Ecotoxicity and Accumulation of Perfluorononanoic Acid in the Fathead Minnow (Pimephales promelas) and an Approach to Developing Protective Thresholds in the Aquatic Environment Through Species Sensitivity Distribution.

Per- and polyfluoroalkyl substances (PFAS) are ubiquitous in the environment. Locations where PFAS-containing aqueous film-forming foam (AFFF) has been used or accidentally released have resulted in persistently high concentrations of PFAS, including in surface water that may be adjacent to release sites. Perfluorooctane sulfonic acid (PFOS) is most frequently measured near AFFF release sites; however, other PFAS are being quantified more frequently and, of those, perfluorononanoic acid (PFNA) is common. The goal of our study was to fill data gaps on PFNA toxicity to freshwater fish using the fathead minnow (Pimephales promelas). We aimed to understand how PFNA may impact apical endpoints following a 42-day exposure to mature fish and a 21-day exposure to second-generation larval fish. Exposure concentrations were 0, 124, 250, 500, and 1000 µg/L for both adult (F0) and larval (F1) generations. The most sensitive endpoint measured was development in the F1 generation at concentrations of ≥250 µg/L. The 10% and 20% effective concentration of the tested population for the F1 biomass endpoint was 100.3 and 129.5 µg/L, respectively. These data were collated with toxicity values from the primary literature on aquatic organisms exposed to PFNA for subchronic or chronic durations. A species sensitivity distribution was developed to estimate a screening-level threshold for PFNA. The resulting hazard concentration protective of 95% of the freshwater aquatic species was 55 µg PFNA/L. Although this value is likely protective of aquatic organisms exposed to PFNA, it is prudent to consider that organisms experience multiple stressors (including many PFAS) simultaneously; an approach to understand screening-level thresholds for PFAS mixtures remains an uncertainty within the field of ecological risk assessment. Environ Toxicol Chem 2023;42:2229-2236. © 2023 SETAC.

Spatial and temporal variability of per- and polyfluoroalkyl substances (PFAS) in environmental media of a small pond: Toward an improved understanding of PFAS bioaccumulation in fish.

Per- and polyfluoroalkyl substances (PFAS) are highly fluorinated compounds with many industrial applications, for instance as ingredients in fire-suppressing aqueous film-forming foams (AFFF). Several PFAS have been demonstrated to be persistent, bioaccumulative and toxic. This study better characterizes the bioaccumulation of PFAS in freshwater fish through a spatial and temporal analysis of surface water and sediment from a stormwater pond in a former Naval air station (NAS) with historic AFFF use. We sampled environmental media from four locations twice per week for five weeks and sampled fish at the end of the sampling effort. The primary PFAS identified in surface water, sediment, and biota were perfluorooctane sulfonate (PFOS) and perfluorohexane sulfonate (PFHxS) followed by perfluorooctanoic acid (PFOA) in environmental media and perfluoroheptane sulfonate (PFHpS) in biota. We observed significant temporal variability in surface water concentrations at the pond headwaters following stochastic events such as heavy rainfall for many compounds, particularly PFHxS. Sediment concentrations varied most across sampling locations. In fish, liver tissue presented the highest concentrations for all compounds except PFHxS, which was highest in muscle tissue, suggesting the influence of fine-scale aqueous PFAS fluctuations on tissue distribution. Calculated log bioaccumulation factors (BAFs) ranged from 0.13 to 2.30 for perfluoroalkyl carboxylates (PFCA) and 0.29-4.05 for perfluoroalkane sulfonates (PFSA) and fluctuated greatly with aqueous concentrations. The variability of PFAS concentrations in environmental media necessitates more frequent sampling efforts in field-based studies to better characterize PFAS contamination in aquatic ecosystems as well as exercising caution when considering single time-point BAFs due to uncertainty of system dynamics.

Diagnoses per Encounter by Telephone, Televideo, and In-Office Visits.

INTRODUCTION: We sought to determine if there are differences between number of International Classification of Disease-10 (ICD-10) codes per visit before and after COVID-19 when comparing in-office visits and between telemedicine vs in-office visits, toward the goal of determining value of telemedicine visits relative to in-office visits. METHODS: We did a chart review study assessing the number of ICD-10 codes noted by providers at a large academic medical institution in 2019 and 2020. Only in-office visits were reviewed in 2019. The focus of analysis was on individual patient visits per visit type; however, a subset of patients who had visits in both 2019 and 2020 were also analyzed. We compared mean number of diagnoses for encounter types using encounter, billing and coding data. RESULTS: We analyzed 211,829 patient encounters. For 2020, 73% were in office. Mean number of diagnoses per encounter for 2019 was 2.65 (in office only), compared with 3.04 in office, 2.76 telephone, and 2.48 televideo for 2020. DISCUSSION: We found an increase in the number of diagnoses addressed during in-office visits from 2019 to 2020. When looking at diagnoses managed per visit, all 3 types of visits had similar complexity. These results may guide future reimbursement policy for telemedicine visits.

Prospective Study of Plant-Based Dietary Patterns and Diabetes in Puerto Rican Adults.

BACKGROUND: Vegetarian-type dietary patterns have been associated with reducing the risk of developing diabetes and may function as an effective strategy for diabetes management. OBJECTIVES: We aimed to examine the associations between adherence to plant-based diet indices and the risk of developing diabetes in the Boston Puerto Rican Health Study. METHODS: Puerto Rican adults (n = 646), aged 45-75 y and free of diabetes at baseline, were included. Dietary intake was assessed via a validated FFQ. Three plant-based dietary indices were calculated: an overall plant-based diet index (PDI), a healthful plant-based diet index (hPDI), and an unhealthful plant-based diet index (uPDI). Incident diabetes was defined as fasting plasma glucose ≥ 126 mg/dL (7.0 mmol/L), glycated hemoglobin ≥ 6.5% (48 mmol/mol), or use of hypoglycemic agents during follow-up. Cox proportional hazards were used to evaluate associations between the dietary patterns and incidence of diabetes, adjusting for potential confounders, such as age, sex, socioeconomic status, lifestyle factors, obesity, total energy intake, depressive symptomatology, and plasma concentrations of lipids. RESULTS: During a mean of 4.2 y of follow-up, we identified 134 diabetes cases. After adjustment for covariates, higher hPDI was associated with lower risk of developing diabetes (adjusted HR for the highest compared with the lowest tertile: 0.54; 95% CI: 0.31, 0.94; P-trend = 0.03). In contrast, the PDI and uPDI were not significantly associated with the risk of diabetes (P-trend > 0.3 for both). CONCLUSIONS: The healthful plant-based dietary index, but not the total plant-based dietary index, was inversely associated with diabetes risk. These findings suggest that the quality of plant-based diets must be considered when recommending plant-based diets for the prevention of diabetes.This trial was registered at clinicaltrials.gov as NCT01231958.

Chronic Reproductive Toxicity Thresholds for Northern Bobwhite Quail (Colinus virginianus) Exposed to Perfluorohexanoic Acid (PFHxA) and a Mixture of Perfluorooctane Sulfonic Acid (PFOS) and PFHxA.

Terrestrial toxicology data are limited for comprehensive ecotoxicological risk assessment of ecosystems contaminated by per- and polyfluoroalkyl substances (PFAS) partly because of their existence as mixtures in the environment. This complicates logistical dose-response modeling and establishment of a threshold value characterizing the chronic toxicity of PFAS to ecological receptors. We examined reproduction, growth, and survival endpoints using a combination of hypothesis testing and logistical dose-response modeling of northern bobwhite quail (Colinus virginianus) exposed to perfluorohexanoic acid (PFHxA) alone and to PFHxA in a binary mixture with perfluorooctane sulfonic acid (PFOS) via the drinking water. The exposure concentration chronic toxicity value (CTV) representative of the lowest-observable-adverse effect level (LOAEL) threshold for chronic oral PFAS toxicity (based on reduced offspring weight and growth rate) was 0.10 ng/mL for PFHxA and 0.06 ng/mL for a PFOS:PFHxA (2.7:1) mixture. These estimates corresponded to an adult LOAEL average daily intake CTV of 0.0149 and 0.0082 µg × kg body weight-1 × d-1 , respectively. Neither no-observable-adverse effect level threshold and representative CTVs nor dose-response and predicted effective concentration values could be established for these 2 response variables. The findings indicate that a reaction(s) occurs among the individual PFAS components present in the mixture to alter the potential toxicity, demonstrating that mixture affects avian PFAS toxicity. Thus, chronic oral PFAS toxicity to avian receptors represented as the sum of the individual compound toxicities may not necessarily be the best method for assessing chronic mixture exposure risk at PFAS-contaminated sites. Environ Toxicol Chem 2021;40:2601-2614. © 2021 SETAC.

Dysrhythmias with Loperamide Used for Opioid Withdrawal.

The antidiarrheal loperamide has had a recent, drastic increase in off-label use as an alternative treatment for symptoms of opioid withdrawal. The concept of this is easily discovered on the Internet and social media, where there are multiple blogs and forums promoting loperamide use at doses of 70 to 200 mg per day. Unfortunately, the serious side effects are not well recognized. Multiple cases of cardiac dysrhythmias contributing to death have been highlighted in recent literature. In November 2016, the US Food & Drug Administration released a statement highlighting the potential heart effects and risk of death with high doses of loperamide.1 This case regards a 22-year-old who took 200 mg of loperamide per day for 2 years as an alternative to methadone in her attempts to wean off heroin. Her subsequent spontaneous collapse, dysrhythmias, and acute hospital treatment are reviewed in detail as they were contradictory to standard therapy and required a multidisciplinary approach. Her outpatient management addressed the complex biological, psychological, and social aspects of her addiction.

End-of-life care in advanced dementia.

In the next 30 years, the average age of the population will continue to increase, as will the prevalence of dementia. The management of advanced dementia requires the careful orchestration of communication, prognostication, patient care, and caregiver education. Understanding the specific tools available to establish prognosis and guide medical management in these complicated medical patients greatly improves patient and caregiver satisfaction at the end of the patient's life. In caring for patients with advanced-stage dementia, providers should be knowledgeable regarding the terminal nature of the condition and its common comorbid diseases, and should be prepared to educate the patients' caregivers, building a structure of support for the patient's benefit and navigating the complexities of end-of-life care.

Pyrolysis of cellulose under ammonia leads to nitrogen-doped nanoporous carbon generated through methane formation.

Here, we present a simple one-step fabrication methodology for nitrogen-doped (N-doped) nanoporous carbon membranes via annealing cellulose filter paper under NH3. We found that nitrogen doping (up to 10.3 at %) occurs during cellulose pyrolysis under NH3 at as low as 550 °C. At 700 °C or above, N-doped carbon further reacts with NH3, resulting in a large surface area (up to 1973.3 m(2)/g). We discovered that the doped nitrogen, in fact, plays an important role in the reaction, leading to carbon gasification. CH4 was experimentally detected by mass spectrometry as a product in the reaction between N-doped carbon and NH3. When compared to conventional activated carbon (1533.6 m(2)/g), the N-doped nanoporous carbon (1326.5 m(2)/g) exhibits more than double the unit area capacitance (90 vs 41 mF/m(2)).