inhibitor-induced diabetic ketoacidosis following tooth extraction: improving awareness among dental practitioners.

Sodium glucose co-transporter-2 inhibitors (SGLT-2i) are a relatively new class of oral glucose lowering agents that improve glycaemic control and also provide significant cardiac and renal benefits. However, SGLT-2i use is associated with a small but significant increased risk of diabetic ketoacidosis (DKA) especially during periods of reduced oral intake such as following dental procedures, bowel preparation for colonoscopy, surgery and concurrent illness. In contrast with typical DKA, in many cases of SGLT2i-associated DKA, the blood glucose is normal or only slightly elevated, giving rise to the term euglycaemic DKA (euDKA). Patients with euDKA often present with non-specific symptoms. Moreover, their normal or only mildly elevated blood glucose levels might lead to delayed diagnosis and treatment and hence potentially life-threatening complications. Not only should patients taking an SGLT-2i be informed about the risk of euDKA, and be provided with SGLT-2i sick day management education, but clinicians should also be alert to this diagnosis.

Humic acid inhibition of hydrolysis and methanogenesis with different anaerobic inocula.

There is increasing evidence that humic acid (HA) is hampering the performance of anaerobic digesters treating animal manures and thermally-hydrolysed waste activated sludge. In the present study, HA inhibition and inhibition resilience was examined for hydrolysis (carbohydrate and protein) and acetotrophic methanogenesis with four distinct full-scale anaerobic inocula. The aim was to further understand HA inhibition and to explore potential relationships between microbial factors and inhibition resilience. For two of the four tested inocula, cellulose degradation showed a start-up delay that lengthened as HA concentration increased from 0 to 2 g L-1. This inhibition was reversible because, after the initial delay, subsequent hydrolysis rates and methane yields were not significantly influenced by HA concentration. Cellulose hydrolysis results at HA concentrations below 2 g L-1 support a threshold inhibition mechanism, i.e. HA complexes with hydrolytic enzymes preventing them from binding with cellulose, but once all the HA had been complexed, enzymes subsequently released are free to bind with cellulose. Inocula with higher cellulose hydrolytic activity were less affected by HA inhibition, suggesting a potential link between HA inhibition resilience and microbial activity. However, above 5 gHA L-1, cellulose hydrolysis rates decreased with increasing HA concentration; indicating that the mechanisms of inhibition may change depending on some threshold HA concentration. Protein hydrolysis and acetotrophic methanogenesis were less susceptible to HA inhibition than cellulose hydrolysis, since signs of inhibition were only observed above 5 gHA L-1. Acetotrophic methanogenesis was partially inhibited at 10 gHA L-1 and completely inhibited at 20 gHA L-1. These results further support that HA inhibition is selective towards particular enzymes.

Indigenous microbial capability in solid manure residues to start-up solid-phase anaerobic digesters.

Batch solid-phase anaerobic digestion is a technology for sustainable on-farm treatment of solid residues, but is an emerging technology that is yet to be optimised with respect to start-up and inoculation. In the present study, spent bedding from two piggeries (site A and B) were batch digested at total solids (TS) concentration of 5, 10 and 20% at mesophilic (37°C) and thermophilic (55°C) temperatures, without adding an external inoculum. The results showed that the indigenous microbial community present in spent bedding was able to recover the full methane potential of the bedding (140±5 and 227±6L CH4 kgVSfed-1 for site A and B, respectively), but longer treatment times were required than for digestion with an added external inoculum. Nonetheless, at high solid loadings (i.e. TS level>10%), the digestion performance was affected by chemical inhibition due to ammonia and/or humic acid. Thermophilic temperatures did not influence digestion performance but did increase start-up failure risk. Further, inoculation of residues from the batch digestion to subsequent batch enhanced start-up and achieved full methane potential recovery of the bedding. Inoculation with liquid residue (leachate) was preferred over a solid residue, to preserve treatment capacity for fresh substrate. Overall, the study highlighted that indigenous microbial community in the solid manure residue was capable of recovering full methane potential and that solid-phase digestion was ultimately limited by chemical inhibition rather than lack of suitable microbial community.

Pilot-scale testing of a leachbed for anaerobic digestion of livestock residues on-farm.

A leachbed is a relatively simple anaerobic digester suitable for high-solids residues and on-farm applications. However, performance characteristics and optimal configuration of leachbeds are not well-understood. In this study, two 200 L pilot-scale leachbeds fed with spent straw bedding from pigs/swine (methane potential, B0 = 195-218 L CH4 kg(-1) VS fed) were used to assess the effects of leachate recirculation mode (trickling vs. flood-and-drain) on the digestion performance. Results showed comparable substrate solubilisation extents (30-45% of total chemical oxygen demand fed) and methane conversion (50% of the B0) for the trickling and flood-and-drain modes, indicating that digestion performance was insensitive to the mode of leachate flow. However, the flood-and-drain leachbed mobilised more particulates into the leachate than the trickling leachbed, an undesirable outcome, because these particulates were mostly non-biodegradable. Inoculation with solid residues from a previous leachbed (inoculum-to-substrate ratio of 0.22 on a VS basis) hastened the leachbed start-up, but methane recovery remained at 50% of the B0 regardless of the leachate recirculation mode. Post-digestion testing indicated that the leachbeds may have been limited by microbial activity/inhibition. The high residual methane potential of leachate from the trickling (residual Bo = 732 ± 7 L CH4 kg(-1) VS fed) and flood-and-drain leachbeds (582 ± 8 L CH4 kg(-1) VS fed) indicated an opportunity for further processing of leachate via a separate methanogenic step. Overall, a trickling leachbed appeared to be more favourable than the flood-and-drain leachbed for treating spent bedding at farm-scale due to easier operation.