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.

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.

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.

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.

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.

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

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.

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.

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.

Prospective randomized comparison of a combined ultrasonic and pneumatic lithotrite with a standard ultrasonic lithotrite for percutaneous nephrolithotomy.

PURPOSE: To compare the efficiency and cost effectiveness of a combined pneumatic and ultrasonic lithotrite (Lithoclast Ultra) and a standard ultrasonic lithotrite, (LUS-1) during percutaneous nephrolithotomy. MATERIALS AND METHODS: In a prospective randomized trial, 30 patients undergoing percutaneous nephrolithotomy (PCNL) were randomized to PCNL with either the combined pneumatic and ultrasonic lithotrite (PUL) or a standard ultrasonic lithotrite (SUL). Patient demographics, stone composition, location, pre- and post-operative stone burden, fragmentation rates, and device failures were compared. RESULTS: There were 13 patients in the PUL group and 17 patients in the SUL group. Stone burden and location were equal. Overall, 64% of the PUL group had hard stones (defined as stones that were either pure or a mixture of cystine [3], calcium oxalate monohydrate [CaOxMono; 2], and calcium phosphate [CaPO4; 2]), and four had soft stones (3 struvite and 1 uric acid [UA]). In the SUL group, there were eight hard stones (5 CaOxMono and 3 CaPO4), and six soft stones (4 calcium oxalate dihydrate [CaOxDi] and 2 UA) (P = 0.51). Stone composition data were unavailable for five patients. Fragmentation time for the PAL was 37 minutes versus 31.5 minutes for the SUL (P = 0.22). Stone retrieval and mean operative times were similar for both groups. There were a total of three (23.1%) device-related problems in the PUL group, and eight (47%) in the SUL group. There was one (7.7%) device malfunction in the PUL group due to probe fracture. There were two (11.7%) device failures in the SUL group; one failure required the device to be reset every 30 minutes, and the second was an electrical failure. Suction tubing obstruction occurred twice (15.3%) in the PUL group and 35.3% in the SU group (P = 0.35). The stone-free rates for the PUL and SUL were 46% and 66.7%, respectively (P = 0.26). CONCLUSION: Although the PUL was more costly, stone ablation and clearance rates were similar for both the combined pneumatic and ultrasonic device and the standard ultrasonic device. When stratified with respect to stone composition, the PUL was more efficient for harder stones, and the SUL was more efficient for softer stones.

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.

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.

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.

An evidence-based review of medical and surgical treatments of genital warts.

Genital human papillomavirus (HPV) infection is the most common sexually transmitted disease. Each year 1 million new cases of genital warts are diagnosed, two thirds of which are in women. The estimated prevalence rate in the US population is 15 percent. HPV infects keratinocytes. Such infection can manifest clinically as warts. Treatment options for genital warts are numerous, well established, and effective. Topical treatments include podophyllin resin, imiquimod, trichloroacetic acid, and podophyllotoxin. Surgical or destructive therapies include carbon dioxide laser, surgical excision, loop excision, cryotherapy, and electrodessication. Interferon can be injected locally or administered systemically to treat genital warts. Evidence of efficacy in the treatment of genital warts is drawn from randomized blind-controlled trials, prospective studies, and retrospective cohort studies. Evidence of efficacy appears to be good, but more head-to-head studies and comparisons of combination therapies versus monotherapy need to be done. Treatment of choice depends on the number, size, and location of lesions. There is little certainty that any approach is more effective than another, however costs differ. It would seem that the first line destructive treatment is cryotherapy, but surgery and electrodesiccation are more effective. The first line topical treatments appear to be podophyllotoxin and imiquimod. Interferon is too expensive and trichloracetic acid is too inconsistent to be recommended as primary treatment. It is unclear if combinations of therapies are more effective than monotherapy. Side effect profile, cost, effectiveness and convenience (ability to attend physician's office or to undertake protracted home treatment) define the choice of therapy.

Condyloma with lichen nitidus.

A 32-year-old black man presented with two separate eruptions on his penis (Figure). He has had a 10-year history of asymptomatic 1-3 mm shiny papules on the shaft of his penis. He also has had one asymptomatic verrucous brown plaque 1.5 cm in diameter on his penis. A small shave biopsy was performed for each process. The former showed lymphocytes and histocytes in the papillary dermis in a "ball-in-claw" relation to the rete ridges of the epidermis. The latter showed an acanthotic epidermis with papillomatosis. Diagnoses of lichen nitidus and condyloma acuminata were respectively made. As the shiny papules did not bother the patient, but he wanted to be rid of the verrucous plaque, only the latter was treated. Liquid nitrogen was applied to the plaque. The patient was also given podofilox 0.5% gel to apply to the condyloma overnight on Monday, Tuesday, and Wednesday, with a 4-day respite. This cycle was to be repeated for 3 more weeks. He was examined several more times and treated with cryotherapy and podofilox gel with the near disappearance of the condyloma over 4 months.

Salvage of complications of hallux valgus surgery.

Complications following hallux valgus surgery can occur and are a frequent source of patient dissatisfaction. The treatment of these complications begins with careful preoperative planning to ensure that the chosen procedure is appropriate for the specific patient. When complications occur, treatment must also be individualized to address the symptoms of the patient. This article presented an overview of the more common complications that are seen following hallux valgus surgery. Nonsurgical and surgical options for treatment were outlined to assist in the management of these complications.

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.

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.