Efficacy of prophylactic oral erythromycin to improve enteral feeding tolerance in preterm infants: a randomised controlled study.

INTRODUCTION: Enteral feeding intolerance is a major problem in preterm infants. This study evaluated the safety and efficacy of prophylactic low-dose oral erythromycin, a motilin agonist, as a prokinetic agent in reducing the incidence of this problem. METHODS: From February to May 2008, a prospective randomised controlled trial was conducted at the Isfahan University of Medical Sciences, Isfahan, Iran. 70 uncomplicated preterm infants (28-34 weeks' gestation) weighing 1,000-1,500 g were randomly assigned to either a case group receiving low-dose oral erythromycin (6 mg/kg/day, in four doses over ten days) or a control group (n is 35 in each group) until they were fully fed enterally (150 ml/kg/day). Gavage feeding of the mother's milk was started within the first three days of life, and erythromycin was given simultaneously. The time taken to reach full enteral feeding and the total duration of feeding interruption due to intolerance were compared. RESULTS: The time taken to reach full enteral feeding was significantly shorter in the erythromycin group than the control group (10.11 +/- 2.51 versus 12.71 +/- 5.76 days, p is 0.01). In the control group, the mean duration of feeding interruption was significantly longer (84.00 +/- 62.58 versus 32.57 +/- 11.93 hours, p is 0.005) and more episodes of abdominal distention and significant gastric residue were also noted (p less than 0.05). No infant in the erythromycin group developed cardiac arrhythmias or pyloric stenosis. CONCLUSION: The prophylactic use of erythromycin may be warranted in very low birth weight infants, provided the efficacy and safety of the drug can be confirmed in further studies.

Parental consanguinity among parents of neonates with congenital hypothyroidism in Isfahan.

We determined the prevalence of congenital hypothyroidism and the rate of consanguin-ity among parents of hypothyroid neonates among 93 381 neonates born in 17 hospitals in Isfahan from May 2002 to April 2005. Serum thyroxine (T4) and thyroid stimulating hormone (TSH) levels were measured on the 3rd-7th day of birth and neonates with abnormal levels were recalled and the levels reassessed. Those with TSH > or = 10 mlU/L and T4 < 6.5 microg/dL on the second assay were considered hypothyroid. In all, 1038 neonates were recalled and 274 were diagnosed as hypothyroid. There was a significant association between parental consanguinity and congenital hypothyroidism (P = 0.006); congenital hypothyroidism was commoner in neonates with 1st cousin parental consanguinity than 2nd cousin parental consanguinity (P = 0.008).

Evaluation of thermophilic anaerobic digestion processes for full-scale Class A biosolids disinfection at Hyperion Treatment Plant.

This paper describes 5 phases of full-scale testing at the City of Los Angeles Hyperion Treatment Plant (HTP) for producing Class A biosolids (U.S. EPA Part 503 Biosolids Rule) by thermophilic anaerobic digestion. Phases I and II were tests with a two-stage continuous-batch process in a thermophilic battery of six digesters and a designated post-digestion train that was isolated from mesophilic operations. These tests demonstrated that digester outflow biosolids met the Class A limits for fecal coliforms and Salmonella sp. However, fecal coliform densities sharply increased during post-digestion. The recurrence was possibly related to a combination of a large drop of the biosolids temperature after the dewatering centrifuges and contamination of thermophilically digested biosolids from mesophilic operations. Phase III was conducted after insulation and electrical heat-tracing of the post-digestion train to maintain a biosolids temperature throughout post-digestion at about the same level as in the digester outflow. Biosolids monitoring at the last points of plant control (silos at Truck Loading Facility and farm for land application) indicated that fecal coliform recurrence was prevented. After completing the conversion of HTP to thermophilic operation, certification tests of Phases IV and V demonstrated Class A compliance of a two-stage continuous-batch process under Alternatives 1 and 3 of the Part 503 Biosolids Rule, respectively. HTP received the permit for Class A (indeed exceptional quality) biosolids land application in Kern County, California, in December 2002 under Alternative 3. Since 2003, HTP has consistently complied with the federal and local standards for Class A biosolids, indicating that Class A limits can be met under conditions less stringent than defined by the Alternative 1 time-temperature requirement for batch treatment.

Parental consanguinity among parents of neonates with congenital hypothyroidism in Isfahan

We determined the prevalence of congenital hypothyroidism and the rate of consanguinity among parents of hypothyroid neonates among 93 381 neonates born in 17 hospitals in Isfahan from May 2002 to April 2005. Serum thyroxine [T4] and thyroid stimulating hormone [TSH] levels were measured on the 3rd-7th day of birth and neonates with abnormal levels were recalled and the levels reassessed. Those with TSH </= 10 mIU/L and T4 < 6.5 micro g/dL on the second assay were considered hypothyroid. In all, 1038 neonates were recalled and 274 were diagnosed as hypothyroid. There was a significant association between parental consanguinity and congenital hypothyroidism [P = 0.006]; congenital hypothyroidism was commoner in neonates with 1st cousin parental consanguinity than 2nd cousin parental consanguinity [P = 0.008]

[Tc]-99m thyroid scintigraphy in congenital hypothyroidism screening program.

The aetiology of congenital hypothyroidism (CH) may be important in determining disease severity, outcome and treatment schedules because athyroid patients need higher treatment doses and close monitoring particularly early in life. The aim of this study was to evaluate thyroid scintigraphy (TS) findings in infants with CH and to determine the relationship of serum TSH and T4 values with thyroid agenesia, in an attempt to identify factors that may detect thyroid agenesia before treatment. Since August 2002 to April 2005, screening program for CH was carried out in the Isfahan University of Medical Sciences and Health Services, Isfahan, Iran. Screening was performed by measuring both the serums T4 and TSH concentration at day 3-7 of birth. Full-term newborns were recalled based on a serum TSH >20 mIU/l or serum T4 < 6.5 microg/dl and premature newborns based on T4 level by weight and TSH level by age. After repeating the laboratory test and clinical evaluation, Tc-99m TS was recommended for all infants with suspected CH before thyroxin replacement therapy. On the basis of Tc-99m TS, the thyroid gland was classified as normal scan, ectopic, goiter and athyrosis. TS results were compared with serum T4 and TSH levels. Of 93 381 newborns screened over a period of nearly 3 years, 262 neonates were found to have CH. The overall incidence of CH was 1 : 357 live births with a female/male ratio (F/M) of 1.4/1. Thyroid scan was performed on 116 (54%) of the infants with CH; of them, 33 cases (28.4%) were athyrotic (F/M = 0.8/1) while seven infants (6%) had ectopic thyroid (F/M = 1.3/1) and 76 cases (65.6%) had a normal thyroid scan (F/M = 1.5/1). Infants with the absence of thyroid in TS had significantly higher TSH value in comparison with those with ectopic or normal TS (116.3 +/- 109.64 vs. 108.10 +/- 62.92 or 55.35 +/- 48.26 mIU/l, respectively, P < 0.0001). Although not statistically different, the mean T4 level was higher in normal TS group than in ectopic and athyrotic groups (8.03 +/- 3.48 vs. 6.36 +/- 5.57 or 5.04 +/- 3 microg/dl, respectively, P = 0.09). We conclude that Tc-99m TS is a useful diagnostic tool for the initial investigation of suspected CH and considering the correlation of TS results with blood TSH levels, proper management and close monitoring of hypothyroid infants with severe hormonal alterations is necessary for the detection of thyroid agenesia.

Thermophilic-anaerobic digestion to produce class A biosolids: initial full-scale studies at Hyperion Treatment Plant.

The highest quality of biosolids is called exceptional quality. To qualify for this classification, biosolids must comply with three criteria: (1) metal concentrations, (2) vector-attraction reduction, and (3) the Class A pathogen-density requirements. The City of Los Angeles Bureau of Sanitation Hyperion Treatment Plant (HTP) (Playa del Rey, California) meets the first two requirements. Thus, the objective of this study was to ensure that HTP's biosolids production would meet the Class A pathogen-reduction requirements following the time-temperature regimen for batch processing (U.S. EPA, 1993; Subsection 32, Alternative 1). Because regulations require the pathogen limits to be met at the last point of plant control, biosolids sampling was not limited to immediately after the digesters, i.e., the digester outflows. The sampling extended to several locations in HTP's postdigestion train, in particular, the last points of plant control, i.e., the truck loading facility and the farm for land application. A two-stage, thermophilic-continuous-batch process, consisting of a battery of six egg-shaped digesters, was established in late 2001 for phase I of this study and modified in early 2002 for phase II. As the biosolids were discharged from the second-stage digesters, the Salmonella sp. (pathogen) and fecal-coliform (indicator) densities were well below the limits for Class A biosolids, even though the second-stage-digester temperatures were a few degrees below the temperature required by Alternative 1. Salmonella sp. densities remained below the Class A limit at all postdigestion sampling locations. Fecal-coliform densities were also below the Class A limit at postdigestion-sampling locations, except the truck-loading facility (phases I and II) and the farm for final use of the biosolids (phase II). Although federal regulations require one of the limits for either fecal coliforms or Salmonella sp. to be met, local regulations in Kern County, California, where the biosolids are land-applied, require compliance with both bacterial limits. Additional work identified dewatering, cooling of biosolids after the dewatering centrifuges, and contamination as possible factors in the rise in density of fecal coliforms. These results provided the basis for the full conversion of HTP to the Los Angeles continuous-batch, thermophilic-anaerobic-digestion process. During later phases of testing, this process was demonstrated to produce fully disinfected biosolids at the farm for land application.

Effects of transient temperature increases on odor production from thermophilic anaerobic digestion.

The City of Los Angeles, Bureau of Sanitation, has implemented thermophilic anaerobic sludge digestion at the Hyperion and Terminal Island Treatment Plants (HTP and TITP). A two-stage continuous-batch process was established at HTP, while a single-stage sequencing batch process was established at TITP. This was to evaluate compliance with the Class A pathogen reduction requirements of U.S. EPA 40 CFR Part 503. A rapid increase of the digester temperature at TITP from 57.5 to 65.5 degrees C caused an increase of the volatile fatty acid to alkalinity ratio, a decline in digester performance, and an elevated production of methyl mercaptan and hydrogen sulfide. A rapid increase of the digester temperature at HTP from 54 to 58 degrees C caused an elevated production of methyl mercaptan, but the effect on the volatile fatty acid to alkalinity ratio and digester performance was insignificant. It is likely that these effects observed at TITP and HTP were transient responses to rapid changes in temperature.

Solving fecal coliform growth/reactivation in biosolids during full-scale post-digestion processes.

Fecal coliform recurrence has been observed at the City of Los Angeles Hyperion Treatment Plant during pilot-scale experiments with a designated thermophilic battery of six anaerobic digesters, while other digesters were still at a mesophilic temperature. Several lab and full-scale experiments indicated the following possible causes of the growth/reactivation of fecal coliforms in post-digestion: a) contamination of thermophilically digested biosolids with mesophilically digested biosolids; b) a large drop in the biosolids temperature between the centrifuges and silos, which could have allowed the reactivation and/or growth of fecal coliforms. These were resolved by the full plant conversion to thermophilic anaerobic digestion and design modifications of the post-digestion train.

Fifteen years of offgas transfer efficiency measurements on fine-pore aerators: key role of sludge age and normalized air flux.

Fine-pore diffusers, often called fine-bubble diffusers, have nearly replaced coarse bubble diffusers in municipal wastewater treatment over the past 20 years. The rapid increases in energy costs, which began in the 1970s, created financial incentives to upgrade to this more expensive and maintenance-intensive method of aeration. Fine-pore diffusers have the added benefit of reducing volatile organic compound stripping and reduced aeration heat loss. This paper summarizes 15 years of oxygen transfer efficiency measurements using the offgas technique. Efficiencies are shown for different types of diffusers at various tank geometries (depth, diffuser size, and number), airflow rates, and mean cell retention times (MCRT or sludge age). By normalizing the airflow rates per unit of depth and diffusing area, efficiencies measured in different plants can be compared. The results show that aeration efficiencies are logarithmically related to the ratio between MCRT and the normalized air flux, with transfer rates suppressed by low MCRT or high normalized air flux systems. There is no evidence for different alpha factors among the different types of fine-bubble diffuser types.

Effect of clofibrate in jaundiced term newborns.

OBJECTIVE: Clofibrate is a glucuronosyl transferase inducer that has been proposed to increase the elimination of bilirubin in neonates with hyperbilirubinemia. The aim of this study was to characterize the therapeutic effect of clofibrate in neonates born at full term and present with non-hemolytic jaundice. METHODS: A clinical controlled study was performed in two groups of healthy full term neonates. Thirty neonates were treated with a single oral dose of clofibrate (100 mg/kg) plus phototherapy (clofibrate-treated group) while another 30 neonates (control group) received only phototherapy. RESULT: The mean plasma total bilirubin levels of 12th, 24th and 48th hours were significantly lower in the clofibrate-treated group as compared with the control group (P < 0.0001, P < 0.0001 and P = 0.004, respectively). Treatment with clofibrate also resulted in a shorter duration of jaundice and a decreased use of phototherapy (P < 0.0001). No side effects were observed. CONCLUSION: Although other pharmacological agents such as metalloporphyrins and Sn-mesoporphyrin also seem to be effective in decreasing bilirubin production, these products are not available for routine use and cannot be used because the safety of these drugs has to be confirmed prior to their widespread use. Therefore, clofibrate is now the only available pharmacological treatment of neonatal jaundice.

Serum lipid levels during carbamazepine therapy in epileptic children.

The aim of the study was to evaluate serum lipid levels during carbamazepine therapy in epileptic children. Thirty epileptic children (18 male, 12 female; age range, 30 months to 14 years) with idiopathic or cryptogenic partial or generalized tonic-clonic seizures (13 CPS, 17 GTC) were evaluated for serum lipids at the onset and the third month of carbamazepine therapy. Carbamazepine was started at 10 mg/kg/day. Mean total cholesterol, low-density lipoprotein, very low density lipoprotein, and triglyceride levels significantly increased during treatment (P < 0.05), but mean high-density lipoprotein levels were not statistically significant throughout the study. Carbamazepine treatment alters the serum lipid profile of children in such a way that it could potentially facilitate the development of atherosclerosis.

Odor and volatile organic compound removal from wastewater treatment plant headworks ventilation air using a biofilter.

Laboratory-scale experiments and field studies were performed to evaluate the feasibility of biofilters for sequential removal of hydrogen sulfide and volatile organic compounds (VOCs) from wastewater treatment plant waste air. The biofilter was designed for spatially separated removal of pollutants to mitigate the effects of acid production resulting from hydrogen sulfide oxidation. The inlet section of the upflow units was designated for hydrogen sulfide removal and the second section was designated for VOC removal. Complete removal of hydrogen sulfide (H2S) and methyl tert-butyl ether (MTBE) was accomplished at loading rates of 8.3 g H2S/(m3 x h) (15-second empty bed retention time [EBRT]) and 33 g MTBE/(m3 x h) (60-second EBRT), respectively. In field studies performed at the Hyperion Treatment Plant in Los Angeles, California, excellent removal of hydrogen sulfide, moderate removal of nonchlorinated VOCs such as toluene and benzene, and poor removal of chlorinated VOCs were observed in treating the headworks waste air. During spiking experiments on the headworks waste air, the percentage removals were similar to the unspiked removals when nonchlorinated VOCs were spiked; however, feeding high concentrations of chlorinated VOCs reduced the removal percentages for all VOCs. Thus, biofilters offer a distinct advantage over chemical scrubbers currently used at publicly owned treatment works in that they not only remove odor and hydrogen sulfide efficiently at low cost, but also reduce overall toxicity by partially removing VOCs and avoiding the use of hazardous chemicals.

Toxicity of di-(2-ethylhexyl) phthalate on the anaerobic digestion of wastewater sludge.

Previous studies on the microbial degradation of individual phthalic acid esters (PAEs) have demonstrated that the compounds with short ester hydrocarbon chains are easily biodegraded and mineralized, but PAEs with long ester chains are less susceptible to degradation and some of them are considered recalcitrant. Moreover, they inhibit methanogenesis. However, studies have not been made on the effect of feeding a combination of recalcitrant and biodegradable PAEs into anaerobic digesters treating wastewater sludge. The present study was conducted with wastewater sludge from the Los Angeles Bureau of Sanitation's Hyperion Treatment Plant. Di (2-ethylhexyl) phthalate (DEHP), the most common persistent PAE found in wastewater, and di-n-butyl phthalate (DBP), a common PAE with short ester chains, were sorbed into the sludge fed to a bench-scale digester for a period of 12 weeks. DEHP degradation was always poor, and accumulation of DEHP was correlated with inhibition of the microbial degradation of DBP and with process instability of the test digester. Inhibition of the DBP removal was completely reversed after DEHP addition was discontinued, but biogas production never recovered to the level observed in a control digester. Other process parameters of digester performance were not affected by DEHP accumulation. These results are similar to the toxic effects of long chain fatty acids on sludge digestion, suggesting that DEHP or its degradation products affect all the microbial populations in the anaerobic bioreactor. Our results imply that high levels of DEHP or other recalcitrant PAEs in wastewater sludge are likely to compromise methanogenesis and removal of biodegradable PAEs in sludge digesters.

Glucose-6-phosphate dehydrogenase deficiency in neonates.

OBJECTIVE: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an inherited deficiency that may be the cause of neonatal hyperbilirubinemia, as has been found in several countries and among widely different ethnic groups, especially in Mediterranean region. Our aim was to study the prevalence of G6PD deficiency in relation to neonatal jaundice. METHODS: From March 1998 to April 2001 we studied 705 clinically icteric neonates who were admitted to Al-Zahra and Beheshti hospitals, two teaching hospitals in Isfahan, Iran. Laboratory investigations included determination of direct and indirect serum bilirubin concentrations, blood group typing, direct coomb's test, hemoglobin, blood smear, reticulocyte count and G6PD level. RESULTS: In only 53 (7.5%) of cases G6PD deficiency was diagnosed. In all G6PD deficient neonates no evidence of other factors known to cause hyperbilirubinemia were detected. The sex distribution was 13 (24.5%) females and 40 (75.5%) males in the G6PD deficient group. The mean bilirubin level in G6PD deficient and G6PD normal groups were 22.26 +/- 8.36 and 18.14 +/- 3.85 mg/dl, respectively (p=0.001). Phototherapy was required in G6PD deficient and other icteric neonates with duration of 3.76 +/- 1.93 and 3.13 +/- 2.14 days, respectively (p=0.045). Twenty-seven of the 53 (50.9%) G6PD deficient infants required exchange transfusion. None of them developed kernicterus. CONCLUSIONS: Since the prevalence of severe hyperbilirubinemia among our neonates was relatively high and about half of them required exchange transfusion, early detection of this enzymopathy regardless of sex and close surveillance of the affected newborns may be important in reducing the risk of severe hyperbilirubinemia and exchange transfusion.

Changing mesophilic wastewater sludge digestion into thermophilic operation at Terminal Island Treatment Plant.

This paper describes the progress up to June 2000 for thermophilic digestion of wastewater sludge at the Los Angeles, California, Bureau of Sanitation's Terminal Island Treatment Plant. The development of the microorganism culture has followed a course similar to that seen at other successful plants for establishment of a stable, well-balanced thermophilic culture in a large digester, but at an accelerated pace. This study began with rapid heating, increasing the temperature of the 4500 m3 (1.2 mil. gal) digester to the target temperature of 55 degrees C at approximately 3 degrees C/d. A method of feeding to maximize the rate of culture development was used as feeding accelerated to approximately 400 m3/d (0.1 mgd). An initial rise of acid concentration (primarily acetate) was seen. Within two weeks, acid concentration declined and stabilized, indicating that acidogenic and methanogenic microbial communities came into balance. Coliform data indicate that digester disinfection was stably effective from the middle of April. The salmonella tests done to date satisfy the U.S. Environmental Protection Agency (U.S. EPA) class A specification. Testing with helminth ova and enteric viruses before and after the digester shows satisfaction of class A standard for those organisms. The present combination of low volatile fatty acids and low hydrogen sulfide is good news for odor control. The data show increases in volatile solids destruction and estimated gas production, compared with the previous mesophilic operation; however, large uncertainties have been calculated from the data. As the digester is now operating successfully at the current feed rate, there seems to be no barriers to processing the entire sludge production of the plant. Other results indicate that the U.S. EPA requirements for exceptional quality class A biosolids are likely to be achieved.

State of the art and future perspectives of thermophilic anaerobic digestion.

The state of the art of thermophilic digestion is discussed. Thermophilic digestion is a well established technology in Europe for treatment of mixtures of waste in common large scale biogas plants or for treatment of the organic fraction of municipal solid waste. Due to a large number of failures over time with thermophilic digestion of sewage sludge this process has lost its appeal in the USA. New demands on sanitation of biosolids before land use will, however, bring the attention back to the use of elevated temperatures during sludge stabilization. In the paper we show how the use of a start-up strategy based on the actual activity of key microbes can be used to ensure proper and fast transfer of mesophilic digesters into thermophilic operation. Extreme thermophilic temperatures of 65 degrees C or more may be necessary in the future to meet the demands for full sanitation of the waste material before final disposal. We show data of anaerobic digestion at extreme thermophilic temperatures.

Odor and volatile organic compound treatment by biotrickling filters: pilot-scale studies at hyperion treatment plant.

A pilot-scale biotrickling filter was installed at the Hyperion Treatment Plant in Los Angeles, California, to study hydrogen sulfide (odor) and volatile organic compound (VOC) removal from headworks waste air. The performance of the reactor was continuously monitored during a 10-month period. At an average empty bed gas residence time of 24 seconds, 10 to 50 ppm of hydrogen sulfide was consistently removed at greater than 98% efficiency, corresponding to an average volumetric elimination capacity of 5.2 g/m3 x h. Concentration profiles over the height of the reactor indicated nearly complete removal in the first section of the reactor, suggesting that elimination capacities up to 30 g/m3 x h could be obtained. The odor reduction (as dilution to threshold) was 98%, which correlated with the efficiency of removal of hydrogen sulfide as the primary pollutant. Volatile organic compounds were present at concentrations up to 225 ppb. Moderate but significant removal of toluene and benzene was observed when the biotrickling filter was operated with pH control to neutralize sulfuric acid production from hydrogen sulfide oxidation. Xylenes and chlorinated VOCs were not removed regardless of experimental conditions in the reactor. The results led to the conclusion that VOC removal is the limiting process in biotrickling filters for the simultaneous removal of hydrogen sulfide and VOCs at publicly owned treatment works.

Relationship between oxygen transfer rate and airflow for fine-pore aeration under process conditions.

Although feedback systems that control the air supply to aeration tanks inherently incorporate some assumption about oxygen transfer response to changes in airflow, it is rare to measure this relationship under process conditions. This paper reports measurements of oxygen mass-transfer curves (MTCs) for a tank at the Tillman Water Reclamation Plant in Los Angeles, California. The curves were obtained by measuring the oxygen transfer efficiency (OTE) at selected points for several set values of airflow while the plant was operating. They approximate inverted parabolas because increasing the airflow increases the amount of oxygen supplied by the blowers, but decreases the OTE, which is the fraction of the supplied oxygen that actually enters the water. Data were recorded from both recently cleaned diffusers and ones that were moderately to severely fouled. The peaks in the curves from the fouled diffusers are at or below the midpoints of the observed ranges of airflows. Hence, there is only a narrow range of usable airflows between the lower limit, determined by the manufacturer of the diffusers, and the peak of the MTC, which is the maximum amount of oxygen that can be supplied. The peaks for the cleaned diffusers are higher, which allows more ability to adjust to changing biological loads. These results show that existing dissolved oxygen control systems may not be adequate and that fouling may reduce not only the overall efficiency of an aeration system but its ability to respond to changes in the biological load. The measurements also provide some insight to the limitations of using sparsely distributed dissolved oxygen sensors to control the aeration process and the excess costs that are incurred by the consequent need to compensate for uncertainty with extra air. However, additional testing is needed to determine whether the present results are aberrant or typical of tanks with fouled or cleaned diffusers.

Environmental engineering: energy value of replacing waste disposal with resource recovery

Although in the past, environmental engineering has been primarily concerned with waste disposal, the focus of the field is now shifting toward viewing wastes as potential resources. Because reclamation usually consumes less energy than producing new materials, increasing reclamation not only reduces pollution but saves energy. Technological innovations contributing to this shift are summarized here, and are variously classified as emerging technologies or research topics, as either new departures or incremental improvements, and as opportunistic innovations, or examples of a unifying strategy. Both liquid and solid waste examples are given, such as a recent discovery of effects in disinfecting microfiltered reclaimed wastewater with ultraviolet light. In addition to its value in reducing pollution and conserving energy, this reorientation of environmental engineering could contribute to a more general shift toward greater cooperation among organizations dealing with the environment.