Patient Education Is Associated With Reduced Delay to Presentation for Management of Ischemic Priapism: A Retrospective Review of 123 Men.

BACKGROUND: Adverse outcomes secondary to ischemic priapism (IP) are associated with time to presentation and management. AIM: To characterize patterns in presentation delay as a function of etiology and patient education regarding IP risk. METHODS: Following institutional review board approval, charts of IP patients presenting to our institution from 2010 to 2020 were reviewed. One episode of IP per patient was included for analysis. OUTCOMES: Priapism duration in patients presenting with IP. RESULTS: We identified 123 unique patients with IP. Common etiologies included erectogenic intracavernosal injection (24%), trazodone (16%), and other psychiatric medications (16%). Patients with sickle cell anemia or trait and intracavernosal injection-related IP presented sooner than idiopathic cases and those from psychiatric medication (P < .001). Etiology and provider education on IP risk were associated with presentation ≥ 24 hours. Upon multivariate analysis, only a lack of provider education was independently associated with presentation ≥ 24 hours. CLINICAL IMPLICATIONS: Men who received provider-based education on the risk of IP associated with their condition or medication regimen were more likely to seek prompt medical attention for IP and, therefore, less likely to require surgery. STRENGTHS & LIMITATIONS: This manuscript represents one of the largest series on priapism, an area of urologic practice in need of more evidence-based guidance. The numbers are not inflated by including multiple episodes per patient, and the data collected include etiology, time to presentation, and treatment. Limitations include a retrospective chart review study design at a single institution. CONCLUSION: Educational initiatives on the risk of IP associated with particular disease states and medications should target at-risk individuals, as well as prescribers of medications associated with IP. Dutta1 R, Matz1 EL, Overholt TL, et al. Patient Education Is Associated With Reduced Delay to Presentation for Management of Ischemic Priapism: A Retrospective Review of 123 Men. J Sex Med 2021;18:385-390.

In-line coagulation assessment for ultrafiltration fouling reduction to treat secondary effluent for water reuse.

Low pressure membranes are attracting attention for their potential to improve secondary effluent quality, but membrane fouling can limit their widespread applicability. In this study, in-line coagulation as pre-treatment to ultrafiltration (UF) was investigated using a bench-scale hollow fiber membrane at a constant flux of 33 L/m2 h. Membrane fouling was monitored by observing change in trans-membrane pressure when the membrane was fed with secondary effluent and in-line coagulated secondary effluent over a 24-h period. The impact of four coagulants at different dosages on reversible and irreversible membrane fouling and permeate quality was studied. It was found that in-line coagulation improved UF performance to varying degrees depending on coagulant type and dosage. Generally, higher reduction of fouling was achieved by increasing coagulant dosage within the 0.5-5.0 mg/L range investigated. Ferric-based coagulants were better than aluminum-based coagulants with respect to improving membrane performance for the secondary effluent investigated, even at low dosages (0.5 mg/L). Further investigations are required to determine how in-line coagulation affects removal of organic compounds through UF membranes.

Influence of water quality on nitrifier regrowth in two full-scale drinking water distribution systems.

The potential for regrowth of nitrifying microorganisms was monitored in 2 full-scale chloraminated drinking water distribution systems in Ontario, Canada, over a 9-month period. Quantitative PCR was used to measure amoA genes from ammonia-oxidizing bacteria (AOB) and ammonia-oxidizing archaea (AOA), and these values were compared with water quality parameters that can influence nitrifier survival and growth, including total chlorine, ammonia, temperature, pH, and organic carbon. Although there were no severe nitrification episodes, AOB and AOA were frequently detected at low concentrations in samples collected from both distribution systems. A culture-based presence-absence test confirmed the presence of viable nitrifiers. AOB were usually present in similar or greater numbers than AOA in both systems. As well, AOB showed higher regrowth potential compared with AOA in both systems. Statistically significant correlations were measured between several water quality parameters of relevance to nitrification. Total chlorine was negatively correlated with both nitrifiers and heterotrophic plate count (HPC) bacteria, and ammonia levels were positively correlated with nitrifiers. Of particular importance was the strong correlation between HPC and AOB, which reinforced the usefulness of HPC as an operational parameter to measure general microbiological conditions in distribution systems.

Removal of the cyanotoxin anatoxin-a by drinking water treatment processes: a review.

Anatoxin-a (ANTX-a) is a potent alkaloid neurotoxin, produced by several species of cyanobacteria and detected throughout the world. The presence of cyanotoxins, including ANTX-a, in drinking water sources is a potential risk to public health. This article presents a thorough examination of the cumulative body of research on the use of drinking water treatment technologies for extracellular ANTX-a removal, focusing on providing an analysis of the specific operating parameters required for effective treatment and on compiling a series of best-practice recommendations for owners and operators of systems impacted by this cyanotoxin. Of the oxidants used in drinking water treatment, chlorine-based processes (chlorine, chloramines and chlorine dioxide) have been shown to be ineffective for ANTX-a treatment, while ozone, advanced oxidation processes and permanganate can be successful. High-pressure membrane filtration (nanofiltration and reverse osmosis) is likely effective, while adsorption and biofiltration may be effective but further investigation into the implementation of these processes is necessary. Given the lack of full-scale verification, a multiple-barrier approach is recommended, employing a combination of chemical and non-chemical processes.

Biological Filtration is Resilient to Wildfire Ash-Associated Organic Carbon Threats to Drinking Water Treatment.

Elevated/altered levels of dissolved organic matter (DOM) in water can be challenging to treat after wildfire. Biologically mediated treatment removes some DOM; here, its ability to remove elevated/altered postfire dissolved organic carbon (DOC) resulting from wildfire ash was investigated for the first time. Treatment of wildfire ash-amended (low, moderate, high) source waters by bench-scale biofilters was evaluated in duplicate. Turbidity and DOC were typically well-removed (effluent turbidity ≤0.3 NTU; average DOC removal ∼20%) in all biofilters during periods of stable source water quality. Daily DOC removal across all biofilters (ash-amended and controls) was generally consistent, suggesting that (i) the biofilter DOC biodegradation capacity was not deleteriously impacted by the ash and (ii) the biofilters buffered the ash-associated increases in water extractable organic matter. DOM fractionation indicates this was because the biodegradable low molecular weight neutral fractions of DOM, which increased with ash addition, were reduced by biofiltration while humic substances were largely recalcitrant. Thus, biological filtration was resilient to wildfire ash-associated DOM threats to drinking water treatment, but operational resilience may be compromised if the balance between readily removed and recalcitrant fractions of DOM change, as was observed during brief periods herein.

Common Data Element Collection in Underserved School Communities: Challenges and Recommendations.

OBJECTIVES: To provide recommendations for future common data element (CDE) development and collection that increases community partnership, harmonizes data interpretation, and continues to reduce barriers of mistrust between researchers and underserved communities. METHODS: We conducted a cross-sectional qualitative and quantitative evaluation of mandatory CDE collection among Rapid Acceleration of Diagnostics-Underserved Populations Return to School project teams with various priority populations and geographic locations in the United States to: (1) compare racial and ethnic representativeness of participants completing CDE questions relative to participants enrolled in project-level testing initiatives and (2) identify the amount of missing CDE data by CDE domain. Additionally, we conducted analyses stratified by aim-level variables characterizing CDE collection strategies. RESULTS: There were 15 study aims reported across the 13 participating Return to School projects, of which 7 (47%) were structured so that CDEs were fully uncoupled from the testing initiative, 4 (27%) were fully coupled, and 4 (27%) were partially coupled. In 9 (60%) study aims, participant incentives were provided in the form of monetary compensation. Most project teams modified CDE questions (8/13; 62%) to fit their population. Across all 13 projects, there was minimal variation in the racial and ethnic distribution of CDE survey participants from those who participated in testing; however, fully uncoupling CDE questions from testing increased the proportion of Black and Hispanic individuals participating in both initiatives. CONCLUSIONS: Collaboration with underrepresented populations from the early study design process may improve interest and participation in CDE collection efforts.

Ion-Exchange Treatment of Perfluorinated Carboxylic Acids in Water: Comparison of Polystyrenic and Polyacrylic Resin Structures and Impact of Sulfate on Their Performance.

The removal of three perfluorinated carboxylic acids (PFCAs)-PFHpA, PFOA, and PFNA-in ultrapure and river water was evaluated using two anion-exchange resins-previously unreported macroporous polystyrenic A-500P and a more widely studied macroporous polyacrylic A-860. Both resins had similar properties, allowing direct comparison of PFCA removal performance between the two resin structures/matrices. This study also presents a new gas chromatography-mass spectrometry (GC/MS) method developed for PFCA analysis in water. In ultrapure water, A-500P exhibited higher removal capacity and faster removal compared to A-860, suggesting greater effectiveness of the polystyrenic structure compared to the polyacrylic structure. In the Grand River water, the target PFCAs were well removed by A-500P but not A-860. However, both resins achieved similarly high overall reductions of dissolved organic carbon (∼75%), suggesting, later confirmed in ultrapure water experiments, that inorganic anions (sulfate particularly) were the dominant competitors for the A-860 resin. The uncharged styrenic and acrylic beads (base materials) of the two tested resins were unable to remove PFOA, implying that the dominant removal mechanism involves charge interactions between the negatively charged PFCA and the positively charged anion-exchange functional groups.

Previously unrecognized potential threat to children from manganese in groundwater in rohingya refugee camps in Cox's Bazar, Bangladesh.

The forced displacement of over 700,000 Rohingyas from Myanmar to Bangladesh since the crackdown in August 2017 has resulted in a critical humanitarian and environmental crisis. Groundwater is the primary source of drinking water in the camps that were constructed to provide shelter for the refugee population. The current study explores occurrence of Mn in groundwater in the Rohingya camps and adjacent areas. A total of 52 groundwater samples were collected between August and October 2018 from different camps sites and the adjacent host area. It was found that 64% exceeded the Bangladesh standard (100 µg/L) suggesting the presence of elevated concentrations of Mn in some groundwater aquifers in the camp sites. Mn is a neurotoxicant and previous studies have reported intellectual impairment in children exposed to Mn levels similar to those detected in groundwater in the camp sites. Nearly 450,000 migrant and new-born children live in the camps in already stressed conditions. The occurrence of elevated Mn concentrations in groundwater in the camps and their adjacent areas is likely an additional stressor exposing these children to an increased risk of neurotoxicity. Based on the results of this small-scale study, we recommend undertaking an in-depth study on the occurrence of Mn in groundwater in the camps to come up with appropriate strategies to minimise exposure. In addition, we recommend conducting a systematic epidemiological study on potential impacts of manganese in drinking water on neurological development of the Rohingya children in the camps.

The detection of Yersinia enterocolitica in surface water by quantitative PCR amplification of the ail and yadA genes.

Yersinia enterocolitica has been detected in surface water, and drinking untreated water is a risk factor for infection. PCR-based methods have been used to detect Y. enterocolitica in various sample types, but quantitative studies have not been conducted in water. In this study, quantitative PCR (qPCR)-based methods targeting the Yersinia virulence genes ail and yadA were used to survey the Grand River watershed in southern Ontario, Canada. Initial testing of reference strains showed that ail and yadA PCR assays were specific for pathogenic biotypes of Y. enterocolitica; however the genes were also detected in one clinical Yersinia intermedia isolate. A survey of surface water from the Grand River watershed showed that both genes were detected at five sampling locations, with the ail and yadA genes detected in 38 and 21% of samples, respectively. Both genes were detected more frequently at colder water temperatures. A screening of Yersinia strains isolated from the watershed showed that the ail gene was detected in three Y. enterocolitica 1A/O:5 isolates. Results of this study show that Yersinia virulence genes were commonly detected in a watershed used as a source of drinking water, and that the occurrence of these genes was seasonal.

Describing water treatment process performance: Why average log-reduction can be a misleading statistic.

The degree to which a technology used for drinking water treatment physically removes or inactivates pathogenic microorganisms is commonly expressed as a log-reduction (or log-removal) and is of central importance to the provision of microbiologically safe drinking water. Many evaluations of water treatment process performance generate or compile multiple values of microorganism log-reduction, and it is common to report the average of these log-reduction values as a summary statistic. This work provides a cautionary note against misinterpretation and misuse of averaged log-reduction values by mathematically proving that the average of a set of log-reduction values characteristically overstates the average performance of which the set of log-reduction values is believed to be representative. This has two important consequences for drinking water and food safety as well as other applications of log-reduction: 1) a technology with higher average log-reduction does not necessarily have higher average performance, and 2) risk analyses using averaged log-reduction values as point estimates of treatment efficiency will underestimate average risk-sometimes by well over an order of magnitude. When analyzing a set of log-reduction values, a summary statistic called the effective log-reduction (which averages reduction or passage rates and expresses this as a log-reduction) provides a better representation of average performance of a treatment technology.

Evaluation of groundwater bacterial community composition to inform waterborne pathogen vulnerability assessments.

Microbial water quality evaluations are essential for determining the vulnerability of subsurface drinking water sources to fecal pathogen intrusion. Rather than directly monitor waterborne pathogens using culture- or enumeration-based techniques, the potential of assessing bacterial community using 16S rRNA gene amplicon sequencing to support these evaluations was investigated. A framework for analyzing 16S rRNA gene amplicon sequencing results featuring negative-binomial generalized linear models is demonstrated, and applied to bacterial taxa sequences in purge water samples collected from a shallow, highly aerobic, unconfined aquifer. Bacterial taxa relevant as indicators of fecal source and surface connectivity were examined using this approach. Observed sequences of Escherichia, a genus suggestive of fecal source, were consistently detected but not confirmed by culture-based methods. On the other hand, episodic appearance of anaerobic taxa sequences in this highly aerobic environment, namely Clostridia and Bacteroides, warrants further investigation as potential indicators of fecal contamination. Betaproteobacteria sequences varied significantly on a seasonal basis, and therefore may be linked to understanding surface-water groundwater interactions at this site. However, sequences that are often encountered in surface water bodies (Cyanobacteria and Flavobacteriia) were notably absent or present at very low levels, suggesting that microbial transport from surface-derived sources may be rather limited. This work demonstrates the utility of 16S rRNA gene amplicon sequencing for contextualizing and complementing conventional microbial techniques, allowing for hypotheses about source and transport processes to be tested and refined.

An evaluation of methods for the isolation of Yersinia enterocolitica from surface waters in the Grand River watershed.

Yersinia enterocolitica is a foodborne pathogen, but the importance of water as a route of exposure for human infection is not well known. Y. enterocolitica isolation methods were developed primarily for food and clinical samples, and may not be effective for use with environmental samples. The objective of this study was to assess the recovery of Y. enterocolitica from surface water used for drinking water treatment. Four enrichment broths and an alkaline treatment protocol were compared for the isolation of Y. enterocolitica bioserogroup 4/O:3 spiked into surface water samples. Results showed that the methods tested were not effective for the recovery of Y. enterocolitica, primarily due to inadequate inhibition of interfering background microorganisms. Using one method that showed the most potential for recovery, Yersinia spp. were isolated from rivers in southwestern Ontario, Canada, over a 17-month period. Of 200 samples analysed, Yersinia spp. were isolated from 52 samples. All river isolates belonged to non-pathogenic sub-groups, including Y. enterocolitica biotype 1A, Y. aldovae, Y. bercovieri, Y. frederiksenii, Y. intermedia, Y. kristensenii and Y. mollaretii. Results of this study show that method improvements are required to more fully understand the role of water as a source of clinically important Yersinia strains.

Estimation of endotoxin inhalation from shower and humidifier exposure reveals potential risk to human health.

This paper investigates potential exposure to endotoxin in drinking water through the inhalation of aerosols generated by showers and humidifiers. Adverse health effects attributable to the inhalation of airborne endotoxin in various occupational settings are summarized, as are controlled laboratory inhalation studies. Data from investigations estimating aerosolization of particulate matter by showers and humidifiers provide a basis for similar analyses with endotoxin, which like minerals in water, is nonvolatile. A theoretical assessment of the inhalation of aerosolized endotoxin showed that while the likelihood of an acute response while showering is minimal, the same is not true for humidifiers. Ultrasonic and impeller (cool mist) humidifiers efficiently produce large numbers of respirable particles. It is predicted that airway inflammation can occur if humidifier reservoirs are filled with tap water, sometimes even at typical drinking-water distribution-system endotoxin concentrations. Higher endotoxin levels occasionally found in drinking water (>1,000 EU/ml) are very likely to induce symptoms such as chills and fever if used as humidifier feed water. While it is unlikely that treated drinking water would contain extremely high endotoxin levels occasionally observed in cyanobacterial blooms (>35,000 EU/ml), the potential for serious acute health consequences exist if used in humidifiers.

Pathogen and indicator variability in a heavily impacted watershed.

Water samples were collected from 36 locations within the Grand River Watershed, in Southwestern Ontario, Canada from July 2002 to December 2003 and were analyzed for total coliforms, fecal coliforms, Escherichia coli, Escherichia coli O157:H7, and thermophilic Campylobacter spp. A subset of samples was also analyzed for Cryptosporidium spp., Giardia spp., culturable human enteric viruses, and Clostridium perfringens. Storm and snowmelt events were sampled at two locations including a drinking water intake. For the majority of the events, the Spearman rank correlation test showed a positive correlation between E. coli levels and turbidity. Peaks in pathogen numbers frequently preceded the peaks in numbers of indicator organisms and turbidity. Pathogen levels sometimes decreased to undetectable levels during an event. As pathogen peaks did not correspond to turbidity and indicator peaks, the correlations were weak. Weak correlations may be the result of differences in the sources of the pathogens, rather than differences in pathogen movement through the environment. Results from this investigation have implications for planning monitoring programs for water quality and for the development of pathogen fate and transport models to be used for source water risk assessment.

Effect of ozone on biopolymers in biofiltration and ultrafiltration processes.

The focus of this full-scale study was to determine the effect of ozone on biopolymer concentrations in biofiltration and ultrafiltration (UF) processes treating surface water from Lake Ontario. Ozonation was out of service for maintenance for 9 months, hence, it was possible to investigate ozone's action on biologically active carbon contactors (BACCs) and UF, in terms of biopolymer removal. Given the importance of biopolymers for fouling, this fraction was quantified using a chromatographic technique. Ozone pre-treatment was observed to positively impact the active biomass in biofilters. However, since an increase of the active biomass did not result in higher biopolymer removal, active biomass concentration cannot be a surrogate for biofiltration performance. It was evident that increasing empty bed contact time (EBCT) from 4 to 19 min only had a positive effect on biopolymer removal through BACCs when ozone was out of service. However, as a mass balance experiment showed, ozone-free operation resulted in higher deposition of biopolymers on a UF membrane and slight deterioration in its performance.

Endotoxin inactivation by selected drinking water treatment oxidants.

Exposure to endotoxins in treated drinking water can occur through ingestion, dermal abrasions, inhalation of water vapor, intravenous injection or during dialysis. While the risks associated with endotoxin ingestion and entry through dermal abrasions are not well quantified, adverse effects of intravenous injection and dialysis are well known and some studies indicate that inhalation of moisture-laden air may impact human health. This study quantifies the inactivation of endotoxin derived from Escherichia coli O55:B5 by three substances used either as disinfectants or oxidants in drinking water treatment: chlorine, monochloramine and potassium permanganate. Inactivation rates were found to be 1.4, 1.0 and 0.7 endotoxin units (EU)/mL h, for free chlorine, potassium permanganate and monochloramine, respectively. These rates are relatively slow given that contact times in drinking water distribution systems are typically less than 48 h. While small amounts of endotoxin may be removed by oxidation the observed removals are much less than those provided by physical removal processes. The significance of this finding is important for dialysis considerations but is as yet unclear with regard to inhalation, as the risk of inhaling sufficient quantities of endotoxin-containing aerosolized water droplets to adversely affect human health has not yet been adequately quantified.

Behaviour and fate of perfluoroalkyl and polyfluoroalkyl substances (PFASs) in drinking water treatment: a review.

This article reviews perfluoroalkyl and polyfluoroalkyl substance (PFAS) characteristics, their occurrence in surface water, and their fate in drinking water treatment processes. PFASs have been detected globally in the aquatic environment including drinking water at trace concentrations and due, in part, to their persistence in human tissue some are being investigated for regulation. They are aliphatic compounds containing saturated carbon-fluorine bonds and are resistant to chemical, physical, and biological degradation. Functional groups, carbon chain length, and hydrophilicity/hydrophobicity are some of the important structural properties of PFASs that affect their fate during drinking water treatment. Full-scale drinking water treatment plant occurrence data indicate that PFASs, if present in raw water, are not substantially removed by most drinking water treatment processes including coagulation, flocculation, sedimentation, filtration, biofiltration, oxidation (chlorination, ozonation, AOPs), UV irradiation, and low pressure membranes. Early observations suggest that activated carbon adsorption, ion exchange, and high pressure membrane filtration may be effective in controlling these contaminants. However, branched isomers and the increasingly used shorter chain PFAS replacement products may be problematic as it pertains to the accurate assessment of PFAS behaviour through drinking water treatment processes since only limited information is available for these PFASs.

An approach for assessing potential sediment-bound contaminant threats near the intake of a drinking water treatment plant.

To assist in assessing a potential contaminated sediment threat near a drinking water intake in a large lake, a technique known as the fingerprint analysis of leachate contaminants (FALCON), was investigated and enhanced to help draw more statistically significant definitive conclusions. This represents the first application of this approach, originally developed by the USEPA to characterize and track leachate penetration in groundwater and contaminant migration from waste and landfill sites, in a large lake from the point-of-view of source water protection. FALCON provided valuable information regarding contaminated sediment characterization, source attribution, and transport within a surface water context without the need for knowledge of local hydrodynamic conditions, potentially reducing reliance on complicated hydrodynamic analysis. A t-test to evaluate the significance of correlations was shown to further enhance the FALCON procedure. In this study, the sensitivity of FALCON was found to be improved by using concentration data from both conserved organics and heavy metals in combination. Furthermore, data analysis indicated that it may be possible to indirectly assess the success of remediation efforts (and the corresponding need to plan for a treatment upgrade in the event of escalating contaminant concentrations) by examining the temporal change in correlation between the source and intake sediment fingerprints over time. This method has potential for widespread application in situations where conserved contaminants such as heavy metals and higher molecular weight polycyclic aromatic hydrocarbons (PAHs), are being or have previously been deposited in sediment somewhere in, or within range of, an intake protection zone.

Application of fingerprint-based multivariate statistical analyses in source characterization and tracking of contaminated sediment migration in surface water.

This study investigates the suitability of multivariate techniques, including principal component analysis and discriminant function analysis, for analysing polycyclic aromatic hydrocarbon and heavy metal-contaminated aquatic sediment data. We show that multivariate "fingerprint" analysis of relative abundances of contaminants can characterize a contamination source and distinguish contaminated sediments of interest from background contamination. Thereafter, analysis of the unstandardized concentrations among samples contaminated from the same source can identify migration pathways within a study area that is hydraulically complex and has a long contamination history, without reliance on complex hydrodynamic data and modelling techniques. Together, these methods provide an effective tool for drinking water source monitoring and protection.