Reducing Implant Infection in Orthopaedics (RIIiO): Results of a pilot study comparing the influence of forced air and resistive fabric warming technologies on postoperative infections following orthopaedic implant surgery.

BACKGROUND: Active warming during surgery prevents perioperative hypothermia but the effectiveness and postoperative infection rates may differ between warming technologies. AIM: To establish the recruitment and data management strategies needed for a full trial comparing postoperative infection rates associated with forced air warming (FAW) versus resistive fabric warming (RFW) in patients aged >65 years undergoing hemiarthroplasty following fractured neck of femur. METHODS: Participants were randomized 1:1 in permuted blocks to FAW or RFW. Hypothermia was defined as a temperature of <36°C at the end of surgery. Primary outcomes were the number of participants recruited and the number with definitive deep surgical site infections. FINDINGS: A total of 515 participants were randomized at six sites over a period of 18 months. Follow-up was completed for 70.1%. Thirty-seven participants were hypothermic (7.5% in the FAW group; 9.7% in the RFW group). The mean temperatures before anaesthesia and at the end of surgery were similar. For the primary clinical outcome, there were four deep surgical site infections in the FAW group and three in the RFW group. All participants who developed a postoperative infection had antibiotic prophylaxis, a cemented prosthesis, and were operated under laminar airflow; none was hypothermic. There were no serious adverse events related to warming. CONCLUSION: Surgical site infections were identified in both groups. Progression from the pilot to the full trial is possible but will need to take account of the high attrition rate.

Engineers Without Borders Australia--lessons learned from an innovative approach to the upgrade of water supply infrastructure in Tenganan, Indonesia.

The community of Tenganan in eastern Bali, Indonesia, has requested technical assistance from Engineers Without Borders Australia (EWB) to improve the quantity and quality of water delivered through their water supply system. This is a unique development project in which the Tenganan people have identified their own needs and developed their own conceptual solution to the problem. For the first time, EWB is undertaking the design phase for the water system by an off-shore design team and project assistance team (PAT) based in Australia. This allows EWB to draw on resources and experience of EWB members and their employing companies in Australia. It also enables young engineers to develop skills and experience in development work without having to leave the country. However, the innovative approach also presented significant challenges to the project members, particularly in establishing appropriate design criteria and the co-ordination of simultaneous activities across Australia. This paper describes the approach taken by EWB and makes a preliminary assessment of the benefits and limitations inherent in this approach. The overall aim of the project is to produce a successful "bottom-up" development action that will deliver a sustainable solution to the Tenganan community.

Treatment of nitrogen-rich wastewater using partial nitrification and anammox in the CANON process.

Partial nitrification combined with Anammox in a single reactor (the CANON process) is an energy-efficient N-removal technology that could substantially lower the N-load of a WWTP by separate treatment of nitrogen-rich side streams, preventing the need for extensive expansion and reducing the total energy requirement. This study looks at the enrichment of Anammox from activated sludge and its application in the CANON process on lab-scale. The aim was to identify the critical process control parameters necessary for successful operation of CANON. An Anammox culture capable of removing 0.6 kg N/m3/d was enriched in 14 weeks in a sequencing batch reactor. Nitrifying biomass was inoculated into the Anammox reactor (10% v/v) together with limited oxygen supply (< 8 mL/min) to initiate the CANON process in continuous culture. The small flocs formed by the biomass (< 1000 microm) were sensitive to low O2 concentrations (< 0.1 mg/L) which prevented simultaneous nitrification and Anammox. Operation with 20 min aerobiosis and 30 min anaerobiosis was necessary to achieve sustained, completely autotrophic N-removal for an extended period at a rate of 0.08 kg N/m3/d. Essential process control parameters for stable CANON operation were the nitrite concentration, oxygen concentration, pH and the temperature.

Long-term aeration management for improved N-removal via SND in a sequencing batch reactor.

Management of the aeration length in a sequencing batch reactor (SBR) can improve N-removal by minimising the amount of organic substrate that is oxidised aerobically. This study investigates the long-term effect of aeration control on N-removal via simultaneous nitrification and denitrification (SND) by a mixed culture in a 2L acetate-fed SBR, using PHB as the electron donor for denitrification. The reactor was operated continuously with automated termination of the aerobic phase after ammonium depletion, using the specific oxygen uptake rate (SOUR) as the control parameter. This resulted in an increase of the organic loading rate (OLR) from 0.33 to 0.59 g BOD g(-1)d(-1). Over the first 12 cycles of operation, the PHB content of the biomass increased three-fold and resulted in a progressively increasing SOUR, which allowed an increased amount of nitrogen removal via SND from 34% to 52%. After one month of continuous operation with controlled aeration, the settling efficiency of the biomass had significantly improved (SVI 70 mL g(-1) X). Long-term oxygen management resulted in biomass with a higher capacity for N-removal via SND and improved settling characteristics. Our results may help to explain long-term historical effects of N-removal capabilities in WWTPs and assist design engineers in choosing an appropriate aeration length and OLR.

Enrichment of anammox from activated sludge and its application in the CANON process.

A microbial culture capable of actively oxidizing ammonium to dinitrogen gas in the absence of oxygen, using nitrite as the electron acceptor, was enriched from local activated sludge (Western Australia) in <14 weeks. The maximum anaerobic ammonium oxidation (i.e., anammox) activity achieved by the anaerobic culture was 0.26 mmol NH (4) (+) (g biomass)(-1) h(-1) (0.58 kg total-N m(-3) day(-1)). Qualitative FISH analysis (fluorescence in situ hybridization) confirmed the phylogenetic position of the enriched microorganism as belonging to the order Planctomycetales, in which all currently identified anammox strains fall. Preliminary FISH analysis suggests the anammox strain belongs to the same phylogenetic group as the Candidatus 'Brocadia anammoxidans' strain discovered in the Netherlands. However, there are quite a few differences in the target sites for the more specific probes of these organisms and it is therefore likely to represent a new species of anammox bacteria. A small amount of aerobic ammonium-oxidizing biomass was inoculated into the anammox reactor (10% v/v) to initiate completely autotrophic nitrogen removal over nitrite (the CANON process) in chemostat culture. The culture was always under oxygen limitation and no organic carbon was added. The CANON reactor was operated as an intermittently aerated system with 20 min aerobiosis and 30 min anaerobiosis, during which aerobic and anaerobic ammonium oxidation were performed in sequential fashion, respectively. Anammox was not inhibited by repeated intermittent exposure to oxygen, allowing sustained, completely autotrophic ammonium removal (0.08 kg N m(-3) day(-1)) for an extended period of time.

Optimisation of storage driven denitrification by using on-line specific oxygen uptake rate monitoring during SND in a SBR.

This study builds on previous experience of maximising the formation of COD as poly-hydroxybutyrate (PHB) and now describes a feedback technique of preserving the use of PHB for denitrification resulting in enhanced nitrogen removal rather than allowing its wasteful oxidation by oxygen. The feedback technique uses on-line SOUR monitoring for detecting the end-point of nitrification and controlling the aerobic phase length accordingly. The laboratory SBR was operated such that all organic substrate (acetate) was rapidly converted to PHB, which then served as the electron donor for nitrogen removal via simultaneous nitrification and denitrification (SND) during the aerobic phase (up to 70% SND). During SBR cycling with a fixed aeration length (240 minutes), PHB was unnecessarily oxidised after ammonium depletion, resulting in little denitrification and poor total nitrogen removal (69%). However, when the aerobic phase length was controlled via the SOUR, up to 1.8 CmM PHB (58 mg L(-1) COD) could be preserved, enabling improved total nitrogen removal (86%). The drop in the SOUR after ammonium depletion was a reproducible event that could be detected even when using raw wastewater and fresh activated sludge. The SOUR-control technique holds promise to build up PHB over a number of SBR cycles. While advanced oxygen-control is used for improved N-removal in several existing WWTPs, this study investigates the importance of oxygen control with relevance to PHB driven SND in sequencing batch reactors.

The presence of ammonium facilitates nitrite reduction under PHB driven simultaneous nitrification and denitrification.

For economic and efficient nitrogen removal from wastewater treatment plants via simultaneous nitrification and denitrification the nitrification process should stop at the level of nitrite such that nitrite rather than nitrate becomes the substrate for denitrification. This study aims to contribute to the understanding of the conditions that are necessary to improve nitrite reduction over nitrite oxidation. Laboratory sequencing batch reactors (SBRs) were operated with synthetic wastewater containing acetate as COD and ammonium as the nitrogen source. Computer controlled operation of the reactors allowed reproducible simultaneous nitrification and denitrification (SND). The oxygen supply was kept precisely at a low level of 0.5 mgL(-1) and bacterial PHB was the only electron donor available for denitrification. During SND little nitrite or nitrate accumulated (< 20% total N), indicating that the reducing processes were almost as fast as the production of nitrite and nitrate from nitrification. Nitrite spiking tests were performed to investigate the fate of nitrite under different oxidation (0.1-1.5 mgL(-1) of dissolved oxygen) and reduction conditions. High levels of reducing power were provided by allowing the cells to build up to 2.5 mM of PHB. Nitrite added was preferentially oxidised to nitrate rather than reduced even when dissolved oxygen was low and reducing power (PHB) was excessively high. However, the presence of ammonium enabled significant reduction of nitrite under low oxygen conditions. This is consistent with previous observations in SBR where aerobic nitrite and nitrate reduction occurred only as long as ammonium was present. As soon as ammonium was depleted, the rate of denitrification decreased significantly. The significance of the observed strongly stimulating effect of ammonium on nitrite reduction under SND conditions is discussed and potential consequences for SBR operation are suggested.

Anaerobic ammonium oxidation by marine and freshwater planctomycete-like bacteria.

Recently, two fresh water species, " Candidatus Brocadia anammoxidans" and " Candidatus Kuenenia stuttgartiensis", and one marine species, " Candidatus Scalindua sorokinii", of planctomycete anammox bacteria have been identified. " Candidatus Scalindua sorokinii" was discovered in the Black Sea, and contributed substantially to the loss of fixed nitrogen. All three species contain a unique organelle--the anammoxosome--in their cytoplasm. The anammoxosome contains the hydrazine/hydroxylamine oxidoreductase enzyme, and is thus the site of anammox catabolism. The anammoxosome is surrounded by a very dense membrane composed almost exclusively of linearly concatenated cyclobutane-containing lipids. These so-called 'ladderanes' are connected to the glycerol moiety via both ester and ether bonds. In natural and man-made ecosystems, anammox bacteria can cooperate with aerobic ammonium-oxidising bacteria, which protect them from harmful oxygen, and provide the necessary nitrite. The cooperation of these two groups of ammonium-oxidising bacteria is the microbial basis for a sustainable one reactor system, CANON (completely autotrophic nitrogen-removal over nitrite) to remove ammonia from high strength wastewater.

CANON and Anammox in a gas-lift reactor.

Anoxic ammonium oxidation (Anammox) and Completely Autotrophic Nitrogen removal Over Nitrite (CANON) are new and promising microbial processes to remove ammonia from wastewaters characterized by a low content of organic materials. These two processes were investigated on their feasibility and performance in a gas-lift reactor. The Anammox as well as the CANON process could be maintained easily in a gas-lift reactor, and very high N-conversion rates were achieved. An N-removal rate of 8.9 kg N (m(3) reactor)(-1) day(-1) was achieved for the Anammox process in a gas-lift reactor. N-removal rates of up to 1.5 kg N (m(3) reactor)(-1) day(-1) were achieved when the CANON process was operated. This removal rate was 20 times higher compared to the removal rates achieved in the laboratory previously. Fluorescence in situ hybridization showed that the biomass consisted of bacteria reacting to NEU, a 16S rRNA targeted probe specific for halotolerant and halophilic Nitrosomonads, and of bacteria reacting to Amx820, specific for planctomycetes capable of Anammox.

Control of the redox potential by oxygen limitation improves bacterial leaching of chalcopyrite.

Shake flask and stirred tank bioleaching experiments showed that the dissolution of chalcopyrite is inhibited by ferric ion concentrations as low as 200 mg L(-1) and redox potentials >420 mV (vs. Ag/AgCl). Chemical leaching of chalcopyrite (4% suspension, surface area 2.3 m2 g(-1)) was enhanced fourfold in the presence of 0.1 M ferrous sulphate compared with 0.1 M ferric sulphate. A computer-controlled reactor was designed to function as a "potentiostat"-bioreactor by arresting the air supply to the reactor when the redox potential in solution was greater than a designated setpoint. Leaching at a low, constant redox potential (380 mV vs. Ag/AgCl) achieved final copper recoveries of 52%-61%, which was twice that achieved with a continuous supply of oxygen (<30% extraction). The bacterial populations were observed to continue growing under oxygen limitation but in a controlled manner that was found to improve chalcopyrite dissolution. As the control mechanism is easily established and is likely to decrease production cost, the use of this technology may find application in industry.

The CANON system (Completely Autotrophic Nitrogen-removal Over Nitrite) under ammonium limitation: interaction and competition between three groups of bacteria.

The CANON system (Completely Autotrophic Nitrogen Removal Over Nitrite) can potentially remove ammonium from wastewater in a single, oxygen-limited treatment step. The usefulness of CANON as an industrial process will be determined by the ability of the system to recover from major disturbances in feed composition. The CANON process relies on the stable interaction between only two bacterial populations: Nitrosomonas-like aerobic and Planctomycete-like anaerobic ammonium oxidising bacteria. The effect of extended periods of ammonium limitation was investigated at the laboratory scale in two different reactor types (sequencing batch reactor and chemostat). The lower limit of effective and stable nitrogen removal to dinitrogen gas in the CANON system was 0.1 kg N m(-3) day(-1). At this loading rate, 92% of the total nitrogen was removed. After prolonged exposure (> 1 month) to influxes lower than this critical NH4+-influx, a third population of bacteria developed in the system and affected the CANON reaction stoichiometry, resulting in a temporary decrease in nitrogen removal from 92% to 57%. The third group of bacteria were identified by activity tests and qualititative FISH (Fluorescence In Situ Hybridisation) analysis to be nitrite-oxidising Nitrobacter and Nitrospira species. The changes caused by the NH4+-limitation were completely reversible, and the system re-established itself as soon as the ammonium limitation was removed. This study showed that CANON is a robust system for ammonium removal, enduring periods of up to one month of ammonium limitation without irreversible damage.