The Ins and Outs of Per- and Polyfluoroalkyl Substances in the Great Lakes: The Role of Atmospheric Deposition.

As part of the Integrated Atmospheric Deposition Network, precipitation (n = 207) and air (n = 60) from five sites and water samples (n = 87) from all five Great Lakes were collected in 2021-2023 and analyzed for 41 per- and polyfluoroalkyl substances (PFAS). These measurements were combined with other available data to estimate the mass budget for four representative compounds, PFBA, PFBS, PFOS, and PFOA for the basin. The median Σ41PFAS concentrations in precipitation across the five sites ranged between 2.4 and 4.5 ng/L. The median Σ41PFAS concentration in lake water was highest in Lake Ontario (11 ng/L) and lowest in Lake Superior (1.3 ng/L). The median Σ41PFAS concentration in air samples was highest in Cleveland at 410 pg/m3 and lowest at Sleeping Bear Dunes at 146 pg/m3. The net mass transfer flows were generally negative for Lakes Superior, Michigan, and Huron and positive for Lakes Erie and Ontario, indicating that the three most northern lakes are accumulating PFAS and the other two are eliminating PFAS. Atmospheric deposition is an important source of PFAS, particularly for Lake Superior.

Socio-Economic Factors Impact US Dietary Exposure to Halogenated Flame Retardants.

Although diet is an important route of exposure for brominated flame retardants (BFRs), little is known of their presence in US food. Therefore, we purchased meat, fish, and dairy product samples (n = 72) in Bloomington, IN, from 3 stores representing national retail chains at different price levels. Composite samples (n = 42) were analyzed for polybrominated diphenyl ethers (PBDEs), hexabromocyclododecane (HBCDD), novel BFRs (NBFRs), and dechlorane plus (DP). Concentrations of total halogenated flame retardants (HFRs) ranged between 54 and 1,400 pg/g ww, with PBDEs being the predominant compounds. Concentrations of NBFRs, but not PBDEs, in US food items were significantly impacted by price, raising the issue of environmental justice. Nonorganic food generally had a higher abundance of BDE-209 than organic food items. Estimates of dietary exposure revealed that meat and cheese consumption contribute most to the overall HFR intake and that intakes are highest for children and for non-Hispanic Asians. Taking into account several caveats and limitations of this study, these results as a whole suggest that health burdens from dietary exposure to HFRs have become minimal for US citizens, highlighting the positive impact of regulatory efforts.

Disentangling Source Profiles and Time Trends of Halogenated Flame Retardants in the Great Lakes.

Thirty-five polybrominated diphenyl ethers (PBDEs) and eight other alternative flame retardants were measured in air samples (vapor plus particles) collected at six sites near the North American Great Lakes between 2005 and 2019 as part of the Integrated Atmospheric Deposition Network (IADN). These data were analyzed using a multiple linear regression model to determine spatial and temporal trends. Overall, the levels of flame retardants remain significantly higher in urban sites compared to rural and remote sites except for pentabromoethylbenzene (PBEB), hexabromobenzene (HBB), and total Dechlorane Plus (ΣDP). Here, we report the first findings of decreasing levels of ΣDP at Sturgeon Point, New York. The atmospheric levels of total PBDEs remain unchanged over time near Lakes Michigan and Superior and declined near Lakes Erie and Ontario, with rate constants at the latter two lakes revealing halving times of approximately 7 to 14 years. This work presents results from the first investigation of PBDE source apportionment in the Great Lakes atmosphere. Source apportionment by use of positive matrix factorization (PMF) identified two legacy commercial technical mixtures (i.e., penta-BDE and deca-BDE mixes) and elucidated a factor representing ambient degradation. Our results show that weathered local sources of technical commercial mixtures, and their photolysis contribute most to the total PBDE burden in the Great Lakes atmosphere.

Temporal environmental hysteresis: A definition and implications for polybrominated diphenyl ethers.

We define here "temporal environmental hysteresis" as the time lag between when a pollutant's input to the environment stops and when its concentration in the environment drops to some desired fraction of its maximum concentration. The goal of this paper is to investigate temporal environmental hysteresis for polybrominated diphenyl ethers (PBDEs), which were widely used as flame retardants in consumer goods. These compounds were taken off the North American market in two steps: At the end of 2004, the so-called Penta-BDE and Octa-BDE products were withdrawn, and at the end of 2013, the Deca-BDE product was also discontinued. We focus here on PBDE concentrations in about 700 atmospheric samples collected every 12 days from 2005 to 2018 (inclusive) at two urban sites: Chicago, Illinois, and Cleveland, Ohio. In Chicago, the concentrations of BDE-47 and 99 decreased by a factor of two every 5.9 ±â€¯0.9 and 8.0 ±â€¯1.4 years, respectively, but the concentrations of BDE-209 doubled every 7.6 ±â€¯1.8 years. In Cleveland, the concentrations of BDE-47 and 99 decreased by a factor of two every 5.1 ±â€¯0.4 and 5.7 ±â€¯0.5 years, respectively, and the concentrations of BDE-209 decreased by a factor of two every 9.2 ±â€¯1.6 years. The delay in all these environmental responses relative to when these compounds were removed from the market is a result of decadal scale environmental hysteresis.

The IADN data visualization tool.

Data on atmospheric levels of toxic pollutants in samples collected near the Great Lakes are now readily available online to scientists, researchers, and the public on a website called IADN Data Viz (https://iadnviz.iu.edu/). These data come from the Integrated Atmospheric Deposition Network (IADN), a long term monitoring program run by the U.S. Environmental Protection Agency (US EPA).

Temporal trends of Dechlorane Plus in air and precipitation around the North American Great Lakes.

Dechlorane Plus (DP) is a chlorinated flame retardant manufactured only in Niagara Falls, New York and in Huai'an, China. To determine if the environmental levels of this compound were changing significantly, we measured the long-term temporal trends of its concentrations near the Great Lakes between 2005 and 2015 using air (vapor + particle phase) samples (N = 1047) and precipitation samples (N = 449). We used a multiple linear regression model of DP concentrations to isolate the variabilities due to sampling date and population near the sampling site. The results show that the total DP concentrations in precipitation varied seasonally, maximizing on January 18, but the concentrations in the vapor + particle phase did not show seasonal variations. Vapor + particle phase DP levels were relatively high in Cleveland, and precipitation DP levels were relatively high at Point Petre. DP's concentrations in neither phase were changing as a function of sampling date, indicating that the input of this compound into the environment is continuing, presumably because its use and production are not regulated. Based on the ratio of the anti conformer relative to the total of the two conformer concentrations, we suggest that the syn conformer is somewhat more environmentally stable than the anti conformer.

Precision of Atmospheric Persistent Organic Pollutant Concentration Measurements.

Environmental measurement programs are often undertaken with the assumption that measurements at a given location will be comparable to others that would be observed at the same time in the immediate vicinity, but this assumption has seldom been tested. This paper does so. We discuss here the precision of atmospheric concentration measurements of persistent organic pollutants (POPs) near the North American Great Lakes-measurements that we have been conducting since 1994. We report the relative percent differences between the measured values for 100-200 duplicate samples, and through our use of surrogate (recovery) standards, we have separated the analytical error from the sampling error for the target compounds. The error contributions we calculated were on the order of 5% for the analytical error and 20% for the sampling error, suggesting that the latter is the greatest hindrance to increased precision. In a comparison of relative percent differences for measurements among different atmospheric phases, we observed the highest errors for precipitation samples, with an average median of 35 ± 3, which is more than for vapor-phase samples (27 ± 3) or particle-phase samples (27 ± 2). We suggest that sampling errors are principally the result of inaccuracies in measuring the sample volume and possibly the result of spatial heterogeneity of the atmosphere.

Prospective randomized evaluation of periureteral botulinum toxin type A injection for ureteral stent pain reduction.

PURPOSE: The use of ureteral stents for ureteral obstruction and after ureteroscopy can result in substantial deterioration in patient quality of life due to pain, frequency and urgency. We postulated that many stent related symptoms may be related to detrusor muscle spasm in and around the intramural ureter, and evaluated the effect of botulinum toxin type A (Botox) in patients with indwelling stents after ureteroscopy. MATERIALS AND METHODS: A total of 51 patients between December 2007 and March 2009 were enrolled in an institutional review board approved, prospective, randomized, single-blind study comparing botulinum toxin type A injection at a concentration of 10 U/ml to 3 locations around the ureteral orifice (30) vs no injection after unilateral ureteral stent insertion (21). Pain and urinary symptoms after stent placement were evaluated through the Ureteral Stent Symptom Questionnaire, which was completed on postoperative day 7. In addition, patients were required to maintain a log of narcotic use after stent placement until removal. The Wilcoxon rank sum and Fisher exact tests were used for nonparametric and categorical data, respectively, with p

Prospective comparison of flexible fiberoptic and digital cystoscopes.

OBJECTIVES: To compare the optics, performance, and durability of digital (DC) and fiberoptic (FC) cystoscopes. METHODS: In an office setting, we randomly assigned staff urologists to 1 of the 4 cystoscopes, the Gyrus-ACMI ICN-0564 (AD), Gyrus-ACMI ACN-2 (AF), Olympus CYF-V2 EndoEYE Cysto-Nephro Videoscope (OD), Olympus CYF-5 Cysto-Fiberscope (OF), to perform diagnostic or surveillance cystoscopy and stent removal. The documented metrics included a subjective surgeon assessment of cystoscope optics and function characteristics on a 10-point scale (1, poor to 10, excellent). The measurement of the upward and downward cystoscope deflection and damage and repairs were all documented. RESULTS: A total of 1022 cases were performed. The DC and FC were used 690 and 332 times, respectively. Two repairs (0.2%) were documented (1 AF and 1 AD); both resulted directly from incorrect cystoscope handling/cleaning. The mean operative time per case for the DC and FC was 4.5 and 4.6 minutes, respectively (P = .66). The mean surgeon optical ranking for the DC and FC was 8.4 and 7.8, respectively (P = .0076). The mean surgeon deflection ranking for the DC and FC was 8.6 and 8.0, respectively (P = .0001). The mean surgeon retroflex deflection ranking for the DC and FC was 8.4 and 7.8, respectively (P = .001). The mean overall cystoscope score surgeon ranking for the DC and FC was 8.6 and 7.9, respectively (P = .0001). CONCLUSIONS: In the office setting, with proper care, FCs and DCs are durable for office applications. Overall, surgeons significantly preferred the DCs as demonstrated by discrepancies in both use and differences in the subjective metrics.

Evaluation of bladder insufflants for transurethral cryoablation of the bladder.

OBJECTIVES: To compare helium and carbon dioxide gas insufflation for the creation of pneumocystis during bladder cryoablation in an effort to optimize the technique. METHODS: Nine pigs were divided into 3 groups. The pigs in groups 1, 2, and 3 underwent bladder cryoablation in a normal saline, carbon dioxide gas, and helium gas environment, respectively. Each group underwent 2 freeze-thaw cycles of the bladder dome. The bladder pressure measurements were recorded every 5 seconds throughout the cryoablation procedure. Bladder integrity was evaluated with both cystoscopic and laparoscopic visualization. All pigs were killed at the completion of the procedure, and the bladders were harvested for histopathologic evaluation. RESULTS: All 9 pigs successfully underwent bladder wall cryoablation. Bladder integrity was maintained in all 6 pigs in groups 1 and 3. In group 2, 2 bladder ruptures were documented. All group 2 pigs had a significantly increased bladder pressure during the 2 thaw cycles of the cryoablation procedure, with the peak pressure >70-100 mm Hg before venting of the excess carbon dioxide gas. No intervention was required to stabilize the bladder pressure in groups 1 and 3. The average change in pressure per 5-second interval during both thaw cycles for groups 1, 2, and 3 was 0.16, 6.96, and 0.42 mm Hg/s, respectively (P = .0003). Group 3 showed mild hemorrhage on histologic examination. CONCLUSIONS: The creation of pneumocystis with helium gas reduces sublimation and eliminates the problems of rapidly fluctuating bladder pressures and decreased visibility previously noted with carbon dioxide gas during bladder cryoablation.

Erythropoietin-induced optimization of renal function after warm ischemia.

BACKGROUND AND PURPOSE: Recent preclinical data have indicated that erythropoietin (Epo) can protect organs from ischemic damage. We evaluated the ability of Epo to protect the kidney from the effects of ischemia. METHODS: Thirty dogs underwent a laparoscopic nephrectomy and were allowed to recover for 2 weeks. The dogs were then divided into five groups. Animals in groups 1 and 2 underwent 1.5 hours of abdominal insufflation with placebo (saline) injection (group 1) or Epo injection (group 2) before; groups 3 to 5 underwent 1 hour of laparoscopic renal artery clamping after placebo injection (group 3), Epo injection (group 4), or mannitol injection (group 5). Serum evaluations and 24-hour urine collections were performed weekly. After 28 days, the animals were sacrificed. Statistical analysis was performed with the Kruskal-Wallis test. RESULTS: After recovery from the initial nephrectomy, all dogs had similar serum hematocrit and creatinine levels. Hematocrit was not significantly affected by Epo administration at any time point. Immediately after the second surgery, dogs that underwent renal artery clamping (groups 3-5) had significantly lower 24-hour urine creatinine levels than those that were not clamped (groups 1-2). After 4 weeks of recovery, the dogs that had received Epo before ischemia (group 4) had recovered significantly more renal function than the dogs that received placebo or mannitol before ischemia (urine creatinine level = Epo 149.1 mg/dL v placebo 70.7 mg/dL v mannitol 80.7 mg/dL). At sacrifice, microalbuminuria was also significantly less in dogs receiving Epo before ischemia than their mannitol or placebo counterparts. CONCLUSION: The current study demonstrates that administering Epo before warm ischemia can improve the recovery of renal function after ischemia better than placebo or mannitol.

Minimally invasive management of upper tract malignancies: renal cell and transitional cell carcinoma.

This article focuses on the laparoscopic approaches to radical and partial nephrectomy for the managment of renal cell carcinoma and on the laparoscopic and endoscopic approaches for treating upper tract urothelial carcimoma. An in-depth discussion of treatment for transitional cell carcinoma is also presented.

The effect of intraluminal content on the bursting strength of vessels ligated with the harmonic ACE and LigaSure V.

PURPOSE: Energy-based surgical devices (ESDs) are critical for maintaining hemostasis during laparoscopy; however, there are no studies that have evaluated the function of ESDs under different physiologic conditions. We evaluated the effect of intraluminal vessel content on bursting pressure (BP) after ligation with two ESDs: the Harmonic ACE and the LigaSure V. MATERIALS AND METHODS: Bursting trials were performed on the vasculature of 24 pigs. Blood vessels were distended with blood of different hematocrit concentrations or an albumin solution of varying protein content. The vessel size and BP of each vessel was recorded after ligation with each ESD. RESULTS: In arteries 0 to 3 mm and veins 0 to 3 mm in size ligated with the Harmonic ACE or the LigaSure V, there were significantly elevated vessel BPs with supraphysiologic intraluminal hematocrits. In arteries and veins ligated with the Harmonic ACE, increasing albumin concentrations also led to increasing BPs, though these maximal BPs were lower than those obtained with supraphysiologic hematocrit levels. Increasing albumin concentrations did not increase the BP of the LigaSure V. Within the ranges tested, there was no decrease in vessel BP associated with anemia. CONCLUSION: In small vessels, a supraphysiologic hematocrit increased the BP of both arteries and veins when using the Harmonic ACE or the LigaSure V. With the devices tested, anemia did not seem to affect BP. While factors such as intraluminal protein concentration may play a role with ultrasonic energy devices, the mechanism of the increased BP remains unclear. Better understanding of ESDs will help in the design of future devices.

First Prize (tie): Laparoscopic renal cryoablation: efficacy and complications for larger renal masses.

BACKGROUND AND PURPOSE: In expanding our indications for cryoablation of renal cortical neoplasms, there was an increased morbidity with laparoscopic cryoablation. As such, we evaluated our single institution experience with laparoscopic renal cryoablation for complications and oncologic effectiveness as a function of tumor size. MATERIALS AND METHODS: We retrospectively evaluated our prospectively established urologic oncology database and identified 44 laparoscopic cryoablation procedures performed for the management of 51 renal masses. Measured parameters included patient age, tumor size and location, estimated blood loss, complications, and recurrences. Patients were stratified into two groups. In group 1, the patients presented with a maximum tumor diameter less than 3.0 cm. Group 2 patients had a maximum tumor diameter of 3.0 cm or larger. RESULTS: Group 1 included 30 tumors in 23 patients, and group 2 had 21 tumors in 21 patients. The mean tumor size for groups 1 and 2 were 1.8 cm (range 0.7 to 2.8 cm) and 4.0 cm (range 3.0 to 7.5 cm), respectively (P < 0.0001). The average patient age for group 1 was 70.2 and group 2 was 77.6 years (P = 0.04). The mean American Society of Anesthesiologists score was 1.8 and 2.1 for groups 1 and 2, respectively (P = 0.06). There were no complications in group 1. Group 2 had 13 (62%) complications, including two mortalities. The most common complication was blood transfusions at 38%. With a mean follow-up of 9 months, there were no recurrences in group 1. With a mean follow-up of 11 months, there was a single (4.8%) recurrence in group 2. Biopsy histopathology revealed renal cell carcinoma variants in 46.7% in group 1 and 66.7% in group 2, respectively (P = 0.079). CONCLUSION: Renal cryoablation of renal cortical neoplasms smaller than 3.0 cm is effective and safe. Our initial experience, however, demonstrates that cryoablation of larger renal masses may be associated with increased morbidity.

Risk factors associated with renal parenchymal fracture during laparoscopic cryoablation.

OBJECTIVE: To assess the risk factors for haemorrhage and renal fracture associated with renal cryoablation. MATERIALS AND METHODS: In a porcine model, 120 cryoablations were administered in 26 pigs, with five groups of 24 ice-balls each; in groups 1 and 2 asynchronous cryoprobe activation was evaluated for the 1.47- and 3.4-mm cryoprobes (IceRods, Galil Medical, Plymouth Meeting, PA, USA), respectively; in group 3, three-3.4 mm cryoprobes were used to examine synchronous probe activation; in group 4 the 1.47-mm cryoprobe was used to examine single-probe activation with premature cryoprobe extraction; and in group 5 we used a new 'guillotine' technique for upper-pole renal cryoablation. Ice-ball fractures and haemorrhage were characterized by the location, length and depth of each fracture, was well as the degree of bleeding. RESULTS: In all, 26 domestic pigs successfully had renal cryoablation procedures. In group 1 and 4 there were no episodes of renal fracture; in group 2 renal fracture occurred in 10 (42%) trials. Group 3 had 22 (92%) renal fractures during the freeze/thaw cycle. Group 5 had 13 (54%) renal fractures during the freeze/thaw cycle, and there was an additional ice-ball fracture during probe removal once in 24 times. CONCLUSIONS: Renal fracture is most common with the application of larger 3.4-mm cryoprobes in the synchronous and asynchronous setting. Under standard application, smaller (1.47-mm) cryoprobes result in little renal fracture or bleeding. The use of the guillotine technique is associated with a greater risk of renal fracture.

Cryoablation and radiofrequency for kidney tumor.

The detection of incidental and asymptomatic renal cortical neoplasms has concomitantly increased with radiographic imaging use. The gold standard for treating small renal tumors includes open and laparoscopic partial nephrectomy. Ablative renal procedures intend to duplicate the excellent oncologic outcomes of partial nephrectomy, while decreasing complications and shortening hospitalization time and convalescence. Only short and medium-term data are available, but ablation with cryotherapy or radiofrequency probes may achieve these goals. Ablation also offers the advantages of a minimally invasive surgical approach, with a significantly lower complication rate than partial nephrectomy. Ablated lesions are typically left in situ. Leaving potentially malignant tissues in place, albeit in a nonviable condition, certainly represents a major change in surgical thinking processes. This article reviews the status of cryoablation and radiofrequency ablation, the two ablative modalities currently available for clinical application.

An assessment of urologists' training and knowledge of energy-based surgical devices.

OBJECTIVE: To assess surgeons' training and current understanding of existing energy-based surgical instrumentation (ESI), we disseminated an online questionnaire to urology residents, fellows and attending urologists. SUBJECTS AND METHODS: A two part 24-question survey was disseminated to 1000 urology residents, fellows and attending physicians. The first part of the questionnaire assessed the respondents' demographics and education about ESI; the second part evaluated the respondent's knowledge of surgical energy methods and ESI, and was stratified into nine basic- and six advanced-knowledge questions. RESULTS: In all, 136 people (13.6%) viewed the survey and it was completed by 63 (6.3%). Respondents comprised 27 (43%) attending physicians, 14 (22%) minimally-invasive urology fellows and 22 (35%) urology residents. Among participants, 41 (64%) had received no formal didactic training on ESI, and a further 14% of respondents' didactic experience was limited to one lecture. Of the respondents, 70% said that monopolar energy was the mode most often used in surgery. Overall, the participants correctly answered 41% of the questions. Of the nine questions classified as 'basic' knowledge, respondents correctly answered 49%. Of the six questions classified as 'advanced' knowledge, 29% were answered correctly. The highest percentage score was obtained by the attending urologists, with a mean (range) score of 41 (29-86)%, followed by the fellows, with a mean score of 39.5 (29-57)%, and then the residents, at 34 (14-64)%. CONCLUSION: Despite widespread and growing use of ESI, there is currently minimal formal training on energy modes and current energy devices being provided to urological surgeons. Both practising and training urologists have a limited understanding of surgical energy modes and of existing ESI.

Kidney cancer ablative therapy: indications and patient selection.

The increased application of radiographic imaging has paralleled a simultaneous increase in the detection of incidental and asymptomatic renal neoplasms. The reference standard for treating small renal tumors includes open and laparoscopic partial nephrectomy. The primary objectives of ablative renal procedures are to duplicate the excellent oncologic outcomes of partial nephrectomy while decreasing patient morbidity and shortening hospitalization and overall convalescence. Ablation, with cryotherapy or radiofrequency probes, offers the advantages of minimally invasive surgery, but with a significantly lower complication rate than laparoscopic partial nephrectomy. Ablation now represents a major change in surgical thinking as tumors are ablated and left in situ. This article reviews the status of the two ablative modalities currently available for clinical application, cryoablation and radiofrequency ablation.

Tissue response to surgical energy devices.

OBJECTIVES: There is little data available on the effects of energy-based surgical devices (ESD) on tissues other than arteries and veins. As such, we quantified the lateral thermal damage associated with contemporary ESD: the Harmonic ACE, a prototype bipolar device known as the Gyrus Trisector, the Harmonic LCS-C5, and the LigaSure V. METHODS: We divided 24 domestic pigs into 4 groups, 1 group for each ESD tested. Segments of bladder, stomach, small bowel, colon, ureter, peritoneum, arteries, and veins were exposed to each ESD. The tissues were stained with hematoxylin and eosin and evaluated by an experienced pathologist to quantitate the lateral energy spread associated with each device. We measured blade temperatures of each device using the IR-Flex thermal camera. RESULTS: The Trisector developed the lowest mean blade temperature (97.84 degrees F), whereas the LigaSure's was the second lowest (103.14 degrees F). The ACE and LCS-C5 created the highest blade temperatures, measuring 220.5 degrees F and 205.6 degrees F, respectively. The Trisector's mean full thickness and superficial lateral energy damage were 6.3 mm and 7.0 mm, respectively, whereas the Ligasure's was 4.5 mm and 5.9 mm, respectively. For the ACE, however, mean full thickness and superficial energy spread were 2.4 mm and 2.8 mm, respectively, whereas the LCS-C5's were 3.1 mm and 4.3 mm, respectively. CONCLUSIONS: The Harmonic ACE and LCS-C5 produced the least thermal damage in the tissues tested. ESD-associated tissue energy damage is not directly related to blade temperature, but is likely the result of several factors including blade temperature, transection time, tissue properties, and the vascularity of each transected tissue.