Retrofitting agricultural detention systems can economically enhance nitrogen treatment with payment for services approach.

Despite their global presence and multiple services including water storage and treatment, limited field studies have focused on quantifying water quality effectiveness of agricultural stormwater detention areas (SDAs; farm ponds). Limited data available comes from unverified modeling studies. Economics is another neglected aspect of SDAs. An SDA in the Everglades basin of Florida was monitored to quantify its baseline nitrogen (N) treatment. Design flaws of underutilized surface storage in variably ponded areas and short-circuiting were rectified by retrofitting the SDA through compartmentalization, increase in outflow structure control elevation, and installing channel plugs. Post the retrofits, total N retentions doubled (7500 from 3700 kg), a similar trend was observed with respect to surface water volume indicating that water retention drives N retention. Targeting enhanced water retention through retrofits can achieve reductions in downstream nutrient flows. The cost of additional N treatment from retrofits was $12/kg, an order of magnitude less than the published costs for other detention systems including newly constructed wetlands ($180/kg) and tailwater recovery systems ($214/kg). A scale-up showed that retrofitting SDAs could reduce the N discharge to an estuary in the Everglades basin by over 50 %. A payoff to the farmers for SDA retrofits through a payment for environmental services program can achieve higher N treatment economically and facilitate large-scale adoption.

Social Determinants in Clinical Decision Making: A Case of Mistaken Hepatic Encephalopathy.

Implicit (i.e., unconscious) bias frequently differs from one's explicit or conscious convictions. As humans, we rely on information and experiences that are repeatedly reinforced until they become reflexive, shaping our perceptions of reality. Specialty bias, a form of implicit bias specific to an individual's medical specialty, is a form of this bias. These cognitive processes of making assumptions aid efficient decision-making and likely confers an evolutionary advantage. However, automatic thinking can contribute to stereotyping, prejudice, and discrimination at both explicit and implicit levels. Despite a person's explicit beliefs evolving, the lasting implicit bias significantly impacts their behavioral interactions with individuals from stereotyped groups. We present a case of an 83-year-old non-English speaking gentleman with a reported past medical history of an ischemic stroke who presented with acute encephalopathy and fever without jaundice and Aspartate transaminase/ Alanine transaminase (AST/ALT) of 64 and 34, respectively. He was initially treated for acute meningoencephalitis in the Neurologic Intensive Care Unit. With no clinical improvement in symptoms, his care was transferred to the Internal Medicine service later that week, and it was noted that he had features consistent with liver disease. Further history-taking revealed that the patient was intermittently confused with episodes of constipation. On examination, he had palmar erythema and asterixis, and additional labs showed elevated liver enzymes and ammonia levels. Computerized Tomography of the abdomen was suggestive of cirrhosis. He was treated for hepatic encephalopathy with lactulose and rifampin, with improvement in his mental status. We believe our patient's clinical diagnosis was compromised by incomplete information related to a language barrier, and anchoring biases prevented a thorough history taking from the patient family and later on from the patient. Physician's anchoring bias, a form of implicit bias, can negatively impact outcomes in patients, especially those with limited language proficiency, due to communication barriers leading to misunderstanding of the patient's clinical presentation and overreliance on clinical heuristics.

Early Identification and Intervention in Malignant Transformation of Respiratory Papillomatosis.

BACKGROUND Human papilloma virus is a ubiquitous and preventable disease with the potential to cause recurrent respiratory papillomatosis. These papillomas affect the mucosal surface of the airways and may lead to airway obstruction. The papillomas require excision when breathing is compromised, and may be fatal if untreated. Rarely, these papillomas progress to cancer. CASE REPORT We report the case of a 21-year-old woman with a history of HPV 11- and 16-positive recurrent laryngeal and respiratory papillomatosis (RRP) since the age of 7 months, requiring multiple local resections in her respiratory tract. Chest CT demonstrated multiple cavitary lesions throughout both lungs with a rapidly growing mass that occupied most of her right lung. Imaging supported a diagnosis of malignant transformation to squamous cell carcinoma of the lung. Bilateral involvement of the lungs indicated stage IVa squamous cell lung cancer, which is not curable. CONCLUSIONS Clinicians should suspect malignant transformation in patients with HPV type 11, especially if they have required multiple excisions. Earlier age at onset and number of excisions may be predictors for severity of the disease course. These patients need continued surveillance imaging to allow early interventions if malignant transformation occurs. We present the case of a 21-year-old being diagnosed with an incurable disease that may have been avoided with adequate preventive care.

Valorization of farm pond biomass as fertilizer for reducing basin-scale phosphorus losses.

Long-term fertilizer phosphorus (P) inputs are causing phosphorous saturation of agricultural soils globally. The saturation is spreading to the edge-of-the-farm stormwater detention systems (SDSs) from where the legacy P is potentially being released to downstream surface waters. We use site-specific and literature data for P-saturated SDSs, to develop and evaluate the biogeochemical and economic feasibility of a P recycling program that targets both low (LIC, sugarcane) and high intensity cropping (HIC, fresh-produce) systems within a watershed. The focus is to close the P cycle loop to rejuvenate P sink function of SDSs. It involves harvesting and composting the SDS's biomass and it's on-farm use as an organic fertilizer for crops. Results showed that harvesting-composting can conservatively increase the P retention from 50% to 77% for HIC and almost complete treatment for LIC. Beyond potentially increasing yield and improving soil health, compost use can further increase in-field retention of P (and water). Additional costs incurred in harvesting and composting can be offset by the economic value of compost and the reduction in State's expenditure on regional P treatment systems. Treatment costs were $26/kg of P for HIC and $42/kg for LIC, 10 times less than the current state expenditure of $355-$909/kg P using constructed wetlands. We propose an incentivized, payment for services (PS) program, where producers are paid for P recycling. The PS program considers the intensity of cropping systems and their location along the drainage network from headwaters to the outlet, to achieve basin-scale P load reduction. The LIC SDSs recover regional P by passing the public water through them while recycling is implemented at the HIC. The estimated basin-scale P retention with harvest-compost approach was 854 metric tons, 5 times the P that entered the Everglades Protection Area in 2018, at 88%-93% less cost than the State treatment systems.

Vulvovaginitis Caused by Candida Species Following Antibiotic Exposure.

PURPOSE OF REVIEW: Goal was to review epidemiology, pathophysiology, and prevention of post-antibiotic Candida vulvovaginitis (VVC). RECENT FINDINGS: Antibacterial therapy, whether systemic or locally applied to the vagina, represents the single most frequent and predictable cause or triggering mechanism of symptomatic vulvovaginal candidiasis (VVC). Such initiating mechanisms may precipitate sporadic or recurrent episodes of VVC. In spite of this widely recognized association, the exact mechanism whereby antibiotics of all classes cause acute exacerbation of symptomatic vaginal disease remains largely unstudied and therefore largely unknown. Pathophysiology is hypothesized to be reduction or alteration of vaginal microbiome restraints of yeast colonization, proliferation, and expression of virulence characteristics. The predictable link between antibiotic use and post-antibiotic VVC affords practitioners an opportunity for timely intervention using selective, convenient antimycotics usually drugs but possibly probiotic measures. Indications and limitation of these steps are discussed.

Volume reduction outweighs biogeochemical processes in controlling phosphorus treatment in aged detention systems.

Stormwater detention areas (SDAs) play an important role in treating end-of-the-farm runoff in phosphorous (P) limited agroecosystems. Phosphorus transport from the SDAs, including those through subsurface pathways, are not well understood. The prevailing understanding of these systems assumes that biogeochemical processes play the primary treatment role and that subsurface losses can be neglected. Water and P fluxes from a SDA located in a row-crop farm were measured for two years (2009-2011) to assess the SDA's role in reducing downstream P loads. The SDA treated 55% (497kg) and 95% (205kg) of the incoming load during Year 1 (Y1, 09-10) and Year 2 (Y2, 10-11), respectively. These treatment efficiencies were similar to surface water volumetric retention (49% in Y1 and 84% in Y2) and varied primarily with rainfall. Similar water volume and P retentions indicate that volume retention is the main process controlling P loads. A limited role of biogeochemical processes was supported by low to no remaining soil P adsorption capacity due to long-term drainage P input. The fact that outflow P concentrations (Y1=368.3µg L-1, Y2=230.4µg L-1) could be approximated by using a simple mixing of rainfall and drainage P input further confirmed the near inert biogeochemical processes. Subsurface P losses through groundwater were 304kg (27% of inflow P) indicating that they are an important source for downstream P. Including subsurface P losses reduces the treatment efficiency to 35% (from 61%). The aboveground biomass in the SDA contained 42% (240kg) of the average incoming P load suggesting that biomass harvesting could be a cost-effective alternative for reviving the role of biogeochemical processes to enhance P treatment in aged, P-saturated SDAs. The 20-year present economic value of P removal through harvesting was estimated to be $341,000, which if covered through a cost share or a payment for P treatment services program could be a positive outcome for both agriculture and public interests.