Environmental side effects of pharmaceutical cocktails: what we know and what we should know.

Cocktails of pharmaceuticals are released in the environment after human consumption and due to the incomplete removal at the wastewater treatment plants. Pharmaceuticals are considered as contaminants of emerging concern and, a plethora of journal articles addressing their possible adverse effects have been published during the past 20 years. The emphasis during the early years of research within this field, was on the assessment of acute effects of pharmaceuticals applied singly, leading to results regarding their environmental risk, potentially not realistic or relevant to the actual environmental conditions. Only recently has the focus been shifted to chronic exposure and to the assessment of cocktail effects. To this end, this review provides an up-to-date compilation of 57 environmental and human toxicology studies published during 2000-2014 dealing with the adverse effects of pharmaceutical mixtures. The main challenges regarding the design of experiments and the analysis of the results regarding the effects of pharmaceutical mixtures to different biological systems are presented and discussed herein. The gaps of knowledge are critically reviewed highlighting specific future research needs and perspectives.

Investigating the fate of iodinated X-ray contrast media iohexol and diatrizoate during microbial degradation in an MBBR system treating urban wastewater.

The capability of a moving bed biofilm reactor (MBBR) to remove the iodinated contrast media (ICM) iohexol (IOX) and diatrizoate (DTZ) from municipal wastewater was studied. A selected number of clones of microorganisms present in the biofilm were identified. Biotransformation products were tentatively identified and the toxicity of the treated effluent was assessed. Microbial samples were DNA-sequenced and subjected to phylogenetic analysis in order to confirm the identity of the microorganisms present and determine the microbial diversity. The analysis demonstrated that the wastewater was populated by a bacterial consortium related to different members of Proteobacteria, Firmicutes, and Nitrisporae. The optimum removal values of the ICM achieved were 79 % for IOX and 73 % for DTZ, whereas 13 biotransformation products for IOX and 14 for DTZ were identified. Their determination was performed using ultra-performance liquid chromatography-tandem mass spectrometry. The toxicity of the treated effluent tested to Daphnia magna showed no statistical difference compared to that without the addition of the two ICM. The MBBR was proven to be a technology able to remove a significant percentage of the two ICM from urban wastewater without the formation of toxic biodegradation products. A large number of biotransformation products was found to be formed. Even though the amount of clones sequenced in this study does not reveal the entire bacterial diversity present, it provides an indication of the predominating phylotypes inhabiting the study site.

Use of monoclonal antibodies to dissect specificity and pathogenesis of antiphospholipid antibodies.

Monoclonal antiphospholipid antibodies (aPL) have been utilized to dissect the relationship between their sequence, structure, binding and biological properties relevant to the pathogenesis of the antiphospholipid syndrome. In particular, sequence analysis of aPL has highlighted the clustering of certain amino acid residues in the antigen contact sites of their heavy and light chains. Therefore, these sequence motifs are likely to be important in determining aPL binding properties and their pathogenic effects. Experiments, however, using monoclonal aPL engineered to contain specific point mutations in their sequence which alter their ability to bind relevant antigens have shown that these alterations in binding are not directly mirrored by their pathogenic effects. In this review we focus on work carried out by others and ourselves using monoclonal antibodies with specific binding properties to extend our knowledge of the non-linear structure-binding-function relationship of aPL.

Examining the non-linear relationship between monoclonal antiphospholipid antibody sequence, structure and function.

In the antiphospholipid syndrome (APS), pathogenic antiphospholipid antibodies (aPL) that cause thrombosis or pregnancy morbidity are characterized by binding to anionic phospholipids (PL) and beta2-glycoprotein I (beta(2)GPI). Sequence analysis of human monoclonal aPL has shown that high affinity for these antigens is associated with the presence of three particular amino acids: arginine (Arg), asparagine and lysine in the complementarity determining regions (CDRs) of their heavy and light chains. In vitro expression systems have been used to create variants of the antibodies in which these amino acids have been altered. In general, removal of Arg residues reduces affinity for anionic PL and beta(2)GPI. Arg at different positions in the sequence, however, have different effects on binding affinity and effects on binding are not always mirrored by effects on pathogenicity. This review will focus upon the sequence motifs that have been found to distinguish pathogenic from non-pathogenic aPL, and whether these or other properties may help to identify distinct pathogenic subsets of aPL. In particular, we will focus on our recent work in which we are trying to develop a better understanding of the molecular mechanisms involved in activation of target cells by pathogenic aPL. These studies, together with molecular models of antigen/antibody complexes, help us to understand exactly how pathogenic antibodies interact with antigens. Ultimately, this understanding may aid the design of more powerful diagnostic/prognostic assays and targeted therapeutic agents to block the pathogenic effects of these antibodies.

B cell depletion therapy for patients with systemic lupus erythematosus results in a significant drop in anticardiolipin antibody titres.

BACKGROUND: B cell depletion therapy (BCDT) has recently been used with success to treat patients with rheumatoid arthritis and systemic lupus erythematosus (SLE). As antiphospholipid antibodies have been implicated in the pathogenesis of the antiphospholipid syndrome (APS), we asked the question whether BCDT affects levels of IgG anticardiolipin antibodies (aCL) in our cohort of 32 SLE patients given this treatment. METHODS: We identified seven SLE patients who had undergone BCDT and had had at least two moderate positive aCL titres at least 12 weeks apart. Of these only one patient had APS. IgG aCL were measured at time 0 and 6-9 months post BCDT. RESULTS: At time 0, the mean IgG aCL level was 20.6 standardized IgG antiphospholipid units (GPLU) (range (SD) 10-32, (10.1), normal level <5). At 6-9 months post depletion the IgG aCL levels in six of the seven patients was undetectable and in the other patient the level reduced from 25 GPLU to 15 GPLU (p<0.005, two-tailed paired t test). At baseline, only one patient had a mildly positive anti-beta(2)-glycoprotein I (beta(2)GPI) antibody level at 30% (compared to an in-house standard), which fell to 5% post-BCDT. CONCLUSIONS: This small observational study in patients with SLE is the first to demonstrate that BCDT results in a significant reduction in levels of IgG aCL.

Medullary sponge disease in horseshoe kidney.

We report on a patient with a combination of medullary sponge disease and horseshoe kidney. The coexistence of two uncommon conditions of the kidney in this case obscured the clinical picture, and the patient was perhaps subjected to unnecessary invasive tests to establish the diagnosis. Medullary sponge disease occasionally will present as hematuria, and the condition should be kept in mind as a differential diagnosis since it is almost always recognizable on intravenous urography.

Primary retroperitoneal teratoma in adults.

We report on a case of primary monodermal retroperitoneal teratoma composed solely of thyroid tissue. The CT scan appearance of such a tumor is presented.

Acute pancreatitis complicating excessive intake of phenolphthalein.

A case is described in which a patient presented with acute pancreatitis following inadvertent ingestion of large quantities of phenolphthalein for the treatment of his chronic constipation. There was complete recovery and no sequelae from the acute attack of pancreatitis.

Penetrating stab injuries of the chest and abdomen.

A retrospective review was carried out of 100 consecutive patients with penetrating stab injuries of the chest and/or abdomen, requiring admission to hospital. Laparotomies were performed in 44 patients, while a further 7 were subjected to thoracotomy. Only 1 patient died, and this was a case of combined thoraco-abdominal injury. There was an annual increase in the numbers of such injuries, which were particularly prevalent in young, unemployed persons, often under the influence of alcohol.

Abdominal tuberculosis.

In Britain abdominal tuberculosis is an uncommon condition and most cases come to laparotomy for diagnosis. A high index of suspicion is required in areas with a large immigrant population and in areas which are overcrowded and nutritionally deprived. Nine of 28 patients presented acutely and a wide variety of preoperative diagnoses were entertained. Most of the remainder had a long history of vague constitutional symptoms and laparotomy was required for diagnosis in all but 5. Histology proved the surest way of establishing the diagnosis.