Occurrence and profiling of multiple nitrosamines in source water and drinking water of China

Analytical Methodologies to Detect N-Nitrosamine Impurities in Active Pharmaceutical Ingredients, Drug Products and Other Matrices

Since 2018, N-nitrosamine impurities have become a widespread concern in the global regulatory landscape of pharmaceutical products. This concern arises due to their potential for contamination, toxicity, carcinogenicity, and mutagenicity and their presence in many active pharmaceutical ingredients, drug products, and other matrices. N-Nitrosamine impurities in humans can lead to severe chemical toxicity effects. These include carcinogenic effects, metabolic disruptions, reproductive harm, liver diseases, obesity, DNA damage, cell death, chromosomal alterations, birth defects, and pregnancy loss. They are particularly known to cause cancer (tumors) in various organs and tissues such as the liver, lungs, nasal cavity, esophagus, pancreas, stomach, urinary bladder, colon, kidneys, and central nervous system. Additionally, N-nitrosamine impurities may contribute to the development of Alzheimer's and Parkinson's diseases and type-2 diabetes. Therefore, it is very important to control or avoid them by enhancing effective analytical methodologies using cutting-edge analytical techniques such as LC-MS, GC-MS, CE-MS, SFC, etc. Moreover, these analytical methods need to be sensitive and selective with suitable precision and accuracy, so that the actual amounts of N-nitrosamine impurities can be detected and quantified appropriately in drugs. Regulatory agencies such as the US FDA, EMA, ICH, WHO, etc. need to focus more on the hazards of N-nitrosamine impurities by providing guidance and regular updates to drug manufacturers and applicants. Similarly, drug manufacturers should be more vigilant to avoid nitrosating agents and secondary amines during the manufacturing processes. Numerous review articles have been published recently by various researchers, focusing on N-nitrosamine impurities found in previously notified products, including sartans, metformin, and ranitidine. These impurities have also been detected in a wide range of other products. Consequently, this review aims to concentrate on products recently reported to contain N-nitrosamine impurities. These products include rifampicin, champix, famotidine, nizatidine, atorvastatin, bumetanide, itraconazole, diovan, enalapril, propranolol, lisinopril, duloxetine, rivaroxaban, pioglitazones, glifizones, cilostazol, and sunitinib.

Research progress on the generation of NDMA by typical PPCPs in disinfection treatment of water environment in China: A review

The drugs and personal care products in water sources are potential threats to the ecological environment and drinking water quality. In recent years, the presence of PPCPs has been detected in multiple drinking water sources in China. PPCPs are usually stable and resistant to degradation in aquatic environments. During chlorination, chloramination, and ozonation disinfection processes, PPCPs can act as precursor substances to generate N-nitrosodimethylamine (NDMA) which is the most widely detected nitrosamine byproduct in drinking water. This review provides a comprehensive overview of the impact of PPCPs in China's water environment on the generation of NDMA during disinfection processes to better understand the correlation between PPCPs and NDMA generation. Chloramine is the most likely to form NDMA with different disinfection methods, so chloramine disinfection may be the main pathway for NDMA generation. Activated carbon adsorption and UV photolysis are widely used in the removal of NDMA and its precursor PPCPs, and biological treatment is found to be a low-cost and high removal rate method for controlling the generation of NDMA. However, there are still certain regional limitations in the investigation and research on PPCPs, and other nitrosamine by-products such as NMEA, NDEA and NDBA should also be studied to investigate the formation mechanism and removal methods.

N-nitrosamines in electroplating and printing/dyeing industrial wastewater treatment plants: Removal efficiency, environmental emission, and the influence on drinking water

The discharge of industrial wastewater containing high concentrations of N-nitrosamines to the aquatic environment can impair downstream source waters and pose potential risks to human health. However, the transport and fate of N-nitrosamines in typical industrial wastewater treatment plants (IWWTPs) and the influence of these effluents on source water and drinking water are still unclear. This study investigated nine N-nitrosamines in four full-scale electroplating (E-) and printing/dyeing (PD-) IWWTPs, two drinking water treatment plants (DWTPs) in the lower reaches of these IWWTPs, and the corresponding tap water in South China. The total concentrations of N-nitrosamines (∑NAs) were 382-10,600, 480-1920, 494-789, and 27.9-427 ng/L in influents, effluents, source water, and tap water, respectively. The compositions of N-nitrosamine species in different influents varied a lot, while N-nitrosodi-n-butylamine (NDBA) and N-nitrosodimethylamine (NDMA) dominated in most of the effluents, source water, and tap water. More than 70 % N-nitrosamines were removed by wastewater treatment processes used in E-IWWTPs such as ferric-carbon micro-electrolysis (Fe/C-ME), while only about 50 % of N-nitrosamines were removed in PD-IWWTPs due to the use of chlorine reagent or other inefficient conventional processes such as flocculation by cationic amine-based polymers or bio-contact oxidation. Therefore, the mass fluxes of N-nitrosamines discharged from these industrial wastewaters to the environment in the selected two industrial towns were up to 14,700 mg/day. The results based on correlation and principal component analysis significantly demonstrated correlations between E-and PD-effluents and source water and tap water, suggesting that these effluents can serve as sources of N-nitrosamines to local drinking water systems. This study suggests that N-nitrosamines are prevalent in typical IWWTPs, which may infect drinking water systems. The findings of this study provide a basis data for the scientific evaluation of environmental processes of N-nitrosamines.

Occurrence and fate of N-nitrosamines in full-scale domestic wastewater treatment plants and their impact on receiving waters along the Lijiang River, China

Domestic wastewaters contaminated with N-nitrosamines pose a significant threat to river ecosystems worldwide, particularly in urban areas with riparian cities. Despite widespread concern, the precise impact of these contaminants on receiving river waters remains uncertain. This study investigated eight N-nitrosamines in wastewater treatment plants (WWTPs) and their adjacent receiving river, the Lijiang River in Guilin City, Southwest China. By analyzing thirty wastewater samples from five full-scale WWTPs and twenty-three river water samples from Guilin, we quantified the mass loads of N-nitrosamines discharged into the surrounding watershed via domestic effluents. The results revealed that N-nitrosodimethylamine (10-60 ng/L), N-nitrosodiethylamine (3.4-22 ng/L), and N-nitrosopyrrolidine (not detected-4.5 ng/g) were predominant in influents, effluents, and sludge, respectively, with the overall removal efficiencies ranging from 17.7 to 65.6% during wastewater treatment. Cyclic activated sludge system and ultraviolet disinfection were effective in removing N-nitrosamines (rates of 59.6% and 24.3%), while chlorine dioxide disinfection promoted their formation. A total of 30.4 g/day of N-nitrosamine mass loads were observed in the Lijiang River water, with domestic effluents contributing about 31.3% (19.4 g/day), followed by livestock breeding wastewater (34.5%, 12.0 g/day), and unknown sources (24.7%, 7.5 g/day). These findings highlight the critical role of WWTPs in transporting N-nitrosamines to watersheds and emphasize the urgent need for further investigation into other potential sources of N-nitrosamine pollution within watersheds.

Applications of artificial intelligence (AI) in drinking water treatment processes: Possibilities

In water treatment processes (WTPs), artificial intelligence (AI) based techniques, particularly machine learning (ML) models have been increasingly applied in decision-making activities, process control and optimization, and cost management. At least 91 peer-reviewed articles published since 1997 reported the application of AI techniques to coagulation/flocculation (41), membrane filtration (21), disinfection byproducts (DBPs) formation (13), adsorption (16) and other operational management in WTPs. In this paper, these publications were reviewed with the goal of assessing the development and applications of AI techniques in WTPs and determining their limitations and areas for improvement. The applications of the AI techniques have improved the predictive capabilities of coagulant dosages, membrane flux, rejection and fouling, disinfection byproducts (DBPs) formation and pollutants' removal for the WTPs. The deep learning (DL) technology showed excellent extraction capabilities for features and data mining ability, which can develop an image recognition-based DL framework to establish the relationship among the shapes of flocs and dosages of coagulant. Further, the hybrid techniques (e.g., combination of regression and AI; physical/kinetics and AI) have shown better predictive performances. The future research directions to achieve better control for WTPs through improving these techniques were also emphasized.

Detection with NO Modification: (N═O)-Au Interactions for Instantaneous Label-Free Detection of N-Nitrosodiphenylamine

Increasing concerns have been raised about dangerous, yet nearly undetectable levels of nitrosamines in foods, medications, and drinking water. Their ubiquitous presence and carcinogenicity necessitates a method of sensitive and selective detection of these potent toxins. While the detection of two major nitrosamines─N-nitrosodimethylamine and N-nitrosodiethylamine─has seen success, low detection limits are scarcer for the other members of this class. One member, N-nitrosodiphenylamine (NDPhA), has had little progress not only in its detection in low quantities but also in its detection at all. NDPhA has unique difficulty in its identification due to its aromaticity, making it far more problematic to distinguish in the common GC-MS or LC-MS/MS methods used for nitrosamine sensing. Despite this detection barrier, it has been listed among the top 6 carcinogenic nitrosamines by the Food and Drug Administration as of 2023. Due to its evasive nature, a unique methodology must be applied to facilitate its sensitive identification. Herein, we describe the use of surface-enhanced Raman spectroscopy for the first account of liquid-phase detection of NDPhA using cysteamine-functionalized gold nanostars and a portable Raman spectrometer. Our methodology requires no chemical modification to the nitrosated structure as well as the usage of two well-understood biocompatible materials: cysteamine and gold nanoparticles.

Analysing N-nitrosamine occurrence and sources in karst reservoirs, Southwest China

N-nitrosamines in reservoir water have drawn significant attention because of their carcinogenic properties. Karst reservoirs containing dissolved organic matter (DOM) are important drinking water sources and are susceptible to contamination because of the fast flow of various contaminants. However, it remains unclear whether N-nitrosamines and their precursor, DOM, spread in karst reservoirs. Therefore, this study quantitatively investigated the occurrence and sources of N-nitrosamines based on DOM properties in three typical karst reservoirs and their corresponding tap water. The results showed that N-nitrosamines were widely spread, with detection frequencies > 85%. Similar dominant compounds, including N-nitrosodimethylamine, N-nitrosomethylethylamine, N-nitrosopyrrolidine, and N-nitrosodibutylamine, were observed in reservoirs and tap water, with average concentrations of 4.7-8.9 and 2.8-6.7 ng/L, respectively. The average carcinogenic risks caused by these N-nitrosamines were higher than the risk level of 10-6. Three-dimensional fluorescence excitation-emission matrix modeling revealed that DOM was composed of humus-like component 1 (C1) and protein-like component 2 (C2). Fluorescence indicators showed that DOM in reservoir water was mainly affected by exogenous pollution and algal growth, whereas in tap water, DOM was mainly affected by microbial growth with strong autopoietic properties. In the reservoir water, N-nitrosodiethylamine and N-nitrosopiperidine were significantly correlated with C2 and biological indicators, indicating their endogenously generated sources. Based on the principal component analysis and multiple linear regression methods, five sources of N-nitrosamines were identified: agricultural pollution, microbial sources, humus sources, degradation processes, and other factors, accounting for 46.8%, 36.1%, 7.82%, 8.26%, and 0.96%, respectively. For tap water, two sources, biological reaction processes, and water distribution systems, were identified, accounting for 75.7% and 24.3%, respectively. Overall, this study presents quantitative information on N-nitrosamines' sources based on DOM properties in typical karst reservoirs and tap water, providing a basis for the safety of drinking water for consumers.

Chromatographic Methods for the Determination of Organic Pollution in Urban Water: A Current Mini Review

The number of pollutants and chemicals with the potential to reach the environment is still largely unknown, which poses great challenges for researchers in various fields of science, environmental scientists, and analytical chemists. Chromatographic techniques, both gas chromatography (GC) and liquid chromatography (LC) coupled with different types of detection, are now invaluable tools for the identification of a wide range of chemical compounds and contaminants in water. This review is devoted to chromatographic techniques GC-MS, GC-Orbitrap-MS, GC-MS/MS, GC-HRMS, GC × GC-TOFMS, GC-ECD, LC-MS/MS, HPLC-UV, HPLC-PDA, UPLC-QTOFMS, used to determinate emerging organic contaminants in aquatic media, mainly in urban water, published in the scientific literature over the past several years. The article also focuses on sample preparation methods used in the analysis of aqueous samples. Most research focuses on minimizing the number of sample preparation steps, reducing the amount of solvents used, the speed of analysis, and the ability to apply it to a wide range of analytes in a sample. This is extremely important in the application of sensitive and selective methods to monitor the status of urban water quality and assess its impact on human health.

Feasibility of NDEA formation control from DEDTC in chlorination/chloramination by pre-ozonation: Mechanisms and influencing factors

N-nitrosodiethylamine (NDEA), which is the most toxic nitrosamine among the 9 detected species, has been widely detected in drinking water. Amines containing diethylamine (DEA) groups in the structure would generate NDEA during the disinfection processes. The aim of this study was to evaluate the feasibility of reducing NDEA formation from a commonly used dithiocarbamate pesticide sodium diethyldithiocarbamate (DEDTC) in subsequent chlorination and chloramination by pre-ozonation. The results demonstrated that NDEA could be generated directly during ozonation, its amounts increased from 0 to 14.34 μg/L with increasing ozone dosages (0-4 mg/L), which was higher than that chlorination (2.68 μg/L) and chloramination (4.91 μg/L) when the initial concentration of DEDTC was 20 μM. Pre-ozonation significantly raised NDEA formation from 2.68 to15.32 μg/L in subsequent chlorination; and that from 4.91 to 9.54 μg/L during subsequent chloramination processes. The addition of •OH scavenger tert-butanol (tBA) increased the production of NDEA from 8.14 to 20.80 μg/L during ozonation, and that from 6.76 to17.98 μg/L in O3/HClO process, 8.74 to 17.33 μg/L in O3/NH2Cl process. Except for NO3- and CO32-, most of the co-existing substances promoted NDEA generation from DEDTC under disinfection conditions. Based on the results of Gaussian theory calculations, GC/MS and UPLC-Q-TOFMS analysis, the influencing mechanisms of pre-ozonation on NDEA generation in the subsequent disinfection process were proposed. In addition, not only acute/chronic toxicity calculation but also luminescent bacteria test was performed to assess the possibility of pre-ozonation on the risk control of DEDTC. The research results fill a gap in the control of NDEA pollution and help to develop a safer ozone oxidation technology.

Compromised very-low density lipoprotein induced polyunsaturated triglyceride accumulation in N-nitrosodiethylamine-induced hepatic steatosis

N-Nitrosodiethylamine (NDEA), a carcinogen in some foods and medications, is linked to liver damage similar to non-alcoholic fatty liver disease (NAFLD). This study explores how NDEA disrupts liver lipid metabolism. Sprague-Dawley rats were given two doses of NDEA (100 mg/kg) orally, 24 h apart. Liver response was assessed through tissue staining, blood tests, and biochemical markers, including fatty acids, lipid peroxidation, and serum very-low density lipoprotein (VLDL) levels. Additionally, lipidomic analysis of liver tissues and serum was performed. The results indicated significant hepatic steatosis (fat accumulation in the liver) following NDEA exposure. Blood analysis showed signs of inflammation and liver damage. Biochemical tests revealed decreased liver protein synthesis and specific enzyme alterations, suggesting liver cell injury but maintaining mitochondrial function. Increased fatty acid levels without a rise in lipid peroxidation were observed, indicating fat accumulation. Lipidomic analysis showed increased polyunsaturated triglycerides in the liver and decreased serum VLDL, implicating impaired VLDL transport in liver dysfunction. In conclusion, NDEA exposure disrupts liver lipid metabolism, primarily through the accumulation of polyunsaturated triglycerides and impaired fat transport. These findings provide insight into the mechanisms of NDEA-induced liver injury and its progression to hepatic steatosis.

Study on characteristic and mechanism involved in the formation of N-nitrosodimethylamine precursors during microbial metabolism of amino acids

Amino acid metabolism by microorganisms is a new but important pathway for the formation of NDMA precursors in water. We investigated the properties of nitrosamine precursors produced through microbial metabolism of amino acids by polarity rapid assessment method and molecular weight fractionation by ultrafiltration method. The PRAM results showed that the positively charged fraction and the non-polar fraction accounted for most (45 %-79 % and 6 %-82 %, respectively) of the NDMA precursors. The MW fractionation results also indicate the dominant precursors had MWs <1 kDa or over 10 kDa. NDMA precursors produced through amino acid metabolism were identified and quantified. Dimethylamine, N-methyl-alanine and alanine methyl ester were produced during the metabolism of alanine and peptone. Together, N-methyl-alanine and dimethylamine averagely contributed 24 % (12 %-44 %) of the NDMA precursors in the alanine medium. The NDMA precursor formation pathway during alanine metabolism involves the methylation of alanine to form N-methyl-alanine and the decomposition of alanine anabolism products to form dimethylamine. Nitrosamine precursors are generally formed through anabolism or methylation, but biogenic amines or NH₃ can be produced through catabolism before nitrosamine precursor synthesis. Microbial community analysis was performed and Ralstonia was found to be a likely key genus contributing to NDMA precursor formation during alanine metabolism.

Influencing pathways and toxicity changes of pre-ozonation on carcinogenic NDEA formation from greenhouse gas adsorbent DEAPA in subsequent disinfection processes

This study was to evaluate the feasibility of controlling carcinogenic nitrosodiethylamine (NDEA) formation from greenhouse gas adsorbent 3-diethylaminopropylamine (DEAPA) by pre-O₃ in subsequent chlorination/chloramination processes. The result indicated that the NDEA yields (0.4 %) during chlorination was 1.3 times of that during chloramination (0.3 %); pre-oxidation with 4 mg/L O₃ significantly cut down its formation; the reduction rates were up to 67.5 and 48.5 %, respectively. OH scavenger greatly augmented the final NDEA amount from 1.86 to 5.05 μg/L during ozonation, while its roles on subsequent processes differed with disinfection methods as well as O₃(g) dosages. Most of co-existed substances inhibited NDEA generation, except NO₂^-, CO₃^2- and SO₄^2-, which slightly promoted during ozonation. Basing on Gaussian calculation, GC/MS and UPLC-Q-TOF-MS analysis, the influencing mechanisms of pre-O₃ on NDEA formation in subsequent disinfection processes were proposed. In addition, the calculated toxicity analysis as well as the whole toxicity was applied to evaluate the possibility of pre-O₃ on risk control.

The Minus Approach Can Redefine the Standard of Practice of Drinking Water Treatment

Chlorine-based disinfection for drinking water treatment (DWT) was one of the 20th century's great public health achievements, as it substantially reduced the risk of acute microbial waterborne disease. However, today's chlorinated drinking water is not unambiguously safe; trace levels of regulated and unregulated disinfection byproducts (DBPs), and other known, unknown, and emerging contaminants (KUECs), present chronic risks that make them essential removal targets. Because conventional chemical-based DWT processes do little to remove DBPs or KUECs, alternative approaches are needed to minimize risks by removing DBP precursors and KUECs that are ubiquitous in water supplies. We present the "Minus Approach" as a toolbox of practices and technologies to mitigate KUECs and DBPs without compromising microbiological safety. The Minus Approach reduces problem-causing chemical addition treatment (i.e., the conventional "Plus Approach") by producing biologically stable water containing pathogens at levels having negligible human health risk and substantially lower concentrations of KUECs and DBPs. Aside from ozonation, the Minus Approach avoids primary chemical-based coagulants, disinfectants, and advanced oxidation processes. The Minus Approach focuses on bank filtration, biofiltration, adsorption, and membranes to biologically and physically remove DBP precursors, KUECs, and pathogens; consequently, water purveyors can use ultraviolet light at key locations in conjunction with smaller dosages of secondary chemical disinfectants to minimize microbial regrowth in distribution systems. We describe how the Minus Approach contrasts with the conventional Plus Approach, integrates with artificial intelligence, and can ultimately improve the sustainability performance of water treatment. Finally, we consider barriers to adoption of the Minus Approach.

Seasonal variability, predictive modeling and health risks of N-nitrosamines in drinking water of Shanghai

The prevalence of carcinogenic N-nitrosamines in drinking water is of significant concern. In the present study, eight N-nitrosamines from three representative drinking water treatment plants (DWTPs) in Shanghai, China were monitored for an entire year to evaluate their seasonal variability, probabilistic cancer risk and the resulting disease burden. The possibility of employing routinely monitored water quality parameters as predictors of N-nitrosamines was also examined. The results showed that the Taipu River-fed reservoir suffered more serious N-nitrosamine contamination than the Yangtze River-fed reservoirs. Winter witnessed higher levels of N-nitrosamines in both source and finished water. N-nitrosamine concentrations increased from source water to finished water in autumn or winter, but no spatial variations were observed in summer. The total lifetime cancer risk (LCR) posed by N-nitrosamines in finished water was within the acceptable range (1.00 × 10^-6 to 1.00 × 10^-4), with N-nitrosodimethylamine (NDMA) and N-nitrosodiethylamine (NDEA) being the main contributors. Winter and autumn were found to have higher total LCR values. The average individual disability-adjusted life years (DALYs) lost was 4.43 × 10^-6 per person-year (ppy), exceeding the reference risk level (1.00 × 10^-6 ppy). Liver cancer accounted for 97.1 % of the total disease burden, while bladder and esophagus cancers made a little contribution (2.9 %). A multiple regression model was developed to estimate the total N-nitrosamines in finished water as a function of water quality parameters, and the R² value was 0.735. This study not only provides fundamental data for public health policy development, but also reveals the necessity to incorporate a seasonal control strategy in DWTPs to minimize the associated health risks induced by N-nitrosamines.

Simultaneous Determination for Nine Kinds of N-Nitrosamines Compounds in Groundwater by Ultra-High-Performance Liquid Chromatography Coupled with Triple Quadrupole Mass Spectrometry

The ability to effectively detect N-nitrosamine compounds by liquid chromatography-tandem mass spectrometry presents a challenge due to the problems of high detection limits and difficulty in simultaneous N-nitrosamine compound detection. In order to overcome these limitations, this study reduced the detection limit of N-nitrosamine compounds by applying n-hexane pre-treatment to remove non-polar impurities before the conventional process of column extraction. In addition, ammonium acetate was used as the mobile phase to enhance the retention of nitrosamine target substances on the chromatographic column, with formic acid added to the mobile phase to improve the ionization level of N-nitrosodiphenylamine, to achieve the simultaneous detection of multiple N-nitrosamine compounds. Applying these modifications to the established detection method allowed the rapid and accurate detection of N-nitrosamine in water within 12 min. The linear relationship, detection limit, quantification limit and sample spiked recovery rate of nine types of nitrosamine compound were investigated, showing that the correlation coefficient ranged from 0.9985-0.9999, while the detection limits of the instrument and the method were 0.280-0.928 µg·L^-1 and 1.12-3.71 ng·L^-1, respectively. The spiked sample recovery rate ranged from 64.2-83.0%, with a standard deviation of 2.07-8.52%, meeting the requirements for trace analysis. The method was applied to the detection of N-nitrosamine compounds in nine groundwater samples in Wuhan, China, and showed that the concentrations of N-nitrosodimethylamine and NDEA were relatively high, highlighting the need to monitor water bodies with very low levels of pollutants and identify those requiring treatment.

Lipid metabolism disorders contribute to hepatotoxicity of ICR mice induced by nitrosamines exposure

Health risks caused by crucial environmental carcinogens N-nitrosamines triggered ubiquitous attention. As the liver exerted vital function through metabolic process, lipid metabolism disorders have been confirmed as potential drivers for toxicological effects, and the mechanisms of lipid regulation related to hepatotoxicity induced by N-nitrosamines remained largely unclear. In this study, we comprehensively explored the disturbance of hepatic lipid homeostasis in mice induced by nitrosamines. The results implied that nitrosamines exposure induced hepatotoxicity accompanied by liver injury, inflammatory infiltration, and hepatic edema. Lipidomics profiling analysis indicated the decreased levels of phosphatidic acids (PA), phosphatidylcholines (PC), phosphatidylethanolamines (PE), lyso-phosphatidylcholines (LPC), lyso-phosphatidylethanolamines (LPE), diacylglycerols (DAG) and triacylglycerols (TAG), the elevation of ceramides (Cer) and decomposition of free fatty acids (FFA) in high-dose nitrosamines exposure group. Importantly, nitrosamines exposure promoted fatty acid oxidation (FAO) by facilitating fatty acid uptake and decomposition, together with the upregulation of genes associated with FAO accompanied by the activation of inflammatory cytokines TNF-α, IL-1β and NLRP3. Furthermore, fatty acid translocase CD36-mediated fatty acid oxidation was correlated with the enhancement of oxidative stress in the liver caused by nitrosamines exposure. Overall, our results contributed to the new strategies to interpret the early toxic effects of nitrosamines exposure.

A balancing act: Optimizing free chlorine contact time to minimize iodo-DBPs, NDMA, and regulated DBPs in chloraminated drinking water

Many drinking water treatment plants in the U.S. have switched from chlorination to chloramination to lower levels of regulated trihalomethane (THM) and haloacetic acid (HAA) disinfection byproducts (DBPs) in drinking water and meet the current regulations. However, chloramination can also produce other highly toxic/carcinogenic, unregulated DBPs: iodo-acids, iodo-THMs, and N-nitrosodimethylamine (NDMA). In practice, chloramines are generated by the addition of chlorine with ammonia, and plants use varying amounts of free chlorine contact time prior to ammonia addition to effectively kill pathogens and meet DBP regulations. However, iodo-DBPs and nitrosamines are generally not considered in this balancing of free chlorine contact time. The goal of our work was to determine whether an optimal free chlorine contact time could be established in which iodo-DBPs and NDMA could be minimized, while keeping regulated THMs and HAAs below their regulatory limits. The effect of free chlorine contact time was evaluated for the formation of six iodo-trihalomethanes (iodo-THMs), six iodo-acids, and NDMA during the chloramination of drinking water. Ten different free chlorine contact times were examined for two source waters with different dissolved organic carbon (DOC) and bromide/iodide. For the low DOC water at pH 7 and 8, an optimized free chlorine contact time of up to 1 h could control regulated THMs and HAAs, as well as iodo-DBPs and NDMA. For the high DOC water, a free chlorine contact time of 5 min could control iodo-DBPs and NDMA at both pHs, but the regulated DBPs could exceed the regulations at pH 7.

Dysregulation of fatty acid metabolism associated with esophageal inflammation of ICR mice induced by nitrosamines exposure

Nitrosamines, as ubiquitous environmental carcinogens with adverse impact on human health, were crucial inducers of esophageal cancer (EC). Esophageal inflammation (EI) was an important biological process and considered to be associated with the progression of EC. However, the underlying regulatory mechanism of EI process caused by nitrosamines exposure remained largely unclear. In this study, a metabolomics approach based on mass spectrometry was utilized to explore the effect of nitrosamines exposure to ICR mice. Also, the changes of pivotal metabolic enzyme levels, urinary nitrosamines and histopathological analysis were evaluated. The results showed that nitrosamines exposure was intimately interrelated with EI process in mice. Metabolomics profiling analysis indicated that nitrosamines caused significant alterations of metabolic pathway predominantly enriched in fatty acid metabolism. Targeted metabolomics analysis revealed that nitrosamines promoted decomposition of fatty acids and facilitated fatty acid β-oxidation (FAO) of mice. The significant increase of carnitine palmitoyltransferase 1 (CPT1) and downregulation of acetyl-CoA acyltransferase 2 (ACAA2) would promote FAO in EI process induced by nitrosamines. Additionally, the exposure levels of more than half of nitrosamines in urine were correlated with inflammatory fatty acid biomarkers. Overall, this study found that EI triggered by nitrosamines may be associated with the promotion of FAO, and provided novel insights for evaluating the underlying mechanism of environmental pollutant-caused toxicity based on metabolomics.

Metabolomics-based molecular signatures reveal the toxic effect of co-exposure to nitrosamines in drinking water

Nitrosamines, a group of emerging nitrogenous pollutants, are ubiquitously found in the drinking water system. However, less is known about how systemic biological responses resist or tolerate nitrosamines, especially long-term co-exposure at low concentrations. In this study, untargeted metabolomics was used to investigate the metabolic perturbations in human esophageal epithelial Het-1A cells induced by a mixture of nine common nitrosamines in drinking water at environmentally relevant, human-internal-exposure, and genotoxic concentrations. Generally, the disrupted metabolic spectrum became complicated with nitrosamines dose increasing. Notably, two inflammation-associated pathways, namely, cysteine (Cys) and methionine (MET) metabolism, and nicotinate and nicotinamide metabolism, changed significantly under the action of nitrosamines, even at the environmentally relevant level. Furthermore, targeted metabolomics and molecular biology indicators in cells were identified in mice synchronously. For one thing, the up-regulated Cys and MET metabolism provided methyl donors for histone methylation in the context of pro-inflammatory response. For another, the down-regulated NAD⁺/NADH ratio inhibited the deacetylation of NF-кB p65 and eventually activated the NF-кB signaling pathway. Taken collectively, the metabolomics molecular signatures were important indicative markers for nitrosamines-induced inflammation. The potential crosstalk between the inflammatory cascade and metabolic regulation also requires further studies. These findings suggest that more attention should be paid to long-term co-exposure at low concentrations in the control of nitrosamines pollution in drinking water. Additionally, this study also highlights a good prospect of the combined metabolomic-molecular biology approach in environmental toxicology.

NDMA reduction mechanism of UDMH by O3/PMS technology

Carcinogenic N, N-Dimethylnitrosamine (NDMA) has been reported to generate significantly during ozonation of fuel additive unsymmetrical dimethylhydrazine (UDMH), the combined ozone/Peroxy-Monosulfate (O₃/PMS) technology was tried for reducing its formation in this study. The influence of PMS dosages, ozone concentrations, pH, Br^- and humic acid (HA) on NDMA formation from UDMH were investigated. In addition, the reduction mechanisms were explored by intermediates identification and Gaussian calculation. The results demonstrated that O₃/PMS technology was effective on NDMA reduction, reaching an efficiency of 81% with 80 μM PMS. Higher NDMA reduction rates were achieved by O₃/PMS with increasing pH within the scope of research (from 5 to 9), achieving a maximum of 69.9% at pH 9. The presence of bromide ion facilitated NDMA generation during ozonation, but the reduction efficiency by O₃/PMS slightly improved from 66.3% to 70.6%. The presence of HA reduced NDMA formation in O₃/PMS system. The contribution of SO₄^•- on NDMA reduction accounted for ~64%, which was higher than that of •OH (41.4%); however, its promotion role on conversing UDMH to NDMA was lower than O₃. Therefore, the technology could reduce NDMA formation effectively. In addition, the results of Gaussian calculation manifested that the N atom in -NH₂ group of UDMH was easily attacked not only by •OH but also by O₃, so it is the key path that determines final NDMA formation. This study would provide reference for reducing NDMA formation during ozonation of UDMH-containing water matrixes.

Long-term monitoring and risk assessment of N-nitrosamines in the finished water of drinking water treatment plants in South Korea

Approximately 99.1% of South Koreans have access to drinkable tap water from river basins. Due to such a high access rate, the South Korean government has been running, since 2013, a long-term program for monitoring the quality of tap water for drinking. Under this program, the maximum allowed concentrations of N-nitroso-di-n-methylamine (NDMA) and N-nitrosomethylethylamine (NMEA) are defined and applied. In this study, the data from this monitoring program were used to investigate the changes in six N-nitrosamine substances in the finished water of 33 drinking water treatment plants (DWTPs) in South Korea from 2013 to 2020, based on time and location. The effect of the applied water treatment steps on the appearance of N-nitrosamines was analyzed. The excess cancer risk (ECR) due to the oral intake of these substances was assessed. The results before the maximum allowed concentrations of NDMA and NMEA were defined showed that the oral intake ECR of these substances exceeded the carcinogenesis risk of one per one million people per year. After the maximum allowed concentrations of the substances were applied, the concentrations of the substances in the finished water of the DWTPs significantly dropped. The drinking water treated through sand filtration, and then with granular activated carbon, showed the highest efficiency in preventing the appearance of NDMA. Considering the potency of N-nitrosamines in tap water for drinking, the levels of these substances in the finished water of DWTPs in South Korea should be continuously monitored.

Formation of nitrosamines during chloramination of two algae species in source water-Microcystis aeruginosa and Cyclotella meneghiniana

The contribution of two algae species, Microcystis aeruginosa (M. aeruginosa) and Cyclotella meneghiniana (C. meneghiniana), to the formation of nitrosamines (NAs) during chloramination in drinking water treatment was investigated. A variety of factors including contact time, algae cell concentration, chloramine dosages, and algal cell components (cell debris (CD), intracellular organic matter (IOM), and extracellular organic matter (EOM)) were evaluated for influencing the formation of different NAs, such as N-Nitrosodiethylamine (NDMA), N-Nitrosomethylethylamine (NMEA), N-Nitrosodibutylamine (NDBA), N-Nitrosodi-n-propylamine (NDPA), and N-nitrosopyridine (NPyr). In addition, NAs formation from Chlorophyll-a and Microcystin-LR (MC-LR) after chloramination was studied. These results showed that the increase of reaction time and algae cell concentration enhanced the formation potential of five types of NAs from both algae species, except for the NDMA formation from C. meneghiniana, which increased first and then decreased with increased reaction time. The generation of NDMA was detected as the dominated type of NAs. The formation of total NAs from both algae species followed same pattern of increasing first and then decreasing with the increase of chloramine dosage. The largest NAs formation potential (NAsFP) of M. aeruginosa and C. meneghiniana showed at 1.5 mM and 1.0 mM monochloramine, respectively. Moreover, the impacts of algae cellular components on the formation potential of NAs followed the order of IOM > EOM ≫ CD and IOM ≫ CD > EOM for M. aeruginosa and C. meneghiniana, respectively, indicating that IOM was the main source of NAs precursors for both algae. Furthermore, EEM analysis before and after chloramination confirmed that the soluble microbial products (SMPs) and protein-like substances were the main cellular components that contributed to NAs formation for both algae. The NAs formation potential of Microcystin-LR was much higher than that of Chlorophyll-a chloramination.

Comparison of EI-GC-MS/MS, APCI-LC-MS/MS, and ESI-LC-MS/MS for the Simultaneous Analysis of Nine Nitrosamines Eluted from Synthetic Resins into Artificial Saliva and Health Risk Assessment

Nitrosamines can be produced during the manufacture of rubber-type products such as pacifiers or the nipples of baby bottles. Humans can be exposed to the nitrosamines in these products when they are eluted into saliva. In this study, we compared the efficiency of electron impact ionization (EI), atmospheric pressure chemical ionization (APCI), and electrospray ionization (ESI) methods for the analysis of nine nitrosamines eluted into artificial saliva. In addition, nine nitrosamines eluted from 54 rubber-type products (rubber, thermoplastic elastomer, thermoplastic polyurethane, and polyurethane) marketed in Korea were monitored. Finally, non-carcinogenic and carcinogenic risk assessments of oral exposure to nine nitrosamines were performed based on the monitoring results. EI-GC-MS/MS performed the best for the simultaneous analysis of these nine nitrosamines with respect to overall linearity, trace analysis limit of detection (less than 1 μg), recovery (average 108.66 ± 9.32%), and precision (less than 6%), compared with liquid chromatography-tandem mass spectrometry (LC-MS/MS) (APCI and ESI) methods. Using the EI-GC-MS/MS method, these nine nitrosamines eluted into artificial saliva from 54 rubber-type products were monitored. Based on the monitoring data, risk assessment was performed by calculating the margin of exposure (MOE) for the respective nitrosamines detected. As a result, these nitrosamines were confirmed to be safe with regard to both non-carcinogenic and carcinogenic risks.

Occurrence and fate of N-nitrosamines in three full-scale drinking water treatment systems with different treatment trains

The occurrence of mutagenic and carcinogenic N-nitrosamines in drinking water is of great concern. In this study, dynamics and removal of nine N-nitrosamines in three drinking water treatment systems of a southern city of China are monitored during one year of sampling. The impacts of physicochemical treatment units on the removal and generation of N-nitrosamines were evaluated. The O₃ and KMnO₄ based pre-oxidation units have caused an increase in N-nitrosamines concentration, with O₃ showing the substantial generation of N-nitrosamines. The carbon filter and ultrafiltration membrane units were found effective in removing N-nitrosamine precursors. These drinking water treatment systems have been useful in removing N-nitrosamine precursors; meanwhile, a slight decrease was found in already formed N-nitrosamines concentration. However, N-nitrosomorpholine (NMOR) and N-nitrosodiphenylamine (NDPhA) were found resistant toward all kinds of physicochemical treatments, and negligible changes in concentration were noted in all drinking water treatment systems. The distribution networks in the city provided an effective contact period to residual chlorine and precursors, which caused an increase in N-nitrosamines concentration. Overall, N-nitrosodimethylamine (NDMA) and N-nitroso-diethylamine (NDEA) have been found near the cancer risk threshold (10^-6) in all of the drinking water treatment systems, while the remaining seven N-nitrosamines were found below the risk level.

Quantitative analysis of source and fate of N-nitrosamines and their precursors in an urban water system in East China

The source and fate of N-nitrosamines and their precursors in terms of formation potential (FP) was investigated quantitatively in the city level for the first time. Different sources of nitrosamines and their precursors were investigated in one city in the Yangtze River delta, China. The source water located downstream of the city contained 8.4 ng/L of N-nitrosodimethyamine (NDMA) and 153 ng/L of NDMA FP. The contribution of each discharge source was evaluated based on the concentration, the river water flux, and the amount of wastewater discharges. Textile printing and dyeing wastewater, and electroplating industrial wastewater contained high concentration of nitrosamines and were important discharge sources. Taking NDMA and NDMA FP attenuation by photolysis and biodegradation into consideration, the mass load calculation showed upstream surface water brought about 13 ± 4% of NDMA and 21 ± 3% of NDMA FP to downstream source water. Local wastewater discharges contributed 30 ± 8% of NDMA and 17 ± 2% of NDMA FP to downstream source water. Endogenous formation via amino acids metabolism could contribute 36% of NDMA FP (maximum) to downstream source water. Overall, this study provides a protocol for quantitative evaluation of the nitrosamine contribution to urban water supply from different contamination sources.

Determining the leading sources of N-nitrosamines and dissolved organic matter in four reservoirs in Southern China

The presence of carcinogenic N-nitrosamines and dissolved organic matter (DOM) in freshwater is a significant concern from the perspective of public health and drinking water treatment plant operation. This study investigated the N-nitrosamines concentration and their precursors' distributions, and DOM composition in four reservoirs located in a southern city of China. A total of 22 renowned precursors were identified. Precursors from industrial and pharmaceutical origins were found to be dominant in all reservoirs; however, traces of pesticide-based precursors, i.e. pirimicarb and cycluron were also found. The distribution of nine N-nitrosamines was substantially different among the reservoirs. N-Nitrosodibutylamine (NDBA), N-Nitrosopiperidine (NPIP), N-Nitrosodimethylamine (NDMA), and N-Nitrosopyrrolidine (NPYR) were abundantly present in all reservoirs. Most of N-nitrosamines except NDMA and N-nitrosodiethylamine (NDEA) were far below the generally accepted cancer risk of 10^-6, and NDMA/NDEA were found close to the risk level (10^-6). Anthropogenic DOM was dominant in three reservoirs as depicted by a higher biological index (BIX) than the humification index (HIX). By the principle component analysis, BIX appeared as an indicator of N-nitrosamines (except NDEA and NPIP). A strong and direct relationship was observed between the NDMA-formation potential (FP) and concentration of total N-nitrosamines (∑NA), and BIX. These results confirmed that the anthropogenic activities were the leading source of DOM and N-nitrosamines in this city based on land-use.

Occurrence of N-nitrosamines and their precursors in the middle and lower reaches of Yangtze River water

The presence of some types of N-nitrosamines in water bodies is of great concern worldwide due to their carcinogenic risks and harmful mutagenic effects on human health. In the present study, eight N-nitrosamines and their formation potentials (FPs) were primarily investigated in Yangtze River surface water to evaluate their spatial distribution, mass loads, and ecological risks. The results showed that of the eight N-nitrosamines investigated, NDMA (<1.5-17 ng/L), NDEA (<1.4-9.5 ng/L), NDPA (1.0 ng/L), NMOR (<1.0-1.3 ng/L), NPIP (<2.1-3.7 ng/L), and NDBA (<3.6-30 ng/L) were detected. The FPs of NDMA (<27-130 ng/L), NDEA (<0.9-2.3 ng/L), NDPA (<1.2-1.9 ng/L), NPYR (<1.4-2.9 ng/L), NMOR (<1.0 ng/L), and NDBA (<1.1-14 ng/L) were significantly identified. NDBA was predominantly observed in surface water, while NDMA was noticeably detected in chloraminated water samples. It was estimated that approximately 5.4 t/y of N-nitrosamines were carried by the Yangtze River to the East China Sea, whereas the input flux of N-nitrosamine precursors was estimated to be approximately 69.5 t/y. Spatial variations were observed due to the input of N-nitrosamines from the upstream dams and lakes. The origin of N-nitrosamine precursors was not associated with the presence of sediment in river water. NDEA could be introduced into river water by the discharge of wastewater. NDBA and its precursors could originate from industrial and aquaculture activities. NDMA and its precursors could result from both of the aforementioned sources. Moreover, the wastewater discharge from small cities, pH value, wastewater treatment ratio, and dilution could be the key factors that influence the occurrence of N-nitrosamines along the Yangtze River. More attention should be paid to the cancer risks posed by N-nitrosamines. The ecological risks posed by N-nitrosamines in the Yangtze River can be ignored.

Carcinogenesis: Failure of resolution of inflammation?

Inflammation in the tumor microenvironment is a hallmark of cancer and is recognized as a key characteristic of carcinogens. However, the failure of resolution of inflammation in cancer is only recently being understood. Products of arachidonic acid and related fatty acid metabolism called eicosanoids, including prostaglandins, leukotrienes, lipoxins, and epoxyeicosanoids, critically regulate inflammation, as well as its resolution. The resolution of inflammation is now appreciated to be an active biochemical process regulated by endogenous specialized pro-resolving lipid autacoid mediators which combat infections and stimulate tissue repair/regeneration. Environmental and chemical human carcinogens, including aflatoxins, asbestos, nitrosamines, alcohol, and tobacco, induce tumor-promoting inflammation and can disrupt the resolution of inflammation contributing to a devastating global cancer burden. While mechanisms of carcinogenesis have focused on genotoxic activity to induce mutations, nongenotoxic mechanisms such as inflammation and oxidative stress promote genotoxicity, proliferation, and mutations. Moreover, carcinogens initiate oxidative stress to synergize with inflammation and DNA damage to fuel a vicious feedback loop of cell death, tissue damage, and carcinogenesis. In contrast, stimulation of resolution of inflammation may prevent carcinogenesis by clearance of cellular debris via macrophage phagocytosis and inhibition of an eicosanoid/cytokine storm of pro-inflammatory mediators. Controlling the host inflammatory response and its resolution in carcinogen-induced cancers will be critical to reducing carcinogen-induced morbidity and mortality. Here we review the recent evidence that stimulation of resolution of inflammation, including pro-resolution lipid mediators and soluble epoxide hydrolase inhibitors, may be a new chemopreventive approach to prevent carcinogen-induced cancer that should be evaluated in humans.

Phenylurea herbicide degradation and N-nitrosodimethylamine formation under various oxidation conditions: Relationships and transformation pathways

Four phenylurea herbicides (PUHs) were assessed for degradation and transformation into N-nitrosodimethylamine (NDMA) under three oxidation conditions (chlorine (Cl₂), chlorine dioxide (ClO₂), and ozone (O₃)) from an aqueous solution. Removal ratios correlated with the numbers of halogen elements contained in PUHs (isoproturon ₍₀₎ > chlorotoluron _{(1 Cl)} > diuron _{(2 Cl)} > fluometuron _(3 F)), and the degradation efficiencies of oxidants from fastest to slowest were: O₃, ClO₂, and Cl₂. NDMA can be generated directly from the ozonation of PUHs. Further, compared with chloramination alone, ozonation prominently promoted NDMA formation potential (NDMA-FP) during post-chloramination, and NDMA-FPs increased approximately 23-68 times than those during ozonation only at 2.5 mg/L O₃ over 10 min; molar yields of NDMA from highest to lowest were 11.1% (isoproturon), 1.17% (chlorotoluron), 1.0% (diuron), and 0.73% (fluometuron). The PUH degradation kinetics data during ozonation agreed with the pseudo-first-order model. The rate constant k_obs were 0.31 × 10^-3-19.8 × 10^-3 s^-1. The k_obs and removal ratios of PUHs during ozonation partially scaled with the mass, LogK_ow, and Henry's constants of PUHs. Comparisons of measured NDMA-FPs with calculated NDMA-FPs from residual PUH after oxidation showed that the intermediates produced during ozonation facilitated NDMA-FPs; this contribution was also observed for chlorotoluron and isoproturon during ClO₂ oxidation. Examination of reaction mechanisms revealed that tertiary amine ozonation, N-dealkylation, hydroxylation, the cleavage of N-C bonds, ammonification, and nitrification occurred during the ozonation of PUHs, and the dimethylamine (DMA) functional groups could be decomposed directly and transformed into NDMA via the formation of the intermediate unsymmetrical dimethylhydrazine. NDMA is also formed from the reaction between DMA and phenylamino-compounds. Clarifying primary degradation products of PUHs and transformation pathways of NDMA during oxidation processes is useful to optimize treatment processes for water supplies.

Challenges for Safe and Healthy Drinking Water in China

PURPOSE OF REVIEW

Rapid economic growth and its huge population are putting tremendous pressure on water sustainability in China. Ensuring clean drinking water is a great challenge for public health due to water shortage and pollution. This article reviews current scientific findings on health-related issues on drinking water and discusses the challenges for safe and healthy drinking water in China.

RECENT FINDINGS

From literature published since 2010, a variety of emerging contaminants were detected in drinking water, including disinfection byproducts (DBPs), pharmaceuticals and personal care products (PPCPs), endocrine-disrupting compounds (EDCs), antibiotic resistance genes, and pathogens. Arsenic and fluoride are still the two major contaminants in groundwater. Microcystins, toxins produced by cyanobacteria, were also frequently detected in surface water for drinking. Health effects of exposure to arsenic, fluoride, nitrates, DBPs, and noroviruses in drinking water have been reported in several epidemiological studies. According to literature, water scarcity is still a severe ongoing issue, and regional disparity affects the access to safe and healthy drinking water. In addition, urbanization and climate change have strong influences on drinking water quality and water quantity. Multiple classes of contaminants of emerging concern have been detected in drinking water, while epidemiological studies on their health effects are still inadequate. Water scarcity, regional disparity, urbanization, and climate change are the major challenges for safe and healthy drinking water in China.

Precursors of typical nitrogenous disinfection byproducts: Characteristics, removal, and toxicity formation potential

The emergence of nitrogenous disinfection byproducts (N-DBPs) in drinking water has become a widespread concern. In this study, dichloroacetonitrile (DCAN), dicholoacetamide (DCAcAm) and trichloronitromethane (TCNM) were chosen as representatives to clarify the characteristics of N-DBP precursors in the raw waters of Taihu Lake, the Yangtze River, and Gaoyou Lake. Removal of DCAN and DCAcAm precursors must focus on nonpolar and positively charged organics, but more attention should be paid to micromolecular, polar and non-positively charged organics as TCNM precursors. Compared to molecular weight (MW) and hydrophilicity fractionation, polarity and electrical classification have higher selectivity to intercept N-DBP precursors. The properties of N-DBP precursors are relatively fixed and traceable in water systems, which could contribute to their targeted removal. Based on investigation of their characteristics, the removal efficiency and preferences of organic precursors under different processes were studied in three drinking water treatment plants (DWTPs). The TCNM precursors produced in preozonation can be effectively removed during coagulation. The cumulative removal efficiency of conventional processes on N-DBP precursors was approximately 20-30%, but O₃/BAC process improved removal by about 40%. The key to improving the removal efficiency of N-DBP precursors by O₃/BAC is that it can significantly remove low-MW, nonpolar, positively charged, hydrophilic and transphilic organics. In combined toxicity trials, both cytotoxicity and genotoxicity showed a synergistic effect when DCAN, DCAcAm, and TCNM coexisted, which means that low-level toxicity enhancement in the actual water merits attention. DCAN precursors dominated in the toxicity formation potential (TFP), followed by TCNM precursors. In addition, the removal rate of total N-DBP precursors may be higher than that of TFP, leading to overly optimistic evaluation of precursor removal in water treatment practice. Therefore, the removal effect on TFP must also be considered.

Spatial, temporal variability and carcinogenic health risk assessment of nitrosamines in a drinking water system in China

Nitrosamines, as a class of emerging frequently detected nitrogenous disinfection byproducts (N-DBPs) in drinking water, have gained increasing attention due to their potentially high health risk. Few studies focus on the occurrence variation and carcinogenic health risk of nitrosamines in drinking water systems. Our study aimed to investigate the spatial and temporal variability of nitrosamines in a drinking water system and to conduct a carcinogenic health risk assessment. Three types of water samples, including influent water, treated water and tap water, were collected monthly during an entire year in a drinking water system utilizing a combination of chlorine dioxide and chlorine in central China, and 9 nitrosamines were measured. The nitrosamine formation potentials (FPs) in influent water were also determined. N-nitrosodimethylamine (NDMA) was the most prevalent compound and was dominant in the water samples with average concentrations ranging from 2.5 to 67.4 ng/L, followed by N-nitrosodiethylamine (NDEA) and N-nitrosopiperidine (NPIP). Nitrosamine occurrence varied monthly, and significant seasonal differences were observed in tap water (p < .05). There were decreasing mean NDMA, NDEA and NPIP concentrations from influent water to treated water to tap water, but no significant spatial variability was observed within the water distribution system (p > .05). The average and 95th percentile total lifetime cancer risks for the three main nitrosamines were 4.83 × 10^-5 and 4.48 × 10^-4, respectively, exceeding the negligible risk level (10^-6) proposed by the USEPA. Exposure to nitrosamines in drinking water posed a higher cancer risk for children than for adults, and children aged 0.75 to 1 years suffered the highest cancer risk. These results suggest that nitrosamine occurrence in tap water varied temporally but not spatially. Exposure to drinking water nitrosamines may pose a carcinogenic risk to human health, especially to children.

Seasonal occurrence of N-nitrosamines and their association with dissolved organic matter in full-scale drinking water systems: Determination by LC-MS and EEM-PARAFAC

N-nitrosamines have been identified as emerging contaminants with tremendous carcinogenic potential for human beings. This study examined the seasonal changes in the occurrence of N-nitrosamines and N-nitrosodimethylamine formation potential (NDMA-FP) in drinking water resources and potable water from 10 drinking water treatment plants in a southern city of China. The changes in N-nitrosamines are well correlated with dissolved organic matter (DOM), particularly fluorophores, which were measured and compared between traditional fluorescence indices and excitation-emission matrix coupled with parallel factor analysis (EEM-PARAFAC). Four of N-nitrosamine species including N-nitrosodimethylamine (NDMA), N-Nitrosodibutylamine (NDBA), N-Nitrosopyrrolidine (NPYR), and N-Nitrosodiphenylamine (NDPhA) are found to be abundant compounds with an average of 29.5% (26.7%), 20.0% (25.2%), 18.9% (16.0%), and 9.0% (9.9%) in the source (and treated) water, respectively. The sum of N-nitrosamines concentration is recorded to be low in the wet season (July-September), whereas the dry season (October-December) provided opposite impacts. EEM-PARAFAC modeling indicated the predominance of humic-like component (C1) in the wet season while in the dry season the water was dominant in protein-like component (C2). All the N-nitrosamines excluding NDPhA and N-Nitrosomorpholine (NMOR) showed a strong association with protein-like component (C2). In contrast, humic-like C1, which was directly influenced by rainfall, was found to be a suitable proxy for NMOR and NDPhA. The results of this study are valuable to understand the correlation between different N-nitrosamines and DOM through adopting fluorescence signatures.

Application of chromatographic techniques in the analysis of total nitrosamines in water

The use of ozone, chloramine and chlorine dioxide for water treatment results in the formation N-nitrosamines in the treated water. These groups of chemicals and other nitrogen-containing compounds have been described as disinfection by-products (DBPs) which are known for their toxicity. Nitrosamines are a potential source of nitric oxide (NO) which can bind with metals present in the sample matrix leading to formation of metal - nitrosyl complexes and dissolved metals have the potential to increase the total nitrosamines in water. This phenomenon has not received the desired attention and determination of metal-nitrosyl complexes lack standard analytical technique. Chromatography linked to various detectors is the commonest of the techniques for nitrosamine analysis but it is beset with reduced sensitivity as a result of inappropriate choice of the column. Incidentally, chromatographic techniques have not been really adapted for the analysis of metal-nitrosyl complexes. Therefore, there is need for the survey of existing techniques vis-à-vis metal-nitrosamine analysis and to suggest possible areas for method optimization.

Contributions of volatilization, photolysis, and biodegradation to N‑nitrosodimethylamine removal in conventional drinking water treatment plants

N‑nitrosodimethylamine (NDMA) was detected in the source water of some Chinese drinking water treatment plants (DWTPs), which decreased in concentration along the treatment train. Volatilization, photolysis, and/or biodegradation were suspected of being capable of attenuating NDMA. In this study, the contribution of these mechanisms to NDMA removal was investigated by a field study in a conventional DWTP with aerated bio-pretreatment, as well as in laboratory-based experiments. The effluent of each unit process (i.e., aerated bio-pretreatment tank, horizontal sedimentation tank, sand filter) of this DWTP was sampled in the winter and summer, and the concentration of NDMA, its formation potential, and other water quality parameters were measured. NDMA removal by volatilization and biodegradation was simulated in batch experiments, and that by photolysis was calculated with parameters reported in the literature. The sampling results indicated that the aerated biofilm reactor of this DWTP removed 48% of the NDMA in August and 22% in December. According to modeling results, it could be well explained by photolysis (NDMA removal of 51% in summer and 25% in winter) and biotreatment (NDMA removal of 0.2-12% in summer and 0.1-6.1% in winter), with little contribution from aeration (NDMA removal of 0.8%). The sampling results indicated that the sedimentation tank removed 19% of NDMA in August and 9.2% in December. According to modeling results, it could be well explained by photolysis (NDMA removal of 16% in August and 9.4% in December), but little by volatilization. Thus, photolysis was shown to be the most important process for NDMA removal in this DWTP. Further investigation is needed to better understand NDMA removal during biotreatment.

Regional and Seasonal Distributions of N-Nitrosodimethylamine (NDMA) Concentrations in Chlorinated Drinking Water Distribution Systems in Korea

Volatile N-Nitrosamines (NAs), including N-nitrosodimethylamine (NDMA), an emerging contaminant in drinking water, have been reported to induce cancer in animal studies. This study aims to investigate the regional and seasonal distributions of the concentrations of NDMA, one of the most commonly found NAs with high carcinogenicity, in municipal tap water in Korea. NDMA in water samples was quantitatively determined using high-performance liquid chromatography-fluorescence detection (HPLC-FLD) as a 5-dimethylamino-1-naphthalenesulfonyl (dansyl) derivative after optimization to dry the SPE adsorbent and remove dimethylamine prior to derivatization. Tap water samples were collected from 41 sites in Korea, each of which was visited once in summer and once in winter. The average (±standard deviation) NDMA concentration among all the sites was 46.6 (±22.7) ng/L, ranging from <0.13 to 80.7 ng/L. Significant NDMA differences in the regions, excluding the Jeju region, were not found, whereas the average NDMA concentration was statistically higher in winter than in summer. A multiple regression analysis for the entire data set indicated a negative relationship between NDMA concentration and water temperature. High levels of NDMA in Korea may pose excessive cancer risks from the consumption of such drinking water.

Distribution of N-nitrosamines in drinking water and human urinary excretions in high incidence area of esophageal cancer in Huai'an, China

The Huai'an area in Jiangsu Province of East China is an endemic region of esophageal cancer (EC). The regional heterogeneity of EC suggests that the levels of potential carcinogens might vary throughout the environment. It has been suggested that the most likely carcinogens related to EC are a group known as the N-nitrosamines. In this study, we measured the concentrations of nine nitrosamines in drinking water and human urine in two areas in China, one with a high incidence of EC (Huai'an) and one with a low incidence (Nanjing). Among the nine target analytes, N-nitrosodi-n-propylamine (NDPA), N-nitrosodibutylamine (NDBA), N-nitrosopyrrolidine (NPyr), N-nitrosodiethylamine (NDEA) and N-nitrosomorpholine (NMor) occurred at higher concentrations in drinking water in the high incidence area. Inhabitants from the high incidence area also had urinary excretions with significantly higher concentrations of NDEA, NDBA, N-nitrosopiperidine (NPip) and N-nitrosodiphenylamine (NDPhA). These findings indicated that people in the high EC incidence area were exposed to higher levels of nitrosamines. However, the association between the incidence of EC and nitrosamines exposure will need to be evaluated in more detail.

Removal of chlorpheniramine and variations of nitrosamine formation potentials in municipal wastewaters by adsorption onto the GO-Fe3O4

Chlorpheniramine is a pharmaceutical pollutant and a precursor of carcinogenic nitrosamines during disinfection/oxidation. In our previous study, graphene oxide coated with magnetite (GO-Fe₃O₄) was capable of removing chlorpheniramine in deionized water by adsorption. This study investigated the removal of chlorpheniramine and its nitrosamine formation potentials (FPs) by adsorption onto magnetic GO-Fe₃O₄, with respect to the influence by using real municipal wastewaters as the background. In the results, the adsorption performances of chlorpheniramine in wastewaters decreased in the order: GO-Fe₃O₄ suspension > GO-Fe₃O₄ particles > activated carbon. Chlorpheniramine adsorptions on GO-Fe₃O₄ particles and activated carbon were reduced by using real wastewaters as the background, whereas chlorpheniramine adsorption on GO-Fe₃O₄ suspension was enhanced due to the effects of surface charge on GO-Fe₃O₄ and ionic strength variation in water. The fittings of adsorption isotherms indicated that the wastewater background reduced the surface heterogeneity of GO-Fe₃O₄ suspension and improved the adsorption performance. Appreciable removal efficiencies of NDMA and other nitrosamine FPs were observed when GO-Fe₃O₄ particles were added in real wastewaters. However, when chlorpheniramine was present in wastewaters, chlorpheniramine adsorption and degradation reaction simultaneously occurred on the surface of GO-Fe₃O₄, increasing NDMA and other nitrosamine FPs in wastewaters after GO-Fe₃O₄ addition for chlorpheniramine adsorption. The assumption was further demonstrated by observing the NDMA-FP increase during chlorpheniramine adsorption on GO-Fe₃O₄ in deionized water. GO-Fe₃O₄ is a potential adsorbent for chlorpheniramine removal. Nevertheless, the low treatment efficiencies at high doses limit its application for nitrosamine FP adsorptions in real wastewaters.

Occurrence and ecological risk assessment of disinfection byproducts from chlorination of wastewater effluents in East China

Effluents containing disinfection byproducts (DBPs) from wastewater treatment plants (WWTPs) may be discharged to the receiving water bodies or reused for irrigation, landscaping, and environmental supplies as well as a source to replenish groundwater. Thus the formation and risk of the DBPs in disinfected wastewater effluents should be concerned. In this study, the occurrence of 44 DBPs including 6 trihalomethanes (THMs), 9 haloaceticacids (HAAs), 2 haloketones (HKs), 9 halonitromethanes (HNMs), 9 haloacetonitriles (HANs) and 9 nitrosamines (NAs) was investigated in 12 chlorinated WWTP effluents from five cities of East China. The contribution of each class of DBPs to the total DBPs concentration and additive toxicity was calculated. The average concentrations of the 6 classes of DBPs were ranked as follows: HAAs (47.0 μg/L) > THMs (28.0 μg/L) > HANs (9.9 μg/L) > HNMs (2.9 μg/L) > HKs (0.79 μg/L) > NAs (0.69 μg/L). The significant positive correlations were observed between the formation of THMs and HAAs, THMs and HANs, as well as HAAs and HANs. The results showed that HAAs and THMs were the dominant DBPs on a mass concentration basis and accounted for 54% and 29%, respectively in the total measured DBPs, but they made a minor contribution to the calculated DBP-associated cytotoxicity. HANs and NAs dominated the DBP-associated cytotoxicity, accounting for 50% and 34% on an additive toxicity basis despite the minor contributions to the mass concentration with 10% and 1%, respectively. The risk quotients for three taxonomic groups (fish, daphnid, and green algae) were calculated to assess the ecological risk of DBPs, and the results demonstrated that both HAAs and HANs had high ecological risk for green algae in chlorinated wastewater effluents.

Mutagenic Activity of N-Nitrosodiethylamine in Cell Lines Expressing Human CYP2E1-Adequacy of Dimethylsulfoxide as Solvent

Human CYP2E1 metabolizes many xenobiotics of low-molecular weight, thereby activating various promutagens/procarcinogens. In toxicological studies in vitro, dimethylsulfoxide (DMSO) is a common vehicle for organic compounds. However, it was observed to potently inhibit CYP2E1 activity. We were interested in whether it affects CYP2E1-dependent mutagenic responses. In this study, N-nitrosodiethylamine (NDEA), which is soluble in both water and DMSO, was used as a model promutagen. It induced Hprt gene mutations and micronuclei in a Chinese hamster V79-derived cell line expressing both human CYP2E1 and sulfotransferase (SULT) 1A1 (V79-hCYP2E1-hSULT1A1) even at low-micromolar concentrations, but was inactive in parental V79 cells. Mutagenicity of NDEA was also observed in a recombinant V79-hCYP2E1 cell line that expresses human CYP2E1 at a lower level. NDEA induced micronuclei in human L-02 hepatocytes which expressed CYP2E1 even more weakly. DMSO did not modify NDEA-induced gene mutations or micronuclei, up to 0.2% (v:v, the highest noncytotoxic concentration) in V79-hCYP2E1-hSULT1A1 cells. In parental V79-Mz cells, NDEA induced micronuclei with Aroclor 1254-induced rat liver S9 mix, and this effect was unaffected by DMSO up to 0.2%. However, it inhibited the effect of NDEA in L-02 (by 44%) and V79-hCYP2E1 cells (by 70%) at 0.2%, with the effects of NDEA remaining statistically significant. No effect of DMSO was observed on CYP2E1 protein expression in V79-hCYP2E1-hSULT1A1 or its mRNA transcripts in each cell line. We conclude that DMSO may not significantly affect CYP2E1-dependent mutagenic effects, at concentrations up to 0.2% in cells with relatively high CYP2E1 expression. Environ. Mol. Mutagen. 60:214-226, 2019. © 2018 Wiley Periodicals, Inc.

Probabilistic health risk assessment of nitrosamines in drinking water of Shaoxing, Zhejiang, China

Nitrosamines (NAms) are potent genotoxic and carcinogenic but widely detected in drinking water. This study aimed to investigate the occurrence of major types of NAms in drinking water in Shaoxing, China, and to conduct multi-pathway probabilistic cancer risk (CR) assessment to residents based on age-dependent adjustment Chinese exposure factors. Results showed that concentrations of NAms in water varied from not detected (ND) to dozens of nanograms per liter level. N-Nitrosodimethylamine (NDMA) was detected most frequently (93.06%), followed by N-nitrosodiethylamine (NDEA) (64.08%)-with the highest cancer risk among NAms. The CR of NAms came mainly through the oral exposure pathway. The 95th percentile of the total CR of five major NAms was 1.06 × 10^-4, exceeding the maximum acceptable lifetime CR (1 × 10^-4) recommended by US EPA. Exposure to NDEA contributed the highest to the total CR. The CR of the five NAms through ingestion was 2.5 times higher using the Chinese exposure factors than that of the Americans. The most important variables related to CRs were concentrations of NAms in drinking water, exposure duration, drinking water ingestion rate, and exposure time during bathing. Our findings suggest the urgent need to develop and enforce effective regulatory policies to control the contamination of NAms in drinking water in China. Graphical abstract.

The DBP exposome: Development of a new method to simultaneously quantify priority disinfection by-products and comprehensively identify unknowns

Disinfected drinking water contains hundreds of disinfection by-products (DBPs) that are formed by the reaction of disinfectants with natural and anthropogenic organic matter, bromide, and iodide. Understanding what these DBPs are is important because millions of people worldwide consume drinking water every day, and human epidemiologic studies have reported cancer, miscarriage, and birth defects from consuming such waters. While more than 600 DBPs are reported in the literature, very few studies quantify complete classes of chlorinated, brominated, and iodinated DBPs. Also, very few studies conduct comprehensive non-target analyses of unknown DBPs to characterize the complete DBP exposure (the exposome). We developed a new gas chromatography (GC)-mass spectrometry (MS) method that simultaneously quantifies 39 priority unregulated DBPs from six different chemical classes (haloacetaldehydes, haloketones, haloacetamides, haloacetonitriles, halonitromethanes, and iodinated-trihalomethanes) and analyzes unknown DBPs with mass accuracy <600 ppm under full-scan conditions. Using a new type of time-of-flight (TOF) mass spectrometer, which combines selected ion monitoring (SIM)-level sensitivity with mass accuracy of ±0.05 Da, method detection limits of 3-61 ng/L were achieved. These levels were found to be quite comparable to those of a widely used single quadrupole mass spectrometer (2-90 ng/L) operated in SIM mode. However, analysis using this TOF mass spectrometer offers two additional advantages over traditional quadrupole-MS: (1) full-scan data, which provides additional confidence for target analytes, as well as complete mass spectra for unknown analysis, and (2) two decimal place mass accuracy, which allows additional confidence for target analytes and importantly, molecular formula indication for unknowns. High resolution accurate mass TOF was also used to validate identification of selected compounds. This new method was demonstrated on finished drinking waters from three different drinking water plants, where target quantification and non-target unknown analyses were performed simultaneously during the same run. This enabled the quantification of 39 DBPs, along with the non-target identification of many other drinking water contaminants, including two additional non-target DBPs: N,N-dimethylacetamide and N-nitrosodibutylamine.

Prioritization of unregulated disinfection by-products in drinking water distribution systems for human health risk mitigation: A critical review

Water disinfection involves the use of different types of disinfectants, which are oxidizing agents that react with natural organic matter (NOM) to form disinfection by-products (DBPs). The United States Environmental Protection Agency (USEPA) has established threshold limits on some DBPs, which are known as regulated DBPs (R-DBPs). The human health risks associated with R-DBPs in drinking water distribution systems (DWDSs) and application of stricter regulations have led water utilities to switch from conventional disinfectant (i.e., chlorination) to alternative disinfectants. However, the use of alternative disinfectants causes formation of a new suit of DBPs known as unregulated DBPs (UR-DBPs), which in many cases can be more toxic. There is a growing concern of UR-DBPs formation in drinking water. This review prioritizes some commonly occurring UR-DBP groups and species in DWDSs based on their concentration level, reported frequency, and toxicity using an indexing method. There are nine UR-DBPs group and 36 species that have been identified based on recent published peer-reviewed articles. Haloacetonitriles (HANs) and haloacetaldehydes (HALs) are identified as important UR-DBP groups. Dichloroacetonitrile (DCAN) and trichloroacetaldehye (TCAL) are identified as critical UR-DBPs species. The outcomes of this review can help water regulators to identify the most critical UR-DBPs species in the context of drinking water safety and provide them with useful information to develop guidelines or threshold limits for UR-DBPs. The outcomes can also help water utilities in selecting water treatment processes for the mitigation of human health risk posed by UR-DBPs through drinking water.

Removal of multiple nitrosamines from aqueous solution by nanoscale zero-valent iron supported on granular activated carbon: Influencing factors and reaction mechanism

Due to their significant absorption and reduction abilities, nanoscale zero-valent iron (nZVI)/granular activated carbon (GAC) composites are very effective for the degradation of organic contaminants and heavy metals. However, to date, there is no systematic study on the applicability of nZVI/GAC for the removal of multiple highly toxic nitrosamines from water supplies. For this study, nZVI/GAC was synthesized and applied to the degradation of multiple nitrosamines. The effects of initial nitrosamine concentration, composite dosage, contact duration, competition with coexistent elements, and reaction mechanisms during the nitrosamine removal process from aqueous solutions were investigated. Compared with bare nZVI and GAC, the removal rates of six nitrosamines via nZVI/GAC were initially very rapid. The highest removal ratios of the six nitrosamines were 76.1% (N-nitrosodimethylamine, NDMA), 84.7% (N-nitrosomethylethylamine, NMEA), 89.8% (N-nitrosodiethylamine, NDEA), 93.5% (N-nitrosodi-n-propylamine, NDPA), 95.7% (N-nitrosodi-n-butylamine, NDBA), and 80.4% (N-nitrosomorpholine, NMor). The nitrosamine degradation kinetics data agreed well with the pseudo-second-order model (R₂² > 0.99), the rate constant k₂ for nitrosamine (200 ng/L) removal by nZVI/GAC increased in the order of NDBA (0.3675) > NDPA (0.0254) > NMEA (0.0109) > NDEA (0.0105) > NDMA (0.0101) > NMor (0.0077). In the presence of cations, anions, and humic acid (HA) the removal of the six nitrosamines was inhibited at each concentration. Furthermore, the removal ratios and K₂ of the five linear nitrosamines by nZVI/GAC partially scaled with structure, LogK_ow, and Henry's constant, particularly between K₂ and these properties (R² > 0.80). The reaction mechanism revealed that nitrosamines were adsorbed by GAC and then reduced by Fe⁰, where the reductive products were primarily secondary amines, nitrate, and nitrite. This study serves to improve our understanding, and further characterizes the removal of multiple nitrosamines by nZVI/GAC.

Monitoring of 943 organic micropollutants in wastewater from municipal wastewater treatment plants with secondary and advanced treatment processes

To perform a systematic survey on the occurrence and removal of micropollutants during municipal wastewater treatment, 943 semi-volatile organic chemicals in 32 wastewater samples including influents of secondary treatments, secondary effluents and final effluents (effluents of advanced treatments), which were collected from seven full-scale municipal wastewater treatment plants (MWTPs) in China, were examined by gas chromatography-mass spectrometry (GC-MS) coupled with an automated identification and quantification system with a database (AIQS-DB). In total, 196 and 145 chemicals were detected in secondary and final effluents, respectively. The majority of the total concentrations (average removal efficiency, 87.0%±5.9%) of the micropollutants were removed during secondary treatments. However, advanced treatments achieved different micropollutant removal extents from secondary effluents depending on the different treatment processes employed. Highly variable removal efficiencies of total concentrations (32.7%-99.3%) were observed among the different advanced processes. Among them, ozonation-based processes could remove 70.0%-80.9% of the total concentrations of studied micropollutants. The potentially harmful micropollutants, based on their detection frequency and concentration in secondary and final effluents, were polycyclic aromatic hydrocarbons (PAHs) (2-methylnaphthalene, fluoranthene, pyrene, naphthalene and phenanthrene), phosphorus flame retardants (tributyl phosphate (TBP), tris(2-chloroethyl) phosphate (TCEP) and tris(1,3-dichloro-2-propyl) phosphate (TDCP)), phthalates (bis(2-ethylhexyl)phthalate (DEHP)), benzothiazoles (benzothiazole, 2-(methylthio)-benzothiazol, and 2(3H)-benzothiazolone) and phenol. This study indicated that the presence of considerable amounts of micropollutants in secondary effluent creates the need for suitable advanced treatment before their reuse.

Removal of the precursors of N-nitrosodiethylamine (NDEA), an emerging disinfection byproduct, in drinking water treatment process and its toxicity to adult zebrafish (Danio rerio)

N-nitrosodiethylamine (NDEA) is one of the emerging nitrogenous disinfection byproducts with probable cytotoxicity, genotoxicity, and carcinogenesis. Its potential toxicological effects have received extensive attention but remain to be poorly understood. In this study, changes in NDEA precursors in drinking water treatment process were studied using the trial of its formation potential (FP), and the toxicity induced by NDEA to adult zebrafish was investigated. NDEA FP in the raw water of Taihu Lake ranged from 46.9 to 68.3 ng/L. The NDEA precursors were removed effectively by O₃/BAC process. Hydrophilic fraction and low-molecular-weight fraction (<1 kDa) had the highest NDEA FP. The toxicity results demonstrated that the acute lethal concentration of NDEA causing 50% mortality in 96 h (96-h LC50) was 210.4 mg/L, and NDEA was more likely to be accumulated in kidney, followed by liver and gill. NDEA induced oxidative stress and antioxidant defense to zebrafish metabolism system at concentrations over 5 μg/L. After a 42-day exposure, a significant DNA damage was observed in zebrafish liver cells at NDEA concentrations beyond 500 μg/L. This study investigated NDEA properties in both engineering prospective and toxicity evaluation, thus providing comprehensive information on its control in drinking water treatment process and its toxicity effect on zebrafish as a model animal.

N-Nitrosodimethylamine (NDMA) and its precursors in water and wastewater: A review on formation and removal

This review summarizes major findings over the last decade related to N-Nitrosodimethylamine (NDMA) in water and wastewater. In particular, the review is focused on the removal of NDMA and of its precursors by conventional and advanced water and wastewater treatment processes. New information regarding formation mechanisms and precursors are discussed as well. NDMA precursors are generally of anthropogenic origin and their main source in water have been recognized to be wastewater discharges. Chloramination is the most common process that results in formation of NDMA during water and wastewater treatment. However, ozonation of wastewater or highly contaminated surface water can also generate significant levels of NDMA. Thus, NDMA formation control and remediation has become of increasing interest, particularly during treatment of wastewater-impacted water and during potable reuse application. NDMA formation has also been associated with the use of quaternary amine-based coagulants and anion exchange resins. UV photolysis with UV fluence far higher than typical disinfection doses is generally considered the most efficient technology for NDMA mitigation. However, recent studies on the optimization of biological processes offer a potentially lower-energy solution. Options for NDMA control include attenuation of precursor materials through physical removal, biological treatment, and/or deactivation by application of oxidants. Nevertheless, NDMA precursor identification and removal can be challenging and additional research and optimization is needed. As municipal wastewater becomes increasingly used as a source water for drinking, NDMA formation and mitigation strategies will become increasingly more important. The following review provides a summary of the most recent information available.