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The treatment of wastewater is highly challenging due to large fluctuations in flowrates, pollutants, and variable influent water compositions. A sequencing batch reactor (SBR) and modified SBR cycle-step-feed process (SSBR) configuration are studied in this work to effectively treat municipal wastewater while simultaneously removing nitrogen and phosphorus. To control the amount of dissolved oxygen in an SBR, three axiomatic control strategies (proportional integral (PI), fractional proportional integral (FPI), and fuzzy logic controllers) are presented. Relevant control algorithms have been designed using plant data with the models of SBR and SSBR based on ASM2d framework. On comparison, FPI showed a significant reduction in nutrient levels and added an improvement in effluent quality. The overall effluent quality is improved by 0.86% in FPI in comparison with PI controller. The SSBR, which was improved by precisely optimizing nutrient supply and aeration, establishes a delicate equilibrium. This refined method reduces oxygen requirements while reliably sustaining important biological functions. Focusing solely on the FPI controller's performance in terms of total air volume consumption, the step-feed SBR mechanism achieves an excellent 11.04% reduction in consumption., Competing Interests: The authors declare there is no conflict., (© 2024 The Authors This is an Open Access article distributed under the terms of the Creative Commons Attribution Licence (CC BY 4.0), which permits copying, adaptation and redistribution, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/).)

This study performed bench scale studies on anaerobic co-digestion of cheese whey and septage mixed with biochar (BC) as additive at various dosages (0.5 g, 1 g, 2 g and 4 g) and total solids (TS) concentrations (5%, 7.5%, 10%,12.5% and 15%). The experimental results revealed 29.58% increase in methane yield (486 ± 11.32 mL/gVS) with 27% reduction in lag phase time at 10% TS concentration and 50 g/L of BC loading. The mechanistic investigations revealed that BC improved process stability by virtue of its robust buffering capacity and mitigated ammonia inhibition. Statistical analysis indicates BC dosage had a more pronounced effect (P < 0.0001) compared to the impact of TS concentrations. Additionally, the results were modelled using Gompertz model (GM) and artificial neural network (ANN) algorithm, which revealed the outperformance of ANN over GM with MSE 17.96, R 2 value 0.9942 and error 0.27%. These findings validated the practicality of utilizing a high dosage of BC in semi-solid anaerobic digestion conditions., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Lactose in cheese whey is increasingly challenging to metabolise under normal conditions. The hydrolysis of whey lactose into glucose and galactose using enzymatic methods has been acclaimed to confer benefits like enhanced substrate availability for better degradation in anaerobic digestion. In the present study, whey lactose was subjected to hydrolysis using the enzyme β-galactosidase derived from Aspergillus oryzae fungus to reduce the difficulty of lipid and fat transformation in anaerobic digestion. The individual and combined effects of hydrolysis parameters, pH, enzyme load, reaction time and temperature were studied using Response Surface Methodology by Central Composite Design. The optimum conditions were determined based on variance analyses and surface plots; pH 4.63, temperature 40.47°C, reaction time 25.96 min and enzyme load 0.49%. Results showed a maximum lactose hydrolysis value of 86.21%, while the predicted value was 87.44%. Indeed, enzyme hydrolysis induced a change of soluble chemical oxygen demand around 24.6% and 75.8% reduction in volatile fatty acid concentration. Upon anaerobic digestion, the pre-hydrolysed whey revealed a 3.6-fold higher bio-methane production than that of raw hey, and a visible decrease in volatile fatty acid concentrations. The resultant data agreed with the Gompertz model, and lag phase times were significantly reduced for hydrolysed whey.

Background: Radial probe endobronchial ultrasound (R-EBUS) is often utilized in guided bronchoscopy for the diagnosis of peripheral pulmonary lesions. R-EBUS probe positioning has been shown to correlate with diagnostic yield, but overall diagnostic yield with this technology has been inconsistent across the published literature. Currently there is no standardization for R-EBUS image interpretation, which may result in variability in grading concentricity of lesions and subsequently procedure performance. This was a survey-based study evaluating variability among practicing pulmonologists in R-EBUS image interpretation., Methods: R-EBUS images from peripheral bronchoscopy cases were sent to 10 practicing Interventional Pulmonologists at two different time points (baseline and 3 months). Participants were asked to grade the images as concentric, eccentric, or no image. Cohen's Kappa-coefficient was calculated for inter- and intra-observer variability., Results: A total of 100 R-EBUS images were included in the survey. There was 100% participation with complete survey responses from all 10 participants. Overall kappa-statistic for inter-observer variability for Survey 1 and 2 was 0.496 and 0.477 respectively. Overall kappa-statistic for intra-observer variability between the two surveys was 0.803., Conclusions: There is significant variability between pulmonologists when characterizing R-EBUS images. However, there is strong intra-rater agreement from each participant between surveys. A standardized approach and grading system for radial EBUS patterns may improve inter-observer variability in order to optimize our clinical use and research efforts in the field., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-998/coif). A.C.C. has received research and consulting funding from Olympus, Boston Scientific, Johnson and Johnson and Intuitive Surgical. A.S. is a consultant for Olympus, which manufactures the radial EBUS device. S.P. is a consultant for Ambu Inc. The other authors have no conflicts of interest to declare., (2024 Journal of Thoracic Disease. All rights reserved.)

In recent years, anaerobic digestion (AD) has gained popularity as a practical method for generating clean energy and efficiently managing organic waste. However, the effectiveness of the reactor is compromised by the accumulation of ammonia, acids, and nutrients, leading to inhibition and instability. Because of its adaptability, biochar (BC) has sparked a substantial interest in biogas production and can be created by charring biomass and waste materials. Adding BC to the AD process could yield the following benefits: mitigating toxic inhibition, reducing the duration of the methanogenic lag phase, immobilising functional bacteria, and enhancing the rate of electron transfer between methanogenic and acetogenic microorganisms. Nonetheless, there remains to be more comprehensive knowledge regarding the multifaceted function of BC and its intricate mechanisms in the generation of biogas in AD. The research summarises scattered information from the literature on BC production from various feedstocks and factors affecting its characteristics. Additionally, a comprehensive analysis of the utilisation of BC as an additive within AD is presented here, emphasising how BC characteristics impact AD processes and how they effectively engage key challenges., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Lactose in cheese whey wastewater (CWW) makes it difficult to degrade under normal conditions. The effect of ultra-sonication (US), ozonation and enzymatic hydrolysis on increasing the bioavailability of organic matter in CWW and biogas production were evaluated. The pre-treatment conditions were: specific energy input varied from 2130 to 8773KJ/KgTS for a sonication time of 4.5-18.5 min, Ozone (O 3 ) dosages ranging from 0.03 to 0.045gO 3 /gTS were applied for 4-16 min, pH (3.8-7.1), temperature (35°C-55°C), enzyme dosage (0.18-0.52%), was operated from 7.75 to 53 min for enzymatic hydrolysis by β-galactosidase. The results of the US reported a maximum sCOD solubilisation of 77.15% after 18.5 min of operation, while the corresponding values for ozonation and enzymatic methods were 64.8% at 16 min and 54.79%, respectively. The organic matter degradation rates evaluated in terms of protein and lactose hydrolysis were 68.78%,46.03%; 47.83%,16.15% and 54.22%,86.2%respectively, for US, ozonation and enzymatic methods. The cumulative methane yield for sonicated, ozonised and enzymatically hydrolysed samples were 412.4 ml/g VS, 361.2 ml/g VS and 432.3mlCH 4 /gVS, respectively. Regardless of the lower COD solubilisation rates attained, enzymatic pre-treatment showed maximum methane generation compared to US and ozonation. This could be attributable to the increased activity of β-galactosidase in hydrolysing whey lactose. The energy calculations revealed that the pre-conditioning of organic-rich CWW with enzymatic hydrolysis is more effective and efficient, yielding a net energy gain (gross output energy-input energy) of 9166.7 KJ and an energy factor (ratio of output to input energy) of 6.67. The modified Gompertz model well simulated all experimental values., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Purpose: To report a new photographic macular feature identified on multimodal imaging in eyes with silicone oil in situ., Methods: Retrospective, observational case series of three eyes of three patients., Results: Two eyes had undergone initial vitrectomy for vitreous hemorrhage with fibrovascular membranes causing tractional retinal detachments secondary to retinovascular occlusion. One eye had further vitrectomy for rhegmatogenous retinal detachment complicated with proliferative vitreoretinopathy. All three eyes had multiple, discrete, coarse, hyperreflective deposits at the silicone oil-retina interface on optical coherence tomography macular scans, with increased reflectivity from the inner retinal layers. On multicolor and infrared images, these preretinal deposits produced hyporeflective darker spots giving a quasi-pitting appearance of the retinal surface against glossy bright reflection from silicone oil, thus simulating an appearance of ‟a strawberry." These deposits are causing inverse pitting of the oil bubble. On blue autoflourescence imaging, the preretinal deposits caused hypoautoflourescence. Partial silicone oil emulsification was seen superiorly in two of these patients with a different clinical and optical coherence tomography appearance from these hyperreflective macular deposits., Conclusion: We describe a new distinctive ‟Strawberry Retina" appearance identified on multicolor and infrared macular images associated with hyperreflective, coarse deposits at the silicone oil-retina interface.

Background: To report a novel technique for explantation of cloudy Oculentis intraocular lens (IOL)., Methods: A retrospective review of patient's electronic records was performed. The technique includes pars plana vitrectomy, deflooring (large posterior capsulectomy) of the capsular bag, IOL explantation with preserving the anterior capsule, and a secondary IOL placement., Results: Twenty eyes of 19 symptomatic patients were studied. Preoperative Snellen visual acuity ranged from 6/60 to 6/6; 15 eyes (75%) had visual acuity of 6/12 or better. Postoperative visual acuity ranged from 6/60 to 6/6; 18 eyes (90%) had visual acuity of 6/12 or better, and 2 eyes (10%) had visual acuity worse than 6/12. Among these eyes, 13 eyes (65%) had sulcus-fixated IOL, 5 eyes (25%) had sutureless scleral-fixated IOL, and 2 eyes (10%) had retropupillary iris clip IOL. Perioperative surgical complications included localized choroidal detachment in one eye and retinal detachment in another eye. In addition, most patients reported significant improvement in their postoperative vision satisfaction., Conclusion: Our new technique for explantation of cloudy Oculentis IOL provides a standard surgery allowing a safe predictable and repeatable removal of these lenses comparing with the anterior segment approach. This technique could also be used for removal of other IOLs.

Per- and polyfluoroalkyl substances (PFAS) cause potential threats to biota and are persistent and never-ending substances in the environment. Regulations and ban on legacy PFAS by various global organizations and national level regulatory agencies had shifted the fluorochemical production to emerging PFAS and fluorinated alternatives. Emerging PFAS are mobile and more persistent in aquatic systems, posing potential greater threats to human and environmental health. Emerging PFAS have been found in aquatic animals, rivers, food products, aqueous film-forming foams, sediments, and a variety of other ecological media. This review summarizes the physicochemical properties, sources, occurrence in biota and the environment, and toxicity of the emerging PFAS. Fluorinated and non-fluorinated alternatives for several industrial applications and consumer goods as the replacement of historical PFAS are also discussed in the review. Fluorochemical production plants and wastewater treatment plants are the main sources of emerging PFAS to various environmental matrices. Information and research are scarcely available on the sources, existence, transport, fate, and toxic effects of emerging PFAS to date., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Volatile fatty acids (VFAs) are the building blocks of the chemical industry, and they are the primary contributors to the planet's organic carbon cycle. VFA production from fossil fuels (mostly petroleum) is unsustainable, pollutes the environment, and generates greenhouse gases. As a result of these issues, there is a pressing need to develop alternate sources for the long-term generation of VFAs via anaerobic digestion. The accessible feedstocks for its sustainable production, as well as the influencing parameters, are discussed in this review. The use of VFAs as a raw material to make a variety of consumer products is reviewed in order to find a solution. It also bridges the gap between traditional and advanced VFA production and utilization methods from a variety of solid and liquid waste sources for economical stability., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

PFAs (poly and perfluoroalkyl compounds) are hazardous and bioaccumulative chemicals that do not readily biodegrade or neutralize under normal environmental conditions. They have various industrial, commercial, domestic and defence applications. According to the Organization for Economic Co-operation and Development, there are around 4700 PFAs registered to date. They are present in every stream of life, and they are often emerging and are even difficult to be detected by the standard chemical methods. This review aims to focus on the sources of various PFAs and the toxicities they impose on the environment and especially on humankind. Drinking water, food packaging, industrial areas and commercial household products are the primary PFAs sources. Some of the well-known treatment methods for remediation of PFAs presented in the literature are activated carbon, filtration, reverse osmosis, nano filtration, oxidation processes etc. The crucial stage of handling the PFAs occurs in determining and analysing the type of PFA and its remedy. This paper provides a state-of-the-art review of determination & tools, and techniques for remediation of PFAs in the environment. Improving new treatment methodologies that are economical and sustainable are essential for excluding the PFAs from the environment., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: The Northern Sydney Local Health District was one of the first health regions to be affected by COVID-19 in Australia., Aims: To describe the clinical characteristics, risk factors and outcomes in our low-prevalence Australian population., Methods: This is a retrospective analysis of 517 laboratory-confirmed COVID-19 cases between January and June 2020. Patient information was collected as part of routine care within the COVID-19 Virtual Hospital system. Outcomes examined were death, recovery at 30 days and intensive care unit (ICU) admission., Results: The case fatality rate was 1.8%. Multivariate analysis showed factors independently associated with death, composite outcome of death/ICU admission or incomplete recovery at 30 days were age >80 years and presence of two or more comorbidities. Most cases acquired COVID-19 through international (50.9%) or cruise ship travel (9.1%). Healthcare workers comprised 12.8% of the cohort and represented a disproportionately high percentage of the 'unknown' source group (27.6%). The median incubation period was 5 days (interquartile range 3-8); one patient had an incubation period of 15 days. Hospitalisation was required in 11.8%, ICU admission in 2.1% and ventilation in 1.4%. A Radiographic Assessment of Lung Oedema score on chest X-ray of >10 was independently associated with death., Conclusions: In this low prevalence, well resourced Australian setting, we report an overall low mortality. Factors associated with adverse patient outcomes on multivariate analysis were age greater than 80 and the presence of two or more comorbidities. These data can assist in early risk stratification of COVID-19 patients, and in surge capacity planning for hospitals., (© 2021 Royal Australasian College of Physicians.)

Two cases of acute postoperative Granulicatella adiacens endophthalmitis following uneventful phacoemulsification surgery are reported. The cases had intracameral cefuroxime as antibiotic prophylaxis, visual acuity (VA) was perception of light and hand movements, respectively, and there was severe anterior chamber inflammation and dense vitritis with no fundal view. Vitreous biopsy identified G adiacens using genome sequencing. Intraoperative findings included extensive retinal hemorrhages, abscesses, occluded retinal vessels, and retinal necrosis. Because of the ischemic retinal appearance, pan-retinal photocoagulation endolaser was performed. Postoperatively both cases developed rhegmatogenous retinal detachment (RRD) anterior to the laser marks and were successfully treated. VA improved to 6/18 and 6/60, respectively. Hyperreflective dots and Henle fiber layer hemorrhage are reported for the first time, to the authors' knowledge, in association with endophthalmitis. The successful outcome suggested that intraoperative pan-retinal photocoagulation could be considered in such ischemic cases to prevent rubeosis and to reduce the risk for postoperative RRD or limit its extent if it recurs.

Oral squamous cell carcinoma (OSCC) is highly predominant in India due to excessive use of tobacco. Here we investigated Long INterpersed Element 1 (LINE or L1) retrotransposon activity in OSCC samples in the same population. There are almost 500,000 copies of L1 occupied around 30%  of the human genome. Although most of them are inactive, around 150-200 copies are actively jumping in a human genome. L1 encodes two proteins designated as ORF1p and ORF2p and expression of both proteins are critical for the process of retrotransposition. Here we have analyzed L1 ORF1p expression in a small cohort (n = 15) of paired cancer-normal tissues obtained from operated oral cancer patients. Immunohistochemistry (IHC) with the human ORF1 antibody showed the presence of ORF1p in almost 60%  cancer samples, and few of them also showed aberrant p53 expression.  Investigating L1 promoter methylation status, showed certain trends towards hypomethylation of the L1 promoter in cancer tissues compared to its normal counterpart. Our data raise the possibility that L1ORF1p expression might have some role in the onset and progression of this particular type of cancer., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2020. Published by Elsevier Inc.)

Background/aims: Classical M1 macrophage activation exhibits an inflammatory phenotype while alternative M2 macrophage activation exhibits an anti-inflammatory phenotype. We aimed to determine whether there are discriminant patterns of macrophage polarization in Crohn's disease (CD) and intestinal tuberculosis (iTB)., Methods: Colonic mucosal biopsies from 29 patients with iTB, 50 with CD, and 19 controls were examined. Dual colored immunohistochemistry was performed for iNOS/CD68 (an M1 φ marker) and CD163/CD68 (an M2 φ marker), and the ratio of M1 φ to M2 φ was assessed. To establish the innate nature of macrophage polarization, we analyzed the extent of mitochondrial depolarization, a key marker of inflammatory responses, in monocyte-derived macrophages obtained from CD and iTB patients, following interferon-γ treatment., Results: M1 φ polarization was more prominent in CD biopsies ( P =0.002) than in iTB ( P =0.2) and control biopsies. In granuloma-positive biopsies, including those in CD, M1 φ predominance was significant ( P =0.001). In iTB, the densities of M1 φ did not differ between granuloma-positive and granuloma-negative biopsies ( P =0.1). Interestingly, higher M1 φ polarization in CD biopsies correlated with high inflammatory response exhibited by peripheral blood-derived monocytes from these patients., Conclusions: Proinflammatory M1 φ polarization was more common in colonic mucosa of CD patients, especially in the presence of mucosal granulomas. Further characterization of the innate immune system could help in clarifying the pathology of iTB and CD., Competing Interests: CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported.

Background and Study Aims:  Invagination, which can occur in any part of the intestine, usually affects children and is the second most common cause of intestinal obstruction after pyloric stenosis. The cause of these intussusceptions in children is usually unknown and they typically occur within the ileocolic region. Management of pediatric patients with the condition often consists of surgical intervention. However, this retrospective study from the University Hospital of the University of São Paulo, Brazil, reports a series of cases of intussusception in children in whom a colonoscopy was used to reverse the intussusception., Patients and Methods:  From April 2010 to January 2015, 30 pediatric patients underwent a colonoscopy as an noninvasive method for treatment of children's intestinal intussusception., Results:  Overall, treatment with colonoscopy was successful in reversing invagination in 66.7 % of the patients. However, 33.3 % of patients required surgery to resolve the intussusception., Conclusion:  Noninvasive colonoscopy is a potential treatment for intussusception in children.

Health-related quality of life (QOL) in children is not just related to physical symptoms but also how a disease impacts them psychosocially-mental, emotional, behavioral, and school functioning, all of which contribute to the growth and development of a child. A chronic disease, such as gastroesophageal reflux disease (GERD) characterized by troublesome symptoms and complications, can significantly impair a child's QOL. This makes it vital that treatment options aim at addressing this. Fundoplication, the surgical treatment for GERD, is one of the most common upper gastrointestinal surgeries performed by pediatric surgeons. As with any medical treatment, there is an inherent need to determine the efficacy of the procedure not only in terms of objective physiologic measures but also QOL measures for both the children and parents. There are currently limited and inconsistent data on QOL outcomes postfundoplication in children with GERD. This literature review aims at critically analyzing the data by comparing current trends with research and identifying gaps in evidence to justify the need for further research within the field., (© International Society for Diseases of the Esophagus 2017. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background/aims: Patients with inflammatory bowel disease (IBD) often require immunosuppressive therapy and blood transfusions and therefore are at a high risk of contracting infections due to hepatitis B (HBV) and hepatitis C (HCV) and human immunodeficiency virus (HIV). In the present study, we assessed the prevalence of these infections in patients with IBD., Methods: This retrospective study included 908 consecutive patients with IBD (ulcerative colitis [UC], n=581; Crohn's disease [CD], n=327) who were receiving care at a tertiary care center. Ninety-five patients with intestinal tuberculosis (ITB) were recruited as disease controls. Prospectively maintained patient databases were reviewed for the prevalence of HBV surface antigen, anti-HCV antibodies, and HIV (enzyme-linked immunosorbent assay method). HCV RNA was examined in patients who tested positive for anti-HCV antibodies. Prevalence data of the study were compared with that of the general Indian population (HBV, 3.7%; HCV, 1%; HIV, 0.3%)., Results: The prevalence of HBV, HCV, and HIV was 2.4%, 1.4%, and 0.1%, respectively, in the 908 patients with IBD. Among the 581 patients with UC, 2.2% (12/541) had HBV, 1.7% (9/517) had HCV, and 0.2% (1/499) had HIV. Among the 327 patients with CD, 2.8% (8/288) had HBV, 0.7% (2/273) had HCV, and 0% (0/277) had HIV. One patient with CD had HBV and HCV coinfection. The prevalence of HBV, HCV, and HIV in patients with ITB was 5.9% (4/67), 1.8% (1/57), and 1.2% (1/84), respectively., Conclusions: The prevalence of HBV, HCV, and HIV in north Indian patients with IBD is similar to the prevalence of these viruses in the general community. Nonetheless, the high risk of flare after immunosuppressive therapy mandates routine screening of patients with IBD for viral markers., Competing Interests: Conflict of interest: None.

Background: Association of Mycobacterium avium subspecies paratuberculosis (MAP) and Crohn's disease (CD) has been controversial due to contradictory reports. Therefore, we determined the prevalence of MAP in patients with CD and intestinal tuberculosis (ITB) and its association with clinical course., Methodology: Blood and intestinal biopsies were taken from 69 CD, 32 ITB patients and 41 patients with haemorrhoidal bleed who served as controls. qPCR targeting of MAP-specific IS900 gene was used to detect the presence of MAP DNA. qPCR results were further validated by sequencing. Immunohistochemistry (IHC) was used to detect the presence of MAP antigen in biopsy specimens. CD and ITB patients were followed-up for disease course and response to therapy., Principal Findings: The frequency of MAP-specific DNA in biopsies by qPCR was significantly higher in CD patients (23.2%, p = 0.03) as compared to controls (7.3%). No significant difference in intestinal MAP presence was observed between ITB patients (12.5%, p = 0.6) and controls (7.3%). MAP presence in blood of CD patients was 10.1% as compared to 4.9% in controls while no patients with ITB were found to be positive (p = 0.1). Using IHC for detection of MAP antigen, the prevalence of MAP in CD was 2.9%, 12.5% in ITB patients and 2.4% in controls. However, long-term follow-up of the patients revealed no significant associations between clinical characteristics and treatment outcomes with MAP positivity., Conclusion: We report significantly high prevalence of MAP in intestinal biopsies of CD patients. However, the presence of MAP does not affect the disease course and treatment outcomes in either CD or ITB patients.

Two cases of anaerobic digestion (AD) of sludge, namely (i) with pre-treatment and (ii) without pre-treatment, were assessed using mass-energy balance and the corresponding greenhouse gas (GHG) emissions. For a digestion period of 30 days, volatile solids degradation of the control sludge and the ultrasonicated secondary sludge was 51.4% and 60.1%, respectively. Mass balance revealed that the quantity of digestate required for dewatering, transport and land application was the lowest (20.2 × 10(6) g dry sludge/day) for ultrasonicated secondary sludge at 31.4 g TS/L. Furthermore, for ultrasonicated secondary sludge at 31.4 g TS/L, the maximum net energy (energy output - energy input) of total dry solids (TDS) was 7.89 × 10(-6) kWh/g and the energy ratio (output/input) was 1.0. GHG emissions were also reduced with an increase in the sludge solids concentration (i.e., 40.0 g TS/L < 30.0 g TS/L < 20.0 g TS/L). Ultrasonication pre-treatment proved to be efficient and beneficial for enhancing anaerobic digestion efficiency of the secondary sludge when compared to the primary and mixed sludge., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

The byproduct of cheese-producing industries, cheese whey, is considered as an environmental pollutant due to its high BOD and COD concentrations. The high organic load of whey arises from the presence of residual milk nutrients. As demand for milk-derived products is increasing, it leads to increased production of whey, which poses a serious management problem. To overcome this problem, various technological approaches have been employed to convert whey into value-added products. These technological advancements have enhanced whey utilization and about 50% of the total produced whey is now transformed into value-added products such as whey powder, whey protein, whey permeate, bioethanol, biopolymers, hydrogen, methane, electricity bioprotein (single cell protein) and probiotics. Among various value-added products, the transformation of whey into proteinaceous products is attractive and demanding. The main important factor which is attractive for transformation of whey into proteinaceous products is the generally recognized as safe (GRAS) regulatory status of whey. Whey and whey permeate are biotransformed into proteinaceous feed and food-grade bioprotein/single cell protein through fermentation. On the other hand, whey can be directly processed to obtain whey protein concentrate, whey protein isolate, and individual whey proteins. Further, whey proteins are also transformed into bioactive peptides via enzymatic or fermentation processes. The proteinaceous products have applications as functional, nutritional and therapeutic commodities. Whey characteristics, and its transformation processes for proteinaceous products such as bioproteins, functional/nutritional protein and bioactive peptides are covered in this review., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The effect of thermal pre-treatment on sludge anaerobic digestion (AD) efficiency was studied at different total solids (TS) concentrations (20.0, 30.0 and 40.0 g TS/L) and digestion times (0, 5, 10, 15, 20 and 30 days) for primary, secondary and mixed wastewater sludge. Moreover, sludge pre-treatment, AD and disposal processes were evaluated based on a mass-energy balance and corresponding greenhouse gas (GHG) emissions. Mass balance revealed that the least quantity of digestate was generated by thermal pre-treated secondary sludge at 30.0 g TS/L. The net energy (energy output-energy input) and energy ratio (energy output/energy input) for thermal pre-treated sludge was greater than control in all cases. The reduced GHG emissions of 73.8 × 10(-3) g CO2/g of total dry solids were observed for the thermal pre-treated secondary sludge at 30.0 g TS/L. Thermal pre-treatment of sludge is energetically beneficial and required less retention time compared to control., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: To evaluate the patient's understanding of the importance and adherence to the various lifestyle and Age-Related Eye Disease Study (AREDS) supplement recommendations for age-related macular degeneration (AMD)., Design: Cross-sectional study., Participants: Patients with AMD treated at the vitreoretinal service clinic., Methods: Telephone questionnaire survey was administered to assess knowledge and adherence to various recommendations made to patients with AMD about lifestyle and AREDS supplements in this single-institution study., Results: Among 92 patients with AMD contacted, dietary modification, exercise and weight reduction, smoking cessation, and AREDS supplementation recommendations were recalled by 47 (51%), 21 (23%), 5 (5%), and 90 (98%) patients, respectively. The necessity of making these interventions was believed by 29 (62%), 16 (76%), 4 (80%), and 67 (74%) patients, respectively. Patient adherence to dietary modification was 81%, to exercise and weight reduction was 76%, to smoking cessation was 0%, and to AREDS supplementation was 88% (71% on correct dose). Financially, 29% of the patients noted a mean increase of $88 per month in expenditure because of making dietary modifications, but most reported such as justified; 61% noted a mean increase of $25 per month in expenditure from consumption of AREDS supplements, and most (96%) believed this was justified., Conclusions: Patients with AMD recalled recommendations for AREDS supplementation more often than other lifestyle changes but generally felt recommendations were necessary and affordable. Adherence to smoking cessation recommendation was poor (0%), but to other recommendations was good., (Copyright © 2015 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the effect of intravitreal ciliary neurotrophic factor (CNTF) implant on mean macular thickness (MMT) in eyes with retinitis pigmentosa using high-resolution Fourier domain optical coherence tomography imaging., Methods: A cohort of 8 patients (CNTF-3: n = 5; CNTF-4: n = 3) enrolled in Neurotech sponsored Phase 2 clinical trial underwent Fourier domain optical coherence tomography imaging. A ≥3% change in MMT from baseline or fellow eye was considered as a measurable change., Results: Two patients enrolled in the CNTF-3 study received low-dose implant. At 18 months, a change in MMT from -4.47 μm to 6 μm from baseline was noted. Six patients received high-dose implant (CNTF-3: n = 3; CNTF-4: n = 3). In CNTF-3 group, 1 eye showed an increase in MMT by 19.25 μm (+7.6%) from baseline at 18 months. In CNTF-4 group, 1 eye had an increase in MMT of 27.08 μm (+11%) from baseline at 30 months; second eye had increase in MMT of 31.36 μm (+12%) from contralateral eye. Amongst these 3 responsive high-dose implant eyes, overall thickening of the retina could not be attributed to any specific retinal layer., Conclusion: A heterogeneous dose-dependent response on MMT was noted in eyes treated using intravitreal CNTF implant for retinitis pigmentosa. We recommend corroboration of our findings with Neurotech sponsored clinical trial results.

Background: Because patients with cystic fibrosis (CF) are living longer, chronic malabsorption of carotenoids associated with CF resulting in decreased macular pigment (MP) may affect macular long-term health in later-life pathology. This study compared the macular pigment optical density (MPOD) and corresponding central macular volume (MV) of adult CF subjects and age-matched normal controls subjects to determine whether chronic malabsorption associated with CF could adversely affect macular photoreceptor anatomy., Objective: Our aim was to compare MPOD with measurements of central MV in CF patients with age-matched controls. Design. In nine adult CF patients (ages: 29-46) without a history of carotenoid supplementation or known retinal or optic nerve disease MPOD and MV were measured by heterochromatic flicker photometry (HFP) and optical coherence tomography (OCT), respectively, and compared to results obtained from 14 age-matched controls., Results: MPOD was significantly reduced at 15' and 30' eccentricities in CF subjects compared to normal subjects (mean difference -0.21 at 15', -0.25 at 30', p < 0.005). No significant difference, in MV noted at any of the eccentricities tested between CF and normal subjects (CF: normal MV ratios ranged from 0.94 to 1.1 for all eccentricities with p > 0.1 at all eccentricities). Best corrected vision acuity and fundus examination were normal in all subjects., Conclusions: Unsupplemented CF patients have markedly lower levels of macular carotenoids (e.g., lutein and zeaxanthin), but well-maintained visual function and no significant reductions in central MV primarily composed of macular photoreceptors. Future studies are needed to determine whether the lifelong decrease in protective central retinal carotenoids predisposes CF patients to later-life retinal pathology.

Background: Fragile fractures are most likely manifestations of fatigue damage that develop under repetitive loading conditions. Numerous microcracks disperse throughout the bone with the tensile and compressive loads. In this study, tensile and compressive load tests are performed on specimens of both the genders within 19 to 83 years of age and the failure strength is estimated., Materials and Methods: Fifty five human femur cortical samples are tested. They are divided into various age groups ranging from 19-83 years. Mechanical tests are performed on an Instron 3366 universal testing machine, according to American Society for Testing and Materials International (ASTM) standards., Results: The results show that stress induced in the bone tissue depends on age and gender. It is observed that both tensile and compression strengths reduces as age advances. Compressive strength is more than tensile strength in both the genders., Conclusion: The compression and tensile strength of human femur cortical bone is estimated for both male and female subjecting in the age group of 19-83 years. The fracture toughness increases till 35 years in male and 30 years in female and reduces there after. Mechanical properties of bone are age and gender dependent.

In order to assess the economic benefits of an early discharge (ED) programme for patients with complicated skin and soft tissue infections (cSSTIs) in terms of hospital and regional authority costs, an economic analysis was conducted comparing two possible alternatives: standard hospital management vs. an ED strategy followed by a period of outpatient management. Utilization of resources and costs were derived from the literature and expert panel evaluation. Patients were classified into four groups: low-intensity non-walking (LINW), low-intensity walking (LIW), high-intensity non-walking (HINW) and high-intensity walking (HIW). The overall costs (inpatient/outpatient) of hospitalization with ED for cSSTIs range from Euros 2,079 for LIW to Euros 2,193 for HINW, with the most expensive regimen (HINW) being 50% lower than the costs for 12.6 days of hospitalization alone (Euros 4,619). The weighted average Diagnosis Related Group (DRG) reimbursement for cSSTIs (Euros 2,042) does not cover the costs of such hospitalization. In conclusion, when a patient's conditions allow for early discharge there is an economic advantage for the hospital with an outpatient management plan, especially for patients requiring low-intensity care. However, this could be disadvantageous in terms of regional costs if outpatient management has to be paid in addition to payment by the DRG.

Purpose: To evaluate serially long-term macular morphologic changes after successful macula-involving rhegmatogenous retinal detachment repair and correlate changes with macular function., Methods: Repeat Fourier domain optical coherence tomography (FD OCT) imaging and microperimetry (MP-1) testing of 8 of the initial cohort of 17 eyes studied 5 years earlier., Results: The mean follow-up after rhegmatogenous retinal detachment repair was 3.4 months (range, 1-8.5 months) for the first FD OCT and 5 years (range, 3.75-5.75 years) for the follow-up FD OCT. The final postoperative best-corrected visual acuity mean was 20/201 (range, 20/20 to counting fingers). Six eyes with final best-corrected visual acuity >20/40 had an intact external limiting membrane and progressive resolution of photoreceptor inner segment-outer segment junction disruption and/or subretinal fluid on serial FD OCT, which correlated with improvement in macular function on MP-1. Two eyes with poor or worsening best-corrected visual acuity on follow-up had persistent or worsening inner segment-outer segment disruption on serial FD OCT. External limiting membrane was intact in one eye and persistently disrupted in the other., Conclusion: Macular function may progressively improve or worsen long-term after successful rhegmatogenous retinal detachment repair. Progressive resolution of subretinal fluid and/or inner segment-outer segment disruption on FD OCT correlated with improvement in macular function, whereas worsening or persistent inner segment-outer segment disruption correlates with worsening or persistently poor visual outcome.

Purpose: Two methods were used to study the stages of macular telangiectasia (MACTEL): Power-Doppler optical coherence tomography (PD-OCT), which allows imaging of the retinal circulation in three dimensions, and macular pigment optical density (MPOD), which quantifies the distribution of macular carotenoids., Methods: Among 49 patients with MacTel identified, 12 eyes (6 patients) with MacTel and 7 age-matched control eyes (7 patients) were imaged with a custom-built Fourier-domain OCT instrument to acquire PD-OCT images. MPOD was measured using heterochromatic flicker photometry in 10 eyes (5 patients) with MacTel and compared with 44 age-matched control eyes (44 patients). Clinical staging of MacTel was based on best-corrected visual acuity, fundus biomicroscopy, fluorescein angiography, and OCT., Results: Stage 1 eyes (n = 2) had subtle punctate vascular signal confined to the inner portion of the outer plexiform layer (OPL) on PD-OCT. Stage 2 (n = 2) showed larger oblique vascular signal extending into deeper OPL. Stage 3 (n = 5) had disruption of outer retinal layers with abnormal vasculature extending into the outer nuclear layer. Stage 4 (n = 3) showed diffuse blurring of the retinal layers with vascular channels extending the full thickness of the retina. MPOD values in four eyes with stage 1 or 2 MacTel correlated well with age-matched controls. Six eyes with stage 3 or 4 MacTel had loss of MPOD especially at the fovea., Conclusions: PD-OCT shows penetration of the retinal capillaries into the deeper retinal layers in early stages of MacTel, with full thickness vascular proliferation in advanced disease. MPOD is commonly depleted but may appear normal in early stage MacTel.

Objective: To evaluate the patient's understanding of the importance and adherence to the various lifestyle and Age-Related Eye Disease Study (AREDS) supplement recommendations for age-related macular degeneration (AMD)., Design: Cross-sectional study., Participants: Patients with AMD treated at the vitreoretinal service clinic., Methods: Telephone questionnaire survey was administered to assess knowledge and adherence to various recommendations made to patients with AMD about lifestyle and AREDS supplements in this single-institution study., Results: Among 92 patients with AMD contacted, dietary modification, exercise and weight reduction, smoking cessation, and AREDS supplementation recommendations were recalled by 47 (51%), 21 (23%), 5 (5%), and 90 (98%) patients, respectively. The necessity of making these interventions was believed by 29 (62%), 16 (76%), 4 (80%), and 67 (74%) patients, respectively. Patient adherence to dietary modification was 81%, to exercise and weight reduction was 76%, to smoking cessation was 0%, and to AREDS supplementation was 88% (71% on correct dose). Financially, 29% of the patients noted a mean increase of $88 per month in expenditure because of making dietary modifications, but most reported such as justified; 61% noted a mean increase of $25 per month in expenditure from consumption of AREDS supplements, and most (96%) believed this was justified., Conclusions: Patients with AMD recalled recommendations for AREDS supplementation more often than other lifestyle changes but generally felt recommendations were necessary and affordable. Adherence to smoking cessation recommendation was poor (0%), but to other recommendations was good., (Copyright © 2013 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe the results of photodynamic therapy (PDT) for juxtapapillary and peripheral retinal capillary hemangioma (RCH)., Patients and Methods: Interventional case series of four eyes (four patients) with juxtapapillary RCH and one eye (one patient) with peripheral RCH. Two eyes with juxtapapillary RCH had received two sessions of full-fluence, double-duration PDT; whereas other two eyes had received single session of half-fluence, single-duration PDT. The peripheral RCH was treated with a single session of full-fluence, single-duration PDT., Results: Two patients had von Hippel-Lindau disease. Follow-up duration ranged from 4 months to 1 year. Pre-PDT visual acuity (VA) ranged from 20/200 to HM (juxtapapillary RCH) and 20/100 (peripheral RCH). Among the eyes with juxtapapillary RCH, tumor regression with partial resolution of macular edema was noted in two eyes (one eye each with half-fluence and full-fluence PDT), whereas two eyes had no change in tumor size with persistent macular edema. VA remained stable in three eyes and declined in one eye. In an eye with peripheral RCH, regression of tumor and macular edema with VA improvement was noted. Post-PDT complications included epiretinal membrane (one eye) and transient exudative retinal detachment (one eye)., Conclusion: PDT can be effective in reducing macular edema associated with RCH but this does not always correspond with an improvement in VA especially for juxtapapillary tumors.

Purpose: To determine the macular morphologic features that correlate best with visual outcome in eyes with surgically closed idiopathic macular hole., Methods: Transversal observational case series of 24 eyes (22 subjects) imaged postoperatively using high-resolution Fourier domain optical coherence tomography (FD-OCT). Total and inner macular volume for central 3 mm area, central foveal thickness, and size of foveal inner segment-outer segment junction abnormality were correlated with best-corrected visual acuity. Microperimetry (MP-1) test was performed in a subset of 18 eyes., Results: Mean postoperative best-corrected visual acuity was 20/36 (range, 20/25-20/70). Postoperative follow-up mean was 32.97 ± 24.68 months (range, 5-96 months). Eighteen eyes underwent internal limiting membrane (ILM) peeling. Among FD-OCT parameters, logarithm of the minimum angle of resolution best-corrected visual acuity and mean total microperimetry-1 sensitivity correlated best with inner macular volume in all eyes and ILM-peeled eyes (P < 0.05). Macular surface irregularities were noted in 12 eyes (66.7%) with ILM peeling but in none of the non-ILM-peeled eyes (P = 0.02). No significant correlation was found between microperimetry-1 sensitivity and other FD-OCT parameters., Conclusion: Because inner macular volume strongly correlated with visual outcome in eyes with surgically closed macular hole, the possible effect of ILM peeling on visual outcome needs to be further investigated.

Objective: To compare health care visit rates between infants with false-positive and those with normal newborn screening (NBS) results., Patients and Methods: We analyzed administrative claims of Medicaid-enrolled infants born in Michigan in 2006 and calculated the average number of outpatient, emergency department, and hospital visits for infants aged 3 to 12 months according to NBS results. We calculated an adjusted incidence rate ratio for each visit category, adjusting for covariates and accounting for interaction effects., Results: Of the 49,959 infants in the analysis, 818 had a false-positive NBS result. We noted a significant interaction between gestational age and NBS results. We found that preterm, but not term, infants with false-positive results had more acute outpatient visits than their counterparts with normal NBS results. We found no difference in adjusted rates of other visit types (emergency department, inpatient, outpatient well) between infants with false-positive and normal NBS results, regardless of gestational age., Conclusions: Increased rates of acute outpatient visits among preterm infants with false-positive NBS screening results may be attributable to underlying chronic illness or parental anxiety. The absence of increased health care utilization among term infants may be unique to this Medicaid population or a subgroup phenomenon that was not detectable in this analysis.

We describe an ultrahigh-resolution (UHR) retinal imaging system that combines adaptive optics Fourier-domain optical coherence tomography (AO-OCT) with an adaptive optics scanning laser ophthalmoscope (AO-SLO) to allow simultaneous data acquisition by the two modalities. The AO-SLO subsystem was integrated into the previously described AO-UHR OCT instrument with minimal changes to the latter. This was done in order to ensure optimal performance and image quality of the AO- UHR OCT. In this design both imaging modalities share most of the optical components including a common AO-subsystem and vertical scanner. One of the benefits of combining Fd-OCT with SLO includes automatic co-registration between two acquisition channels for direct comparison between retinal structures imaged by both modalities (e.g., photoreceptor mosaics or microvasculature maps). Because of differences in the detection scheme of the two systems, this dual imaging modality instrument can provide insight into retinal morphology and potentially function, that could not be accessed easily by a single system. In this paper we describe details of the components and parameters of the combined instrument, including incorporation of a novel membrane magnetic deformable mirror with increased stroke and actuator count used as a single wavefront corrector. We also discuss laser safety calculations for this multimodal system. Finally, retinal images acquired in vivo with this system are presented.

Purpose: The purpose of this study is to evaluate the macular morphological changes associated with idiopathic epiretinal membrane (iERM) using high-resolution Fourier-domain optical coherence tomography (FD-OCT), as they correlate with visual acuity and microperimetry (MP-1)., Methods: In all, 24 eyes (19 subjects) with iERM were imaged prospectively using FD-OCT with axial resolution of 4.5 μm and transverse resolution of 10 to 15 μm. MP-1 and Stratus OCT were carried out in a subset of eyes., Results: The mean log of the minimum angle of resolution best-corrected visual acuity (BCVA) was 0.18±0.16 (range: -0.08 to 0.48, Snellen equivalent 20/15(-1) to 20/60). ERM was visualized in all 24 eyes with FD-OCT and in 17 eyes (85%) of 20 eyes imaged with Stratus OCT. Although BCVA correlated with macular thickening in the central 1 mm sub-field of the Stratus ETDRS (P=0.0005) and macular volume (central 3 mm area) on FD-OCT (P<0.0001), macular thickening on thickness map and volume correlated poorly with decrease in macular sensitivity on MP-1 (P=0.16). On FD-OCT, foveal morphological changes correlated best with decrease in BCVA, the strongest being central foveal thickness (P<0.0001). Other significant changes included blurring of the foveal inner segment-outer segment (IS-OS) junction and/or Verhoeff's membrane, vitreal displacement of foveal outer nuclear layer and foveal detachment (P<0.05). Foveal IS-OS junction disruption was seen in 25% of eyes on Stratus OCT but in none of the eyes on FD-OCT., Conclusion: FD-OCT allowed improved visualization of ERM and associated foveal morphological changes that correlated best with BCVA. Macular thickening correlated weakly with decreased macular function as assessed by MP-1.

Ultrasonication is an emerging and very effective mechanical pretreatment method to enhance the biodegradability of the sludge, and it would be very useful to all wastewater treatment plants in treating and disposing sewage sludge. Ultrasonication enhances the sludge digestibility by disrupting the physical, chemical and biological properties of the sludge. The degree of disintegration depends on the sonication parameters and also on sludge characteristics, therefore the evaluation of the optimum parameters varies with the type of sonicater and sludge to be treated. The full-scale installations of ultrasonication have demonstrated that there is 50% increase in the biogas generation, and in addition evaluation of energy balance showed that the average ratio of the net energy gain to electric consumed by the ultrasound device is 2.5. This review article summarizes the benefits of ultrasonication of sludge, the effect of sonication parameters, impact of sludge characteristics on sludge disintegration, and thereby the increase in biogas production in anaerobic digester. Due to uncertainty in the unit representation by many researchers and nonavailability of the data, comparison of these results is complicated. Comparison of ultrasonication with other pretreatment options is necessary to evaluate the best economical and environmental pretreatment technology for sludge treatment and disposal. The optimum parameters for the ultrasonication vary with sludge characteristics., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Context: Although recent trends in obesity have been well documented, generational patterns of obesity from early childhood through adulthood across birth cohorts, which account for the recent epidemic of childhood obesity, have not been well described. Such trends may have implications for the prevalence of obesity-associated conditions among population subgroups, including type 2 diabetes., Objective: Our objective was to evaluate trajectories of obesity over the life course for the US population, overall and by gender and race., Design, Setting and Participants: We conducted an age, period and birth cohort analysis of obesity for US individuals who participated in the National Health and Nutrition Examination Surveys (NHANES) (1971-2006)., Main Outcome Measures: Obesity was defined as a body mass index >or=95th percentile for individuals aged 2-16 years or >or=30 kg m(-2) among individuals older than 16 years. Age was represented by the age of the individual at each NHANES, period was defined by the year midpoint of each survey, and cohort was calculated by subtracting age from period., Results: Recent birth cohorts are becoming obese in greater proportions for a given age, and are experiencing a greater duration of obesity over their lifetime. For example, although the 1966-1975 and 1976-1985 birth cohorts had reached an estimated obesity prevalence of at least 20% by 20-29 years of age, this level was only reached by 30-39 years for the 1946-1955 and 1956-1965 birth cohorts, by 40-49 years for the 1936-1945 birth cohort and by 50-59 years of age for the 1926-1935 birth cohort. Trends are particularly pronounced for female compared with male, and black compared with white cohorts., Conclusions: The increasing cumulative exposure to excess weight over the lifetime of recent birth cohorts will likely have profound implications for future rates of type 2 diabetes, and mortality within the US population.

Welder's maculopathy represents a form of photochemical damage to the retina and is characterized by involvement of the outer retinal layers. Fourier-domain optical coherence tomography (FD OCT) imaging was performed in 5 eyes of 3 patients with clinical findings suggestive of welder's maculopathy in occupational welders. Clinical examination was characterised by a faceted foveal lesion and the FD OCT line scan images showed a distinct discontinuity of the photoreceptor inner and outer segment (IS/OS) junction. The external limiting membrane (ELM) and the retinal pigment epithelial (RPE) layer remained intact at the site of IS/OS defect. FD OCT imaging offers a non-invasive way of evaluating the microstructural changes at the fovea in welder's maculopathy., (Copyright 2010, SLACK Incorporated.)

Purpose: To determine the incidence of endophthalmitis following intravitreal injection of anti-vascular endothelial growth factor (VEGF) agents., Design: A retrospective interventional case series., Methods: A total of 10,254 intravitreal anti-VEGF injections (406 pegaptanib, 3,501 bevacizumab, and 6,347 ranibizumab) were performed from January 5, 2005 to October 18, 2007. The number of the injections was determined from the injection log books and billing records. The injections were performed as an office based procedure with use of povidone-iodine as a part of preinjection preparation. Preinjection antibiotics, eye drape, or surgical attire were not used. The main outcome measures were the incidence of suspected and proven endophthalmitis., Results: There were three cases of suspected endophthalmitis, one case following bevacizumab injection and two cases following ranibizumab injection. There was no case of culture-proven endophthalmitis. All three patients regained their preinjection visual acuity. The incidence of suspected endophthalmitis was 0.029% (95% confidence interval, 0.006% to 0.085%). There was no difference in the incidence of endophthalmitis between ranibizumab and bevacizumab injections (P = .6)., Conclusions: Although there is no consensus regarding the intravitreal injection procedure technique, the incidence of suspected endophthalmitis was very low in a large series of injected patients in a community setting and the incidence compares favorably with that reported in clinical trials where much more extensive preinjection preparation was mandated. We found no difference in the endophthalmitis risk of patients receiving bevacizumab as compared with ranibizumab.