Development and Implementation of an e-Trigger Tool for Adverse Drug Events in a Swiss University Hospital.

PURPOSE: The purpose of the study was to develop and implement an institution-specific trigger tool based on the Institute for Healthcare Improvement medication module trigger tool (IHI MMTT) in order to detect and monitor ADEs. METHODS: We performed an investigator-driven, single-center study using retrospective and prospective patient data to develop ("development phase") and implement ("implementation phase") an efficient, institution-specific trigger tool based on the IHI MMTT. Complete medical data from 1008 patients hospitalized in 2018 were used in the development phase. ADEs were identified by chart review. The performance of two versions of the tool was assessed by comparing their sensitivities and specificities. Tool A employed only digitally extracted triggers ("e-trigger-tool") while Tool B employed an additional manually extracted trigger. The superior tool - taking efficiency into account - was applied prospectively to 19-22 randomly chosen charts per month for 26 months during the implementation phase. RESULTS: In the development phase, 189 (19%) patients had ≥1 ADE (total 277 ADEs). The time needed to identify these ADEs was 15 minutes/chart. A total of 203 patients had ≥1 trigger (total 273 triggers - Tool B). The sensitivities and specificities of Tools A and B were 0.41 and 0.86, and 0.43 and 0.86, respectively. Tool A was more time-efficient than Tool B (4 vs 9 minutes/chart) and was therefore used in the implementation phase. During the 26-month implementation phase, 22 patients experienced trigger-identified ADEs and 529 did not. The median number of ADEs per 1000 patient days was 6 (range 0-13). Patients with at least one ADE had a mean hospital stay of 22.3 ± 19.7 days, compared to 8.0 ± 7.6 days for those without an ADE (p = 2.7×10-14). CONCLUSION: We developed and implemented an e-trigger tool that was specific and moderately sensitive, gave consistent results and required minimal resources.

The tox is in the detail: technical fundamentals for designing, performing, and interpreting experiments on toxicity of microplastics and associated substances.

Over the last 10 years, there has been a plethora of experimental studies estimating the potential of microplastic particles (MPs) to exert toxic effects in the environment, many specifically focusing on their postulated capacity to enhance the transfer of environmental pollutants into organisms after ingestion. Obviously, there is little to no consensus on appropriate experimental design, which is mainly owing to the novelty, the interdisciplinarity of the subject, and the complexity of parameters involved. This results in fundamental discrepancies regarding the materials applied, the approach for spiking MPs with pollutants, and the exact exposure scenario. Aiming for a non-chemist audience and providing illustrative, representative, and comparative examples, this review first outlines the theoretical essentials of processes involved in sorption. Also, it discusses the implications for designing experimental approaches using MPs and interpreting the results obtained under consideration of their relevance for environmental conditions. It may help to improve the interpretation of studies on MP toxicity already published, while also calling experimenters' attention to various aspects important to consider when designing and performing environmentally relevant experiments with MPs.

Microplastic particles reduce EROD-induction specifically by highly lipophilic compounds in RTL-W1 cells.

Microplastic particles (MPs) from lipophilic polymers have been shown to efficiently accumulate hydrophobic organic contaminants (HOCs) in aquatic environments. MPs have, therefore, frequently been discussed as vectors for contaminants, enhancing HOC uptake by various organisms after ingestion followed by pollutant release; however, integrative models of sorption argue against this mechanism and even predict cleansing of pollutants from biological systems under particular circumstances. In order to experimentally investigate such a depuration mechanism, RTL-W1 cells were dosed with three 7-ethoxyresorufin-O-deethylase (EROD) inducers of distinct lipophilicity via the medium before adding both native and hexane-purified polyethylene MPs (20-25 µm) to the medium surface. EROD activity was significantly reduced in the presence of MP, the extent of which correlated with the inducers' lipophilicity (KOW) and thus affinity to MP. For hexane-purged MPs and TCDD (KOW = 6.8), MPs reduce the bioavailability by up to 79%; the effect was marginally weaker with benzo[k]fluoranthene (KOW = 6.11) and almost absent with ß-Naphthoflavone (KOW = 4.68). Compared to hexane-purged MPs, native particles possessed slightly less detoxification potential. These experimental results corroborate theoretically predicted mechanisms of detoxification via MPs. Yet, it is unclear if, under corresponding conditions in the environment, MPs can compete with organismal tissues for highly lipophilic compounds and, if so, to which degree they may act as a sink reducing the amount of bioavailable pollutants in situ. However, the present results suggest that in scenarios where pollutant-free MPs interact with organisms that accumulated HOCs via other routes of uptake, qualitatively the presence of such a mechanism is likely.

Effect of pH on the toxicity of fumonisins towards the RTL-W1 cell line and zebrafish (Danio rerio) embryos.

Fumonisins are common contaminants of maize. The neutral red assay, using the RTL-W1 trout liver cell line, and the fish embryo test (FET), using zebrafish, were selected to assess the effect of pH on the cytotoxicity, acute toxicity and teratogenicity of fumonisin B1 (FB1). The results demonstrated that FB1 exerts low cytotoxicity towards RTL-W1 cells without pH adjustment (IC50 1 746 µM), and no cytotoxicity after pH-adjustment to physiological conditions. The LC50 value for FB1 in the FET (1 058 µM at 48 h) confirmed low acute toxicity. Adjusting the pH to physiological conditions reduced the acute toxicity of FB1 towards zebrafish embryos, emphasising the importance of acidity/basicity of the medium in toxicity testing. Hydrolysed FB1 was less toxic than FB1 (LC50 2 690 µM at 48 h), and neither were teratogenic towards zebrafish embryos. Results confirm that the FET may account for effects not observable in cell cultures.

Bioavailability of microplastic-bound pollutants in vitro: The role of adsorbate lipophilicity and surfactants.

The potential role of microplastic particles (MPs) as vectors for lipophilic organic pollutants enhancing their uptake by organisms has repeatedly been discussed in the scientific community. Likewise, several studies indicate an important role of surfactants in pollutant-transfer from MP to organisms. Employing polyethylene particles, the bioavailability of three MP-bound inducers of 7-ethoxyresorufin-O-deethylase (EROD) with variable lipophilicity was quantitatively compared via EROD activity in RTL-W1 cells. In addition, non-cytotoxic surfactant concentrations of Pluronic F-127, rhamnolipids, sodium deoxycholate and sodium dodecyl sulfate (SDS) supplemented to the medium were tested for their effects on pollutant desorption from MPs as well as on cellular EROD induction. Bioavailability of MP-bound pollutants was negatively correlated with lipophilicity, and all surfactants were found to modulate the cellular response towards inducers by unidentified mechanisms. After experimental correction for effects on the cellular response, all surfactants except SDS moderately increased desorption of inducer from MPs. Results on the impact of lipophilicity agree with previously published thermodynamic models, indicating that appreciable pollutant desorption from MPs may only occur for substances with comparatively low lipophilicity, the accumulation of which on MPs is negligible in the environment. However, the role of surfactants should be considered further with respect to potential effects on sorption of pollutants to and from MPs.

Microplastic testing in vitro: Realistic loading of pollutants, surfactant-free solid surface-dosing and bioanalytical detection using a sensitivity-optimized EROD assay.

Microplastic particles (MPs) are emerging contaminants in aquatic environments, which are assumed to play a role as vectors for lipophilic pollutants, as the particles bear a potential for the accumulation of lipophilic contaminants from the water phase on the MPs' surface and subsequent release in contact with organisms. In an attempt to allow the bioanalytical detection and quantitatively estimate bioavailability of MP-bound pollutants under realistic conditions in vitro, a protocol was developed for water-based loading of lipophilic substances to MPs using a solid-phase extraction (SPE) approach and subsequent detection of the substances in a sensitivity-enhanced 7-ethoxyresorufin-O-deethylase (EROD) assay with RTL-W1 cells. Exemplarily, particles were loaded with benzo[k]fluoranthene (BkF), which was shown to bind to MPs with high affinity. Spiked particles were added to the surface of the culture medium, where they released low, but consistent amounts of BkF, which were quantified by EROD induction. Additionally, a geometrical model was developed for the estimation of numbers, surface areas and masses of MPs interacting with medium. The approach presented allows the experimental in vitro examination of the postulated function of MP as a pollutant vector in a highly sensitive animal-experimentation-free test system.

Genetically engineered zebrafish liver (ZF-L) cells as an in vitro source for zebrafish acetylcholinesterase (zfAChE) for the use in AChE inhibition assays.

Zebrafish acetylcholinesterase (zfAChE) preparations employed for the evaluation of acetylcholinesterase inhibition are usually extracted from animal tissues, a procedure suffering from both technical and ethical limitations, which may be alleviated using an in vitro expression system for enzyme generation. For this end, a protocol for stable transfection and selection of zebrafish liver (ZF-L) cells using an adapted expression plasmid "ZF-L Exp" was developed. After insertion of zfAChE cDNA, the enzyme was efficiently expressed in transgenic ZF-L cell lines, which were then used as a high yield source of zfAChE activity for acetylcholinesterase (AChE) inhibition assays. An adapted assay protocol was used to demonstrate the effects of carbaryl, dichlorvos and caffeine as model AChE inhibitors towards zfAChE. Dimethyl sulfoxide (DMSO) was also strongly inhibitory towards zfAChE. Finally, we provide data on the stability of zfAChE enzyme preparations. The novel test system provides a promising in vitro test system for the assessment of zfAChE inhibition.

Assessment of urban stream sediment pollutants entering estuaries using chemical analysis and multiple bioassays to characterise biological activities.

Stormwater contaminants are a major source of often neglected environmental stressors because of the emphasis placed on the management of municipal and industrial wastewaters. Stormwater-derived pollutants in sediments from two New Zealand estuaries was characterised by analytical chemistry and bioassays. Contaminants were extracted from sediment using accelerated solvent extraction (ASE), recovered and concentrated by solid phase extraction (SPE), and analysed for polycyclic aromatic hydrocarbons (PAHs), selected metals, and musk fragrances. The concentrations of PAHs were below the ANZECC Interim Sediment Quality Guideline values while those of lead and zinc exceeded them in some samples. The sediment extracts containing organic contaminants exhibited acute toxicity in the zebrafish fish embryo toxicity (FET) and teratogenicity, induction of biotransformation (EROD activity), and genotoxicity (comet assay) in zebrafish. The potential of the extracts to interact with endocrine signalling processes was assessed by GeneBLAzer reporter gene bioassays and they exhibited estrogenic, androgenic, and anti-progestagenic activities.

Assessment of cytotoxicity, genotoxicity and 7-ethoxyresorufin-O-deethylase (EROD) induction in sediment extracts from New Zealand urban estuaries.

Sediments represent a major sink for contaminants resulting from industrial and agricultural activities - especially lipophilic substances. This study exclusively used in vitro methodologies to characterize specific toxicity effects of contaminants in sediment extracts from two urban New Zealand estuaries. Sediment extracts were prepared and tested for a range of biological endpoints. The micronucleus and comet assays in V79 cells were used to assess genotoxicity. Induction of 7-ethoxyresorufin-O-deethylase in piscine RTL-W1 cells was determined to estimate dioxin-like toxicity. Cytotoxic potentials were analyzed by neutral red uptake and MTT reduction. There was evidence of strong dioxin-like toxicity and moderate cytotoxicity. Genotoxicity was distinct in the micronucleus assay, but low in the comet assay. The results indicate the presence of chemicals in the sediments with the potential to pose a risk through multiple mechanisms of toxicity, the identities and amounts of which will be disclosed in a parallel study alongside with in vivo toxicity data.

Improving the in vitro ethoxyresorufin-O-deethylase (EROD) assay with RTL-W1 by metabolic normalization and use of ß-naphthoflavone as the reference substance.

The ethoxyresorufin-O-deethylase (EROD) assay is a widely applied method for the evaluation of the dioxin-like activity of single substances and environmental samples. As for most enzyme assays, the specific activity is normally related to total protein contents, the determination of which has clear limitations in high-throughput assays. EROD induction potentials are usually expressed as 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) equivalents, a substance highly toxic to humans. In order to compensate for these shortcomings, two modifications of the EROD protocol are proposed: (1) EROD activity is normalized to the metabolic activity of the cells as determined by a modified thiazolyl blue tetrazolium (MTT) assay and expressed as metabolic cell equivalents (MCE) based on MTT data rather than to protein contents. Via MCE data, cytotoxicity information can always be reported in parallel to EROD data; with the protocol presented here, MTT and EROD data are collected simultaneously. (2) Among several reference substances tested (2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), ß-naphthoflavone and benzo[a]pyrene), ß-naphthoflavone proved to be the most suitable reference for the routine in vitro EROD assay, although TCDD has generally been preferred for purely scientific reasons.