Per- and polyfluoroalkyl substances (PFAS) in river discharge: Modeling loads upstream and downstream of a PFAS manufacturing plant in the Cape Fear watershed, North Carolina.

The Cape Fear River is an important source of drinking water in North Carolina, and many drinking water intakes in the watershed are affected by per- and polyfluoroalkyl substances (PFAS). We quantified PFAS concentrations and loads in river water upstream and downstream of a PFAS manufacturing plant that has been producing PFAS since 1980. River samples collected from September 2018 to February 2021 were analyzed for 13 PFAS at the upstream station and 43-57 PFAS downstream near Wilmington. Frequent PFAS sampling (daily to weekly) was conducted close to gauging stations (critical to load estimation), and near major drinking water intakes (relevant to human exposure). Perfluoroalkyl acids dominated upstream while fluoroethers associated with the plant made up about 47% on average of the detected PFAS downstream. Near Wilmington, Σ43PFAS concentration averaged 143 ng/L (range 40-377) and Σ43PFAS load averaged 3440 g/day (range 459-17,300), with 17-88% originating from the PFAS plant. LOADEST was a useful tool in quantifying individual and total quantified PFAS loads downstream, however, its use was limited at the upstream station where PFAS levels in the river were affected by variable inputs from a wastewater treatment plant. Long-term monitoring of PFAS concentrations is warranted, especially at the downstream station. Results suggest a slight downward trend in PFAS levels downstream, as indicated by a decrease in flow-weighted mean concentrations and the best-fitting LOADEST model. However, despite the cessation of PFAS process wastewater discharge from the plant in November 2017, and the phase-out of perfluorooctane sulfonic acid (PFOS) and perfluorooctanoic acid (PFOA) in North America, both fluoroethers and legacy PFAS continue to reach the river in significant quantities, reflecting groundwater discharge to the river and other continuing inputs. Persistence of PFAS in surface water and drinking water supplies suggests that up to 1.5 million people in the Cape Fear watershed might be exposed.

Gumming Up The Works: Field Tests of a New Food-Grade Gum as Behavioral Disruptor for Drosophila suzukii (Diptera: Drosophilidae).

Drosophila suzukii Matsumura is an economically important pest of small and stone fruits. Its establishment in the Americas and Europe marked an important turning point in crop management programs. Ten years after its first detection, an effective integrated pest management program has yet to be developed and pesticides are mainly used to control this pest. Here we test a new behavioral control tool, with the aim to develop an alternative pest control strategy. A food-grade gum matrix, was evaluated under controlled and open field conditions for its ability to attract the pest and protect the ripening fruit. Here, we report that the gum effectively reduces fruit infestation when used under managed conditions. We show that a single point source can affect D. suzukii behavior over a 3.6 m radius and last for up to 21 d. Open field data reveal that the efficacy of the gum is significantly impacted by water content. We discuss these results in respect to the future implications for D. suzukii management, along with important considerations on gum mechanism of action, possible application strategies and economic suitability for growers.

Evaluation of validity of the STOP-BANG questionnaire in major elective noncardiac surgery.

BACKGROUND: The STOP-BANG questionnaire screens for obstructive sleep apnoea (OSA) in surgical patients. In prior research, the association of STOP-BANG scores with comorbidities and outcomes was inconsistent. The objective of this study was to evaluate the validity of the STOP-BANG score. METHODS: We conducted a retrospective cohort study of patients undergoing major elective noncardiac surgery at the University Health Network (Toronto, ON, Canada) between 2011 and 2015. Cross-sectional construct validity was evaluated based on proportions with diagnosed OSA across STOP-BANG strata. Concurrent construct validity was assessed based on the correlation of STOP-BANG with ASA Physical Status (ASA-PS), the Revised Cardiac Risk Index, and the Charlson Comorbidity Index. Predictive validity was assessed based on the adjusted associations of STOP-BANG risk with 30-day mortality (logistic regression), cardiac complications (logistic regression), and length-of-stay (negative binomial regression). RESULTS: Of 26 068 patients in the cohort, 58% were in the low-risk STOP-BANG stratum, 23% in the intermediate-risk stratum, and 19% in the high-risk stratum. The proportion with previously diagnosed OSA was 4% (n=615) in the low-risk stratum, 12% (n=740) in the intermediate-risk stratum, and 44% (n=2142) in the high-risk stratum. The correlations of STOP-BANG with ASA-PS (Spearman ρ=0.28), Revised Cardiac Risk Index (ρ=0.24), and Charlson Comorbidity Index (ρ=0.10) were weak, albeit statistically significant (P<0.001). After risk-adjustment, STOP-BANG risk strata were not associated with 30-day mortality, cardiac complications, or length-of-stay. CONCLUSIONS: The STOP-BANG questionnaire has modest construct validity but did not predict postoperative mortality, hospital length-of-stay, or cardiac complications.

Association between preoperative ambulatory heart rate and postoperative myocardial injury: a retrospective cohort study.

BACKGROUND: Resting heart rate is well established as a predictor of morbidity and mortality in the general population. However, the relationship between preoperative heart rate and perioperative outcomes, specifically myocardial injury, is unclear. METHODS: This retrospective cohort study included patients undergoing elective major non-cardiac surgery from 2008 to 2014 at a multisite healthcare system. The exposure was ambulatory heart rate measured during the outpatient preoperative clinic visit, whereas the outcome of interest was myocardial injury (peak postoperative troponin I concentration >30 ng L-1). Covariates included patient characteristics, comorbidities, and preoperative medications. We constructed several multivariable regression models that each modelled heart rate in a different manner, including as a simple continuous variable, categories, and fractional polynomials. RESULTS: The cohort included 41 140 patients, of whom 4857 (11.8%) experienced myocardial injury. Based on pre-specified heart categories thresholds, a heart rate ≥90 beats min-1 was associated with an elevated odds of myocardial injury compared with a heart rate <60 beats min-1 (adjusted odds ratio, 1.22; 95% confidence interval, 1.06-1.39; P=0.005). This result was consistent regardless of the method used for categorisation. When fractional polynomials were used to model heart rate, a 'J-shaped' relationship between heart rate and odds of myocardial injury was observed. CONCLUSIONS: This cohort study found that both very high preoperative heart rates, and possibly also very low heart rates, are associated with increased risk of myocardial injury. Whether heart rate is a modifiable risk factor, or rather simply a marker of underlying cardiac pathology, needs to be determined in further research.

Pulling together and pulling apart: influences of convergence and divergence on distributed healthcare teams.

Effective healthcare requires both competent individuals and competent teams. With this recognition, health professions education is grappling with how to factor team competence into training and assessment strategies. These efforts are impeded, however, by the absence of a sophisticated understanding of the the relationship between competent individuals and competent teams . Using data from a constructivist grounded theory study of team-based healthcare for patients with advanced heart failure, this paper explores the relationship between individual team members' perceived goals, understandings, values and routines and the collective competence of the team. Individual interviews with index patients and their healthcare team members formed Team Sampling Units (TSUs). Thirty-seven TSUs consisting of 183 interviews were iteratively analysed for patterns of convergence and divergence in an inductive process informed by complex adaptive systems theory. Convergence and divergence were identifiable on all teams, regularly co-occurred on the same team, and involved recurring themes. Convergence and divergence had nonlinear relationships to the team's collective functioning. Convergence could foster either shared action or collective paralysis; divergence could foster problematic incoherence or productive disruption. These findings advance our understanding of the complex relationship between the individual and the collective on a healthcare team, and they challenge conventional narratives of healthcare teamwork which derive largely from acute care settings and emphasize the importance of common goals and shared mental models. Complex adaptive systems theory helps us to understand the implications of these insights for healthcare teams' delivery of care for the complex, chronically ill.

Reliability of the American Society of Anesthesiologists physical status scale in clinical practice.

BACKGROUND: Previous studies, which relied on hypothetical cases and chart reviews, have questioned the inter-rater reliability of the ASA physical status (ASA-PS) scale. We therefore conducted a retrospective cohort study to evaluate its inter-rater reliability and validity in clinical practice. METHODS: The cohort included all adult patients (≥18 yr) who underwent elective non-cardiac surgery at a quaternary-care teaching institution in Toronto, Ontario, Canada, from March 2010 to December 2011. We assessed inter-rater reliability by comparing ASA-PS scores assigned at the preoperative assessment clinic vs the operating theatre. We also assessed the validity of the ASA-PS scale by measuring its association with patients' preoperative characteristics and postoperative outcomes. RESULTS: The cohort included 10 864 patients, of whom 5.5% were classified as ASA I, 42.0% as ASA II, 46.7% as ASA III, and 5.8% as ASA IV. The ASA-PS score had moderate inter-rater reliability (κ 0.61), with 67.0% of patients (n=7279) being assigned to the same ASA-PS class in the clinic and operating theatre, and 98.6% (n=10 712) of paired assessments being within one class of each other. The ASA-PS scale was correlated with patients' age (Spearman's ρ, 0.23), Charlson comorbidity index (ρ=0.24), revised cardiac risk index (ρ=0.40), and hospital length of stay (ρ=0.16). It had moderate ability to predict in-hospital mortality (receiver-operating characteristic curve area 0.69) and cardiac complications (receiver-operating characteristic curve area 0.70). CONCLUSIONS: Consistent with its inherent subjectivity, the ASA-PS scale has moderate inter-rater reliability in clinical practice. It also demonstrates validity as a marker of patients' preoperative health status.

The James Lind Library: explaining and illustrating the evolution of fair tests of medical treatments.

The James Lind Library (www.jameslindlibrary.org) has been established to improve public and professional general knowledge about fair tests of treatments in healthcare and their history. Its foundation was laid ten years ago at the Royal College of Physicians of Edinburgh, and its administrative centre is in the College's Sibbald Library, one of the most important collections of historic medical manuscripts, papers and books in the world. The James Lind Library is a website that introduces visitors to the principles of fair tests of treatments, with a series of short, illustrated essays, which are currently available in English, Arabic, Chinese, French, Portuguese, Russian and Spanish. A 100-page book-- Testing Treatments--is now available free through the website, both in English and in Arabic and Spanish translations. To illustrate the evolution of ideas related to fair tests of treatments from 2000 BC to the present, the James Lind Library contains key passages and images from manuscripts, books and journal articles, many of them accompanied by commentaries, biographies, portraits and other relevant documents and images, including audio and video files. New material is being added to the website continuously, as relevant new records are identified and as methods for testing treatments evolve. A multinational, multilingual editorial team oversees the development of the website, which currently receives tens of thousands of visitors every month.

Five year review of the Rotaglide total knee arthroplasty.

In this study we present the outcome for patients with the Rotaglide mobile meniscal knee prosthesis implanted for osteoarthritis. All patients reviewed had this prosthesis implanted as a primary total knee Arthroplasty in Crosshouse Hospital. The minimum follow-up period was 5 years (range 5-8.2). Patients were assessed clinically by the junior author (C.W.) and results were standardised using the Hospital for Specialist Surgery (HSS) knee score. Standard radiographs were taken in antero-posterior and lateral planes to assess for loosening using the Knee Society roentgenographic system. Case notes were then examined for evidence of peri and post-operative problems. Sixty-seven patients (71 knees) were reviewed. Ninety-four percent of patients had an excellent clinical outcome with HSS scores of 85 or more. Two knees were revised, one for meniscal fracture and one for meniscal dislocation. Both of these failures were early in our series and in a total of 312 knees to date there have been no other meniscal failures. No knees were revised for aseptic loosening and there have been no deep infections. We feel this prosthesis offers a safe and effective treatment for osteoarthritis with a good clinical outcome at 5 years with a low level of complications.

Utilisation of bone allograft by orthopaedic surgeons in Scotland.

The use of bone allograft in orthopaedic surgery has been predicted to increase, particularly in joint revision surgery. This has led to a potential problem with supply. Questionnaires were distributed to all 146 Consultant Orthopaedic surgeons working in Scotland in 2000. They were asked to indicate their current usage of bone and tissue allograft, any problems encountered with supply and if alternatives to allograft, such as processed bone, might be used. The questions asked were very similar to those asked in a previous study in 1995 to enable comparisons to be made. Replies were received from 125 Consultants (87%) of whom 93 reported using bone allograft. Forty-one consultants (46%) predicted an increase in their requirement for bone allograft, and 23 (26%) felt they could currently use more bone if this was available. Sixty percent of surgeons would consider using processed bone as an alternative. In comparison with figures from 1995, an increasing number of surgeons are prepared to use processed bone as an alternative to fresh frozen allograft.

Effect of ethinyl estradiol on the panic response to the panicogenic agent pentagastrin.

BACKGROUND: Panic disorder (PD) symptomatology has been reported to be altered by hormonal events or treatments which affect estrogen levels. Coryell et al. [Arch. Gen. Psychiatry, 39 (1982) 701-703; Am. J. Psychiatry, 143 (1986) 508-510] have suggested that the increased cardiovascular risk associated with PD is significantly greater in males, alluding to a potential cardioprotective effect of female hormones in the context of panic attacks. In the present study, we were, therefore, interested in elucidating the role of estrogen in modulating the behavioural and cardiovascular responses induced by the panicogenic agent pentagastrin, a cholecystokinin-B (CCK(B)) receptor agonist. METHODS: A double-blind cross-over placebo-controlled design with randomization of the order of a 3-day pretreatment of ethinyl estradiol (EE) (50 microg/day) or placebo was used to assess the effect of a 30-microg i.v. bolus injection of pentagastrin on panic symptom intensity and on increases in heart rate (DeltaHR), systolic (DeltaSBP) and diastolic (DeltaDBP) blood pressure following each pretreatment. Subjects were 9 male healthy controls and 11 male PD patients. RESULTS: EE pretreatment did not significantly reduce the pentagastrin-induced panic symptom scale (PSS) scores and had no effect on DeltaDBP or DeltaSBP. EE did, however, attenuate the pentagastrin-induced increase in HR in both PD patients and healthy controls. LIMITATIONS: Only male subjects were included in the present study; however, we are currently investigating the influence of female gonadal hormones on the panic response to pentagastrin in female PD patients and healthy controls. CONCLUSION: Our results suggest that estrogens may display cardioprotective effects in the context of panic attacks.

Effect of medroxyprogesterone pretreatment on pentagastrin-induced panic symptoms in females with panic disorder.

Clinical observation, as well as epidemiological and research data, suggest that female gonadal hormones influence the course of panic disorder (PD). Panicogenic agents such as pentagastrin are useful tools with which to study the pathophysiology of panic attacks. Nine women with PD were randomly assigned to receive, in a crossover design, a 3-day pretreatment with medroxyprogesterone acetate (MP) prior to an injection of pentagastrin, and a 3-day pretreatment with a placebo prior to another injection of pentagastrin. The panic response and the anxiety response to pentagastrin were decreased after MP pretreatment. These preliminary results support the use of laboratory models for investigations of the interactions between progestins and anxiety.

Use of fax facility improves decision making regarding thrombolysis in acute myocardial infarction.

BACKGROUND: Electrocardiography is the fundamental investigation for decision making regarding thrombolytic treatment in acute myocardial infarction (MI). Increasing the accuracy of ECG analysis by input from consultant staff may assist in management decisions in patients with suspected MI. AIMS: To evaluate a system whereby out of hours ECGs can be faxed to the consultant to aid in decision making regarding thrombolytic treatment. METHODS: 112 patients with suspected MI were assessed on admission by the senior house officer (SHO) who faxed to a cardiology consultant the ECG trace and a predesigned form with information on: clinical assessment of the patient; interpretation of the ECG; and views regarding administration of thrombolytic treatment including choice of agent. The consultant reviewed the information and communicated his views to the SHO. Subsequent diagnosis was recorded in all patients and the forms were analysed in regard to areas of agreement and disagreement between the SHO and the consultant. RESULTS: A diagnosis of MI was confirmed in 52 of the 112 patients (46.4%). The consultant agreed with the SHO's decision on thrombolysis in 98 patients (87.5%). The reason for disagreement in the remaining 14 patients (12.5%) was SHO misinterpretation of the ECG (10 patients) and clinical assessment (four patients). Eight patients were saved unnecessary thrombolytic treatment and four received it when they otherwise would not have. Additionally the choice of thrombolytic agent was changed in six patients from streptokinase to tissue plasminogen activator. CONCLUSION: The use of fax machine assists in decision making with regard to thrombolytic treatment and provides support to junior doctors in what can be a difficult, yet critical decision.

Role of plasma triglyceride in the regulation of plasma low density lipoprotein (LDL) subfractions: relative contribution of small, dense LDL to coronary heart disease risk.

The concentration of plasma LDL subfractions is described in four groups of normocholesterolaemic (total plasma cholesterol < 6.5 mmol/l) male subjects consisting of men with and without coronary artery disease (CAD+/-), as determined by angiography, post-myocardial infarct survivors (PMI) and normal, healthy controls. The CAD(+) and PMI groups were distinguished from the CAD(-) and controls by raised concentrations of plasma triglyceride, very low density lipoprotein (VLDL) cholesterol, small, dense LDL (LDL-III density (d) 1.044-1.060 g/ml) and lower concentrations of high density lipoprotein (HDL) cholesterol and large, buoyant LDL (LDL-I d 1.025-1.034 g/ml). In all groups, a subfraction of intermediate density, LDL-II (d 1.034-1.044 g/ml), was the predominant LDL species but was not related to coronary heart disease risk. Plasma triglyceride showed a positive association with LDL-II (r = 0.51, P < 0.001) below a triglyceride level of 1.5 mmol/l. Above this threshold of 1.5 mmol/l, LDL-II and LDL-I showed significant negative associations with triglyceride (LDL-II r = -0.5, P < 0.001; LDL-I r = -0.45, P < 0.001). Small, dense LDL-III showed a weak positive association with triglyceride that became highly significant above the 1.5 mmol/l threshold (r = 0.54, P < 0.001). While age was positively related to LDL-II within the control subjects (r = 0.3, P < 0.05), there was no difference in the percentage abundance or concentration of LDL-III within control and CAD(-) subjects above and below the age of 40 years. Smoking was associated with a relative deficiency of the LDL-I subfraction (LDL-I to LDL-III ratio in smokers = 0.77, in ex-smokers = 0.95, in non-smokers = 1.89; P < 0.01), as was beta-blocker medication (% LDL-I, users vs. non-users, P < 0.05). Both of these effects could be explained by their primary influence on plasma triglyceride. Analysis of the frequency distributions for the three LDL subfractions revealed the concentration of small, dense LDL-III to be bimodal around a concentration of 100 mg (lipoprotein mass)/100 ml plasma. The calculation of odds ratios based on this figure indicated relative risk estimates of 4.5 (chi 2: P < 0.01) for the presence of coronary artery disease and 6.9 (chi 2: P < 0.001) for myocardial infarction.(ABSTRACT TRUNCATED AT 400 WORDS)

Caveat surgeon: do orthopaedic surgeons take adequate precautions against blood-borne viral infections, in particular the human immunodeficiency virus (HIV)?

One year ago the British Orthopaedic Association issued guidelines for the prevention of cross-infection with special reference to HIV and the hepatitis viruses. We were interested to establish whether the guidelines were being widely applied and whether they had changed general orthopaedic practice. We distributed a questionnaire to Scottish Orthopaedic Fellows, Associates of the BOA, and orthopaedic trainees. With a 70 per cent return rate, it would appear that the recommendations are not adhered to in full. Of respondents, 84 per cent were immunized or undergoing immunization against hepatitis B. In all, 30 per cent were operating on high-risk patients on a monthly basis, 60 per cent thought that their current practice was low risk, and only 15 per cent thought that their future practice would be high risk; 81 per cent were concerned and yet only 60 per cent had altered their practice. It is of some concern that orthopaedic surgeons may not take the threat of HIV cross-infection seriously enough and do not consider precautions mandatory. Further pressure and support from the BOA may be necessary to encourage a change in orthopaedic practice as the threat of HIV is increasing.

Probucol reduces plasma lipid peroxides in man.

Although primarily used as a lipid lowering drug, probucol also possesses anti-oxidant activity and has been shown in animal models to inhibit or delay the progression of atherosclerosis. It has been suggested that this anti-atherosclerotic effect may occur through inhibition of free radical oxidation of low density lipoprotein. The aim of this study was to investigate the effects of probucol on free radical activity in hyperlipidaemic patients. Plasma lipid peroxides were measured before probucol treatment, at 4 and 12 weeks treatment and then 4 weeks after stopping probucol. Lipid peroxide concentrations were significantly reduced during and 4 weeks after stopping treatment with probucol, when compared with baseline values. There were no changes in plasma vitamin E concentrations. The results of this study indicate that probucol reduces lipid peroxidation in patients, an effect which may occur through a free radical scavenging action.

Unnecessary arthroscopies.

A review of the results of arthroscopies on patients taken from an 'open access' service waiting list has been carried out. One-third of all arthroscopies proved to be negative. Accuracy of clinical diagnosis was not related to the clinical grade of the examining doctor. The excess annual cost to the Northern Ireland Orthopaedic Service of unnecessary arthroscopies may have been of the order of 89,000 pounds.

Delayed diagnosis of injuries from the M1 aircraft accident. The Nottingham, Leicester, Derby, Belfast Study Group.

The incidence of a delay in the diagnosis of injuries from the 83 survivors of the M1 aircraft accident is described. A total of 32 injuries in 25 patients were not initially diagnosed, nine each in the upper and lower limbs and 14 in the spine. This was equivalent to 9.6 per cent of all the major injuries suffered by the survivors. Five patients required surgery for a late diagnosed injury. The incidence of a delayed diagnosis injury (DDI) was not related to the overall severity of injury. Delay in diagnosis of injuries after such a major accident was attributable to failure of clinical examination, failure to radiograph symptomatic areas and failure of radiographic interpretation.

Survivors of the M1 aircrash. Outcome of injuries after 1 year. The Nottingham, Leicester, Derby and Belfast Study Group.

The 79 survivors of the M1 aircrash have been assessed at an average of great britain 1 year after the accident. Return to work, continued hospital care and recovery from injuries has been found to be related to the severity of injury. The 188 pelvic and limb fractures have been reviewed and the incidence of complications from these injuries has been low. Spinal and lower limb injuries account for the majority of the residual disability.