Primary school mobile dental program in New South Wales, Australia: protocol for the evaluation of a state government oral health initiative

BACKGROUND

Socioeconomically disadvantaged children are disproportionately affected by oral disease. Mobile dental services help underserved communities overcome barriers to accessing health care, including time, geography, and trust. The NSW Health Primary School Mobile Dental Program (PSMDP) is designed to provide diagnostic and preventive dental services to children at their schools. The PSMDP is mainly targeted toward high-risk children and priority populations. This study aims to evaluate the program's performance across five local health districts (LHDs) where the program is being implemented.

METHODS

The evaluation will use routinely collected administrative data, along with other program-specific data sources, from the district public oral health services to conduct a statistical analysis that determines the reach and uptake of the program, its effectiveness, and the associated costs and cost-consequences. The PSMDP evaluation program utilises data from Electronic Dental Records (EDRs) and other data sources, including patient demographics, service mix, general health, oral health clinical data and risk factor information. The overall design includes cross-sectional and longitudinal components. The design combines comprehensive output monitoring across the five participating LHDs and investigates the associations between socio-demographic factors, service patterns and health outcomes. Time series analysis using difference-in-difference estimation will be conducted across the four years of the program, involving services, risk factors, and health outcomes. Comparison groups will be identified via propensity matching across the five participating LHDs. An economic analysis will estimate the costs and cost-consequences for children who participate in the program versus the comparison group.

DISCUSSION

The use of EDRs for oral health services evaluation research is a relatively new approach, and the evaluation works within the limitations and strengths of utilising administrative datasets. The study will also provide avenues to improve the quality of data collected and system-level improvements to better enable future services to be aligned with disease prevalence and population needs.

1241 MaxSim, a Novel Simulation Based Education Course for OMFS Emergencies

Introduction

For Oral and Maxillofacial Surgery (OMFS) Senior House Officers (SHOs), with no formal medical training, the first exposure to inpatient medical or OMFS emergencies will be the first time they are having to manage them, usually alone. Simulation based education has been demonstrated to increased experience and confidence when used in medical education 1, therefore an OMFS simulation-based education course was created to facilitate this learning in a safe environment.

Method

The course included stations on medical emergencies such as sepsis, and OMFS emergencies centred around scenarios that necessitate rapid response including retrobulbar haemorrhage and carotid artery blowout. A pre and post course questionnaire was given to all delegates to assess their change in confidence when managing the scenarios. Each was asked to score their confidence in managing the scenarios numerically from one to ten.

Results

Delegate numbers were limited due to the Covid-19 pandemic with all ten completing both questionnaires. There was an even distribution between first and second year SHOs. Two had received simulation training before however, very limited. In all ten simulation stations every delegate felt an increase in confidence on average by 4.5 (range: 3.8-5.6) on the ten-point scale, p < 0.05. Positive feedback was also given by all stating it was extremely useful.

Conclusions

Simulation based education has been shown to be invaluable method of training for clinical scenarios and needs to become more common place in Oral and Maxillofacial Surgery. This course is to be expanded post Covid-19 to become available nationally.

1000 Basal-Squamous Cell Carcinoma Collision Tumour Of the Preauricular Region

Case description

An 87-year-old farmer presented to the Maxillofacial Surgery department following referral by his general practitioner concerned with multiple suspected skin neoplasms. Four lesions were identified, two of which required surgical excision with 4mm margins. Following histological investigation, the lesion in the right preauricular area was identified as a basal-squamous cell carcinoma collision tumour which was completely excised with clear margins.

Discussion

This case highlights the possibility of multiple skin neoplasms in a single site and gives an insight into the surgical management of a basal-squamous cell carcinoma collision tumour while aiming to increase clinician awareness of collision tumours especially in high-risk sites such as the head and neck. This case suggests that a 4-5mm surgical margin may be sufficient in removing similar presentations of basal-squamous cell carcinoma collision tumours however highlights the importance of appropriate histological examination of specimens not only to correctly diagnose the tumour but to ensure surgical margins are clear to mitigate recurrence risk. It must be noted that systemic metastases are more common in squamous cell carcinoma than in basal cell carcinoma cases and therefore it is possible that basal-squamous cell carcinoma collision tumours may have higher rates of metastases than traditional basal cell carcinomas.

442 COVID-19 And the Oral Surgery/Orthodontic Interface: Has A Delay in Treatment Complicated the Position of Unerupted And Ectopic Teeth Planned for Surgical Removal or Exposure?

Aim

To evaluate whether there has been a change in clinical or radiographic position and the resultant occurrence of complications of unerupted and ectopic teeth due to delayed treatment during the COVID-19 pandemic

Method

Data was collected over a three-month period at the Royal United Hospital, Bath, Oral and Maxillofacial Surgery Department. This was via a questionnaire distributed to clinicians and prospectively completed for each surgical procedure planned for the removal or exposure of ectopic canines, premolars, and supernumerary teeth.

Results

A total of 20 surgical extractions or exposures were performed during the three-month period, with 33% (n = 6) having a marked difference between their expected and final position. Complications occurred in 66.6% (n = 4) of cases that demonstrated a discrepancy in location. These were an increased surgical time, increased removal of bone or a cancellation of intended treatment. This cancellation occurred as the tooth had erupted enough for non-surgical management. In cases where there was no discrepancy (n = 14), no complications were reported.

Conclusions

These findings suggest the delay in treatment caused by the COVID-19 pandemic has resulted in a clinically significant change in the position of ectopic teeth planned for surgical removal or exposure. Given these findings, it is crucial that clinicians be aware that radiographic investigations are diagnostic and recent. The threshold for repeat imaging in all cases which have been delayed should be low to avoid unexpected surgical complications arising from inaccuracy in tooth localisation.

452 Dermal Filler Injection Leading to Facial Cellulitis: A Case Report

Background

Aesthetic medicine is a rapidly expanding field that is progressively becoming a normal part of society’s health and beauty regime. Hyaluronic Acid dermal filler injections are the second most widely performed aesthetic procedure, following Botulinum Toxin type A. Although serious complications are rare, they can have a detrimental impact on aesthetic outcome and general health. Infections following dermal fillers can be difficult to treat and have the potential to require hospital admission, intravenous antibiotics and surgical intervention.

Case description

We present a case of a 41-year-old female who suffered from facial cellulitis as a consequence of palpebro-malar groove dermal filler injections. The patient had 0.1ml of Monalisa dermal filler injected over her right malar prominence and suffered complications 6 days later, which eventually lead to the need for hospital admission on day 12 following the procedure for intravenous antibiotics. The management of this aesthetic procedure complication is outlined to highlight the risks and serious complications of these procedures.

Conclusions

Facial cellulitis is a rare adverse event following facial filler injection; however, it is an important risk factor to discuss during the consent process for these procedures. In addition, it is important that a highly trained and skilled professional performs these injections using a sterile non-touch technique due to the potential for serious complications and the anatomical proximity to vital structures.

Outcomes of a co-designed, community-led oral health promotion program for Aboriginal children in rural and remote communities in New South Wales, Australia

OBJECTIVE

Improving the oral health of Aboriginal children is an Australian priority. Public policy recommends the development of evidence-based, culturally competent oral health promotion programs. Positive health outcomes are more likely for Aboriginal people when programs are co-designed with the community and tailored to local needs. This study aims to determine the impact of a community-led oral health promotion program for Aboriginal children in rural and remote communities.

BASIC RESEARCH DESIGN

Consecutive surveys. Baseline data were collected on the oral health of Aboriginal children aged five-12 years in rural and remote communities in Central Northern New South Wales in 2014. Then, an evidence-based oral health promotion program was co-designed with local Aboriginal communities. It included daily toothbrushing, water bottle program, regular application of fluoride varnish, regular distribution of toothbrushes and fluoride toothpaste and dental health education and commenced in 2016 in three schools in the region. In 2018, oral health status and oral hygiene behaviours of participating children were compared against baseline data to evaluate the program.

RESULTS

There was a significant reduction in tooth decay, plaque scores and gingivitis. The mean number of teeth affected by tooth decay was 4.13, compared to 5.31 in 2014. An increase was also seen in positive oral hygiene behaviour.

CONCLUSIONS

The co-design elements of the program are critical to its success. Engaging local Aboriginal communities to co-design and deliver oral health promotion can reduce the burden of tooth decay experienced by Aboriginal children.

In-school toothbrushing programs in Aboriginal communities in New South Wales, Australia: A thematic analysis of teachers' perspectives

OBJECTIVE

This qualitative analysis explores how school staff interacted with a daily in-school toothbrushing program in three schools in rural areas in Central Northern New South Wales, Australia, with a high population of enrolled Aboriginal students.

RESEARCH DESIGN

Three focus groups were conducted in the schools. Participants included school teachers and one Aboriginal Oral Health Aide who manage the daily program. Focus groups were conducted, and where permitted, audio-recorded and transcribed verbatim. Thematic analysis was used to analyse the transcripts. This study was granted ethics approval by the New South Wales Aboriginal Health and Medical Research Council (App 1281/17).

RESULTS

Four themes were identified: 1) Belief of Program Need and Benefit; 2) Forming routine; 3) Children's responses and 4) Sustainability. School staff embraced the program and valued the need for and benefit of the program for children in their school, seeing it as part of the extended role of the school to promote students' health and well-being. Two important enablers for the program's sustainability emerged; promoting and supporting local school leadership and training existing school staff or local Aboriginal people to manage it.

CONCLUSION

Training local Aboriginal people or existing school staff to implement a daily in-school toothbrushing program and facilitating school leadership is an important enabler for sustainable oral health promotion, including in-school toothbrushing programs, in Aboriginal communities.

Genome-wide association study of nevirapine hypersensitivity in a sub-Saharan African HIV-infected population

Background

The antiretroviral nevirapine is associated with hypersensitivity reactions in 6%-10% of patients, including hepatotoxicity, maculopapular exanthema, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN).

Objectives

To undertake a genome-wide association study (GWAS) to identify genetic predisposing factors for the different clinical phenotypes associated with nevirapine hypersensitivity.

Methods

A GWAS was undertaken in a discovery cohort of 151 nevirapine-hypersensitive and 182 tolerant, HIV-infected Malawian adults. Replication of signals was determined in a cohort of 116 cases and 68 controls obtained from Malawi, Uganda and Mozambique. Interaction with ERAP genes was determined in patients positive for HLA-C*04:01 . In silico docking studies were also performed for HLA-C*04:01 .

Results

Fifteen SNPs demonstrated nominal significance ( P  <   1 × 10 -5 ) with one or more of the hypersensitivity phenotypes. The most promising signal was seen in SJS/TEN, where rs5010528 ( HLA-C locus) approached genome-wide significance ( P  <   8.5 × 10 -8 ) and was below HLA -wide significance ( P  <   2.5 × 10 -4 ) in the meta-analysis of discovery and replication cohorts [OR 4.84 (95% CI 2.71-8.61)]. rs5010528 is a strong proxy for HLA-C*04:01 carriage: in silico docking showed that two residues (33 and 123) in the B pocket were the most likely nevirapine interactors. There was no interaction between HLA-C*04:01 and ERAP1 , but there is a potential protective effect with ERAP2 [ P  =   0.019, OR 0.43 (95% CI 0.21-0.87)].

Conclusions

HLA-C*04:01 predisposes to nevirapine-induced SJS/TEN in sub-Saharan Africans, but not to other hypersensitivity phenotypes. This is likely to be mediated via binding to the B pocket of the HLA-C peptide. Whether this risk is modulated by ERAP2 variants requires further study.

Rationale and Design of the Genetic Contribution to Drug Induced Renal Injury (DIRECT) Study

Introduction

Nephrotoxicity from drugs accounts for 18% to 27% of cases of acute kidney injury. Determining a genetic predisposition may potentially be important in minimizing risk. The aims of this study are as follows: to determine whether a genetic predisposition exists for the development of drug-induced kidney disease (DIKD), using genome-wide association and whole-genome sequencing studies; to describe the frequency, course, risk factors, resolution and outcomes of DIKD cases; to investigate the role of ethnic/racial variability in the genetics of DIKD; and to explore the use of different tools establishing causality of DIKD.

Methods

A total of 800 patients will be enrolled worldwide and blood samples for DNA collected. Data on the patient risk factors, vital signs, laboratory parameters, drug exposure, and DIKD course will be recorded. A panel of nephrologists will adjudicate all cases. Genome-wide association studies will be conducted using population controls matched on biogeographic ancestry to determine whether there is a genetic predisposition to DIKD. The primary endpoint is the identification of specific drug-related polymorphisms associated with DIKD. Secondary endpoints include the following: frequency of DIKD by causal drug and drug combinations; DIKD genetic variability; exploration of causality assessment tools; risk factor identification; description of the course of DIKD, including mortality and dialysis dependency at hospital discharge and 28 and 90 days post-event.

Results

Data are currently being analyzed. Results are pending.

Discussion

The Genetic Contribution to Drug Induced Renal Injury (DIRECT) study will be the first observational cohort study to investigate the genetic determinants of DIKD. If the trial is positive, its findings will potentially translate into safer patient outcomes, by genotypic individualization of therapy and minimization of harm.

PBDE levels in breast milk are decreasing in California

To assess the efficacy of the bans in reducing PBDE levels, we recruited 67 California first time mothers (sampled during 2009-2012) and collected cord blood at birth (n = 31), breast milk (n = 66) and maternal blood (n = 65) at 3-8 weeks postpartum. Using the same sample extraction procedures and analytical instrumentation method (GC-HRMS), we compared PBDE as well as PCB levels in these breast milk samples to those from our previous study (n = 82, sampled during 2003-2005) and found that the sum of PBDEs over the ∼7 year course declined by 39% (GeoMean = 67.8 ng/g lipid in 2003-2005; 41.5 ng/g lipid in 2009-2012) and that the sum of PCBs declined by 36% (GeoMean = 71.6 ng/g lipid in 2003-2005; 45.7 ng/g lipid in 2009-2012). This supports our earlier finding of a PBDE decline (39%) in blood. We also found that the PBDE concentrations and congener profiles were similar in breast milk and their matched maternal/cord blood: BDE-47 was the dominant congener, followed by BDE-153, -99, and -100. Similar levels and congener profiles of PBDEs in these matrices suggest that they are at equilibrium. Therefore, we propose that maternal serum levels may be used to predict an infant's daily dose of PBDE exposure from breastfeeding when breast milk levels are not available. In addition, our study confirmed that breastfeeding babies are still exposed to high levels of PBDEs, even though PBDE levels are decreasing.

Clinical Features and HLA Association of 5-Aminosalicylate (5-ASA)-induced Nephrotoxicity in Inflammatory Bowel Disease

BACKGROUND AND AIMS

Nephrotoxicity is a rare idiosyncratic reaction to 5-aminosalicylate (5-ASA) therapies. The aims of this study were to describe the clinical features of this complication and identify clinically useful genetic markers so that these drugs can be avoided or so that monitoring can be intensified in high-risk patients.

METHODS

Inflammatory bowel disease patients were recruited from 89 sites around the world. Inclusion criteria included normal renal function prior to commencing 5-ASA, ≥50% rise in creatinine any time after starting 5-ASA, and physician opinion implicating 5-ASA strong enough to justify drug withdrawal. An adjudication panel identified definite and probable cases from structured case report forms. A genome-wide association study was then undertaken with these cases and 4109 disease controls.

RESULTS

After adjudication, 151 cases of 5-ASA-induced nephrotoxicity were identified. Sixty-eight percent of cases were males, with nephrotoxicity occurring at a median age of 39.4 years (range 6-79 years). The median time for development of renal injury after commencing 5-ASA was 3.0 years (95% confidence interval [CI] 2.3-3.7). Only 30% of cases recovered completely after drug withdrawal, with 15 patients requiring permanent renal replacement therapy. A genome-wide association study identified a suggestive association in the HLA region (p = 1×10(-7)) with 5-ASA-induced nephrotoxicity. A sub-group analysis of patients who had a renal biopsy demonstrating interstitial nephritis (n = 55) significantly strengthened this association (p = 4×10(-9), odds ratio 3.1).

CONCLUSIONS

This is the largest and most detailed study of 5-ASA-induced nephrotoxicity to date. It highlights the morbidity associated with this condition and identifies for the first time a significant genetic predisposition to drug-induced renal injury.

Endovascular sac sealing concept: will the Endologix Nellix™ device solve the deficiencies?

The deficiencies in current endovascular aneurysm repair include limited applicability to treat aneurysm anatomies, a significant reintervention rate to manage postprocedural complications and a requirement for postprocedural surveillance. Endovascular aneurysm sealing with the Nellix™ device offers the potential to address these issues by directly treating the aneurysm sac and minimizing the risk of endoleak of any type as well as device migration. The unique sealing technology of polymer filled endobags also provides an opportunity to treat aneurysm anatomies that could not be effectively treated with conventional endografts. The early clinical experience with Nellix™ supports these concepts but long-term durability is yet to be established.

Public opinion

This opinion-based article aims to highlight the worrying decline in support for dental public health as a specialty. Not only is this specialty important for its role in commissioning services, it is crucial for the identification of vulnerable groups in society and ensuring dental services are acceptable and assessable for these populations. Dental public health also addresses the social determinants of health in its approach, acknowledging the impact of these in perpetuating inequalities and looking for multisectoral approaches to their management. This article also looks at the lack of appreciation for these determinants in dental foundation training and how a change in the structure of the programme could both address this and the current shortage of places.

The time-course of single-word reading: evidence from fast behavioral and brain responses

We usually feel that we understand a familiar word “immediately”. However, even basic aspects of the time-line of word recognition are still controversial. Different domains of research have still not converged on a coherent account. An integration of multiple sources of information would lead to more strongly constrained theoretical models, and help finding optimal measures when monitoring specific aspects of word recognition impairments in patient groups. In our multimodal approach – combining fast behavioral measures, ERPs and EEG/MEG source estimation – we provide converging evidence for the latencies of earliest lexical and semantic information retrieval in visual word recognition. Participants performed lexical and semantic decisions (LD, SD) in a Go/NoGo paradigm. We introduced eye-blink latencies as a dependent variable, in order to measure behavioral responses that are faster and less variable than traditional button presses. We found that the earliest behavioral responses distinguishing stimulus categories can occur around 310 ms. Ex-Gaussian analysis of behavioral responses did not reveal reliable differences between LD and SD. The earliest ERP differences between Go and NoGo conditions occurred around 160 ms for both LD and SD. Distributed source analysis of combined EEG/MEG data estimated neuronal generators for the lexicality effect around 200 ms in the left anterior middle temporal lobe. Thus, behavior and brain responses provide coherent evidence that the brain starts retrieving lexical and semantic information near-simultaneously within 200 ms of word onset. Our results support models of word recognition that assume a continuous accumulation of task-related information from the stimulus, which might be described by Bayesian principles.

High postnatal exposures to polybrominated diphenyl ethers (PBDEs) and polychlorinated biphenyls (PCBs) via breast milk in California: does BDE-209 transfer to breast milk?

Breast milk samples collected during 2003-2005 from 82 first-time mothers in 24 communities located throughout California contained levels of polybrominated diphenyl ethers (∑(tri-hexa (8))PBDEs; median = 53.3 ng/g lw, range = 9.60-1291) and polychlorinated biphenyls (∑(12)PCBs; median = 73.4 ng/g lw, range = 22.2-433) that are among the highest in the world. PBDE levels varied 100-fold. BDE-47 was the dominant PBDE congener, with levels exceeding the U.S.EPA Reference Dose (RfD) for neurodevelopmental toxicity (100 ng/kg/day) in most (60%) breast milk samples. In some samples, BDE-209 (2/82) and/or BDE-153 (5/82) were the dominant congeners, suggesting that BDE-209 can transfer to breast milk and/or break down in the mother and transfer to the nursing infant as the lower-brominated PBDEs associated with adverse effects. PBDE levels in California breast milk are approaching those of PCBs, and the trend PBDEs > PCBs may continue as PBDEs migrate from products to the indoor and outdoor environments.

Prey species as possible sources of PBDE exposures for peregrine falcons (Falco peregrinus) nesting in major California cities

Our earlier findings indicate that (1) peregrine falcons (Falco peregrinus anatum Bonaparte) nesting in major California cities have among the highest polybrominated diphenyl ether (PBDE) levels in the world (max ∑PBDEs=100 ppm), and (2) Big City peregrines have higher levels and proportions of the higher-brominated congeners (hepta- to deca-BDEs) than do their Coastal counterparts. In this study we classified the prey species (n =185) from the remains of prey (feathers) at 38 peregrine nest sites over 25 years (1974-1998). We grouped the prey species into 15 categories based on diet and found distinctly different prey patterns for Big City vs. Coastal peregrines. Big City peregrines had a higher (almost three times) weight percentage intake of food waste-eating birds (e.g., rock pigeons, Columba livia) than Coastal peregrines. These differing prey patterns suggest diet as a potential source of the unusually high levels and proportions of higher-brominated PBDEs in Big City peregrines. The relative contributions of diet and dust (e.g., preening) exposure to PBDE patterns in Big City peregrines will be explored in future investigations.

Polybrominated diphenyl ether (PBDE) levels in peregrine falcon (Falco peregrinus) eggs from California correlate with diet and human population density

Peregrine falcons are now considered a conservation success story due in part to the phasing out of harmful contaminants that adversely affected reproduction. Recent studies have shown that peregrine eggs collected from California cities, however, have high levels of the higher-brominated polybrominated diphenyl ethers (SigmaPBDE(183-209)), a class of industrial flame retardants, in comparison to published data for other wildlife. Sources of these high PBDE levels and unusual PBDE profiles are unknown. Here we analyzed the stable carbon (delta(13)C), hydrogen (deltaD), and nitrogen (delta(15)N) isotope composition of peregrine eggs collected from urban and nonurban habitats. We found that delta(13)C values were significantly higher in urban versus nonurban eggs, suggesting that urban peregrines indirectly receive anthropogenic subsidies via their consumption of prey reliant on corn-based anthropogenic foods. delta(15)N and deltaD values were significantly lower in urban versus nonurban eggs, reflecting differences in dietary diversity and food/water sources available to peregrines in each habitat. These patterns suggest a link between an anthropogenic diet and high levels of SigmaPBDE(183-209) in California peregrines, and identify anthropogenic food as a potentially important PBDE exposure pathway for urban wildlife. If diet is an important PBDE exposure pathway for peregrines, continued high body burdens of SigmaPBDE(183-209) may be a potential risk to ongoing peregrine conservation efforts in California.

Time-trends and congener profiles of PBDEs and PCBs in California peregrine falcons (Falco peregrinus)

High levels (microg/g lw) of polybrominated diphenyl ethers (PBDEs) and polychlorinated biphenyls (PCBs) were measured in peregrine falcon eggs from California (n = 90 eggs from 52 birds, 38 nest sites, collected 1986-2007, SigmaPBDEs median = 4.53, range = 0.08-53.1). Over the past 22 years, PBDE levels more than tripled each decade in the eggs, whereas PCB levels had no significant changes. PBDE levels were highest in eggs from major California cities ("Big Cities"), whereas PCBs showed no difference across the regions. For PBDEs, Big City eggs had markedly different patterns from Coastal eggs: BDE-209 and the higher brominated PBDEs (hexa-nona) were dominant congeners in Big City eggs, while BDE-47 and -99 were dominant in Coastal eggs. In many of the birds that gave multiple eggs over time ("time series"), PBDE patterns changed over time: the high proportions of BDE-209 and higher brominated PBDEs (short half-lives) in young birds contrasted with increasingly higher proportions of BDE-153 (long half-life) and other lower brominated PBDEs as the birds aged. These data are consistent with metabolic debromination of BDE-209 (t(1/2) = 1-2 weeks) to the lower brominated PBDEs, with accumulation over time of BDE-153 (t(1/2) = 3-4 years). In contrast, PCB patterns showed no differences by locations, and did not change over time. Diet (prey birds) may explain the urban PBDE pattern, as the patterns in urban pigeons and peregrines were similar, with high proportions of BDE-209 and the higher-brominated PBDEs. Also, our prey data (feathers from peregrine nests) showed urban peregrines having a higher proportion (>2 fold) of granivorous/opportunistic birds (e.g., "introduced feral" pigeons, mourning doves, starlings) in their diet than coastal peregrines. In summary, these data indicate that BDE-209 exits consumer products as an environmental contaminant to be taken up by wildlife (particularly in urban locations), and undergoes metabolic debromination to the banned lower-brominated PBDEs. High levels of the higher-brominated PBDE congeners, especially in urban locations, permitted accurate measures of relative proportions of homologues in each of the hexa-nona congener classes. Using the major hexa-nona homologues in each of these classes, we propose a pathway for the stepwise, metabolic debromination of BDE-209.

Unusual hepta- and octabrominated diphenyl ethers and nonabrominated diphenyl ether profile in California, USA, peregrine falcons (Falco peregrinus): more evidence for brominated diphenyl ether-209 debromination

High (maximum of 4.1 ppm lipid weight) levels of BDE-209 and other higher brominated diphenyl ethers (BDEs) found in California, USA, peregrine falcon (Falco peregrinus) eggs (n = 95) provided an opportunity to examine homolog profiles of nona-, octa-, and hepta-BDEs as possible evidence for biological debromination of BDE-209. We found two congeners in eggs, an unidentified hepta-BDE (BDE-heptaUNK) and BDE-202 (octa-BDE) that are not present in commercial mixtures. In addition, BDE-208 (nona-BDE) was present at much higher (10-fold) proportions in eggs than in commercial mixtures. To examine whether these unusual homolog patterns arose from assimilation of environmentally degraded BDE commercial mixtures, we compared nona-hepta-BDE homolog profiles of peregrine falcon eggs with those of weathered BDEs present in various abiotic matrices (sludge, sediment, and dusts). We found the profiles differed significantly: BDE-207 was the major nona-BDE in eggs, whereas BDE-206 was the major nona-BDE in abiotic matrices. Thus, the evidence for the biological debromination of BDE-209 in peregrine falcons is twofold: Eggs have two congeners (BDE-202 and -heptaUNK) that are not reported for any commercial mixtures nor in the abiotic matrices examined thus far, and eggs have higher-brominated BDE homolog patterns that are different from those found in commercial mixtures or environmental matrices.

Concentrations and time trends of polybrominated diphenyl ethers (PBDEs) and polychlorinated biphenyls (PCBs) in aquatic bird eggs from San Francisco Bay, CA 2000-2003

Concentrations of polybrominated diphenyl ethers (PBDEs) and polychlorinated biphenyls (PCBs) were measured in 169 avian eggs. We analyzed randomly collected eggs of two species of piscivorous birds: Caspian tern (Sterna caspia) (n=78) and Forster's tern (Sterna forsteri) (n=76). We also analyzed fail-to-hatch eggs from two species protected under the Federal Endangered Species Act of 1973, that breed in the San Francisco Bay region: the piscivorous California Least tern (Sterna antillarum brownii) (n=11) and the omnivorous California Clapper rail (Rallus longirostris obsoletus) (n=4). San Francisco Bay eggs were collected annually for four years (2000-2003), and additional 20 eggs were collected and analyzed from Gray's Harbor, Washington in 2001. Geometric mean PBDE concentrations did not significantly differ in the three tern species, but concentrations in eggs from the fail to hatch California Clapper rail eggs were significantly lower than those found in the randomly collected tern eggs. Median concentrations of SigmaPBDEs in Caspian tern eggs for 2000-2003 were 2410, 4730, 3720 and 2880 ng/g lipid weight (lw), respectively, in Forster's terns 1820, 4380, 5460 and 3600 ng/g lw, respectively, and in California Least terns for 2001 and 2002 were 5060 and 5170 ng/g lw, respectively. In contrast, median SigmaPBDEs concentration in California Clapper rail eggs for 2001 was 379 ng/g lw. Five PBDEs were the major congeners found and decreased in the order BDE-47, -99, -100, -153, and -154. BDE-32, -28, -71, -66, -85, -183 were less prevalent, minor congeners, as was BDE-209, which was measured in a subset of samples. PBDE concentrations in bird eggs from San Francisco Bay were site related. There was no significant difference in PBDE concentrations in Caspian tern eggs from San Francisco Bay and Gray's Harbor, WA. Average PBDE concentrations in eggs did not significantly increase over the period 2000-2003.

Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial

BACKGROUND

Our aim was to investigate whether a nurse-coordinated multidisciplinary, family-based preventive cardiology programme could improve standards of preventive care in routine clinical practice.

METHODS

In a matched, cluster-randomised, controlled trial in eight European countries, six pairs of hospitals and six pairs of general practices were assigned to an intervention programme (INT) or usual care (UC) for patients with coronary heart disease or those at high risk of developing cardiovascular disease. The primary endpoints-measured at 1 year-were family-based lifestyle change; management of blood pressure, lipids, and blood glucose to target concentrations; and prescription of cardioprotective drugs. Analysis was by intention to treat. The trial is registered as ISRCTN 71715857.

FINDINGS

1589 and 1499 patients with coronary heart disease in hospitals and 1189 and 1128 at high risk were assigned to INT and UC, respectively. In patients with coronary heart disease who smoked in the month before the event, 136 (58%) in the INT and 154 (47%) in the UC groups did not smoke 1 year afterwards (difference in change 10.4%, 95% CI -0.3 to 21.2, p=0.06). Reduced consumption of saturated fat (196 [55%] vs 168 [40%]; 17.3%, 6.4 to 28.2, p=0.009), and increased consumption of fruit and vegetables (680 [72%] vs 349 [35%]; 37.3%, 18.1 to 56.5, p=0.004), and oily fish (156 [17%] vs 81 [8%]; 8.9%, 0.3 to 17.5, p=0.04) at 1 year were greatest in the INT group. High-risk individuals and partners showed changes only for fruit and vegetables (p=0.005). Blood-pressure target of less than 140/90 mm Hg was attained by both coronary (615 [65%] vs 547 [55%]; 10.4%, 0.6 to 20.2, p=0.04) and high-risk (586 [58%] vs 407 [41%]; 16.9%, 2.0 to 31.8, p=0.03) patients in the INT groups. Achievement of total cholesterol of less than 5 mmol/L did not differ between groups, but in high-risk patients the difference in change from baseline to 1 year was 12.7% (2.4 to 23.0, p=0.02) in favour of INT. In the hospital group, prescriptions for statins were higher in the INT group (810 [86%] vs 794 [80%]; 6.0%, -0.5 to 11.5, p=0.04). In general practices in the intervention groups, angiotensin-converting enzyme inhibitors (297 [29%] INT vs 196 [20%] UC; 8.5%, 1.8 to 15.2, p=0.02) and statins (381 [37%] INT vs 232 [22%] UC; 14.6%, 2.5 to 26.7, p=0.03) were more frequently prescribed.

INTERPRETATION

To achieve the potential for cardiovascular prevention, we need local preventive cardiology programmes adapted to individual countries, which are accessible by all hospitals and general practices caring for coronary and high-risk patients.

Interventional radiology: a survey of trainees

A survey of trainees on the RANZCR training programme was carried out regarding their training in and attitudes towards interventional radiology. There was a 37% response rate with 132 respondents. Approximately 60% of trainees are moderately or strongly interested in interventional radiology. Factors involved in deciding on interventional radiology as a career are discussed, as is the current level of interventional training in Australasia. The idea of a separate interventional radiology stream was met with moderate support. Early training involvement, a more rigorous training programme and providing a high-quality service were identified as the most important factors in improving and maintaining standards in interventional radiology.

Depuration of polybrominated diphenyl ethers (PBDEs) and polychlorinated biphenyls (PCBs) in breast milk from California first-time mothers (primiparae)

BACKGROUND

Little is known about the rates of loss (depuration) of polybrominated diphenyl ethers (PBDEs) and polychlorinated biphenyls (PCBs) from mothers during lactation. Depuration rates affect infant exposure to chemicals during breast-feeding, and fetal and lactational transfers during subsequent pregnancies.

OBJECTIVE

Our objective in this study was to estimate depuration rates of PBDEs and PCBs using serial samples of breast milk.

METHOD

Nine first-time mothers (primiparae) each collected samples at 4, 6, 8, 12, 16, 20, and 24 weeks after birth. Nine additional primiparae each collected two samples at varying time intervals (18 to > 85 weeks after birth). Analytical precision was assessed to evaluate the accuracy of measured monthly percentage declines in PBDEs and PCBs.

RESULTS

The four major PBDE congeners decreased 2 or 3% +/- 1% per month over the 6-month period. These decreases were consistent over a 50-fold range (21-1,330 ng/g lipid weight) of initial PBDE concentrations in breast milk. The change in PCB-153 ranged from + 0.3% to -0.6% per month, with heterogeneous slopes and greater intraindividual variability. PBDE and PCB concentrations declined 1% per month over longer periods (up to 136 weeks).

CONCLUSIONS

Our data indicate that PBDEs and PCBs are not substantially (4-18%) reduced in primiparae after 6 months of breast-feeding. Consequently, the fetal and lactational exposures for a second child may not be markedly lower than those for the first. Participants were volunteers from a larger study population (n = 82), and were typical in their PBDE/PCB levels and in many demographic and lifestyle factors. These similarities suggest that our results may have broader applicability.

Polybrominated diphenyl ethers (PBDEs) and polychlorinated biphenyls (PCBs) in breast milk from the Pacific Northwest

Breast milk samples from 40 first-time mothers from the Pacific Northwest of the US and Canada were analyzed for polybrominated diphenyl ethers (PBDEs) and polychlorinated biphenyls (PCBs). Total PBDEs (summation operator PBDEs), calculated by summing values for the 12 PBDEs congeners analyzed, ranged from 6 to 321 ppb (lipid weight) (mean=96 ppb; median=50 ppb). In approximately 40% of the women (15/40), summation operator PBDEs>100 ppb lw in their milk, and four samples had levels >250 ppb lw. PBDE 47 was the dominant congener in most samples, whereas PBDE 153 was predominant in a few (3/40). summation operator PCBs were calculated by summing values for the 82 PCB congeners analyzed, and ranged from 49 to 415 ppb (lipid weight) (mean=147 ppb; median=126 ppb). approximately 30% of the mothers (13/40) have summation operator PBDEs> summation operator PCBs in their milk samples, and approximately 65% (25/40) have BDE 47>PCB 153 in breast milk samples, with BDE 47 averaging 3-fold greater levels than PCB 153. Clearly, the lower brominated PBDEs are surpassing PCBs as a major environmental concern in North America, and are likely affecting significant portions of the populations in these regions. PBDEs have become a major persistent organic pollutant. However, there are no positive correlations between levels of summation operator PBDEs and summation operator PCBs, or between levels of PBDE 47 and PCB 153, suggesting there may be some differences in exposure pathways for PBDEs and PCBs in humans.

Renal artery stent revascularization with embolic protection in patients with ischemic nephropathy

A prospective analysis of renal artery stent revascularization with distal embolic protection in a high-risk patient population with ischemic nephropathy is presented. A total of 63 patients (median age 70.2 years, range 54-86 years) had significant atherosclerotic stenosis of 83 renal arteries documented on pre-procedural imaging. All patients had baseline chronic renal insufficiency with a documented deterioration in renal function in the 6 months before revascularization. The endovascular technique used in all patients involved primary passage of an embolic filter into the distal main renal artery followed by primary stent deployment with a balloon expandable stainless steel stent. The filter baskets were recaptured and contents submitted for pathological analysis. At 6 months post-intervention, 97% of patients demonstrated stabilization or improvement in renal function. Only 3% of patients had an inexorable decline in renal function, unchanged by the intervention. After a mean follow up of 16.0 months (6-27), 94% of patients demonstrated stabilization or improvement in renal function. One patient suffered an acute post-procedural deterioration in renal function. In total, 60% of the filter baskets contained embolic material. This study confirms the technical feasibility of renal artery stent deployment with adjuvant embolic protection. The excellent results for renal preservation at 6 months post-intervention also suggest that a distal embolic protection device may improve the impact of percutaneous renal revascularization on progressive deterioration in renal function. The postulated mechanism is through the prevention of atheromatous embolization and the embolic yield from the distal filters supports this hypothesis. Patients most likely to receive the greatest benefit are those with mild baseline chronic renal insufficiency and a recent decline in renal function.

Spontaneous coeliac artery dissection

A patient with spontaneous coeliac artery dissection that presented as upper abdominal pain is reported. This was diagnosed on contrast-enhanced multislice helical CT. The patient was treated conservatively and follow-up CT showed mild aneurysmal change of the splenic artery and a small splenic infarct. Isolated dissection of the visceral arteries (and, in particular, the coeliac artery) is extremely rare. With such limited evidence, decisions over best management are difficult, but depend on initial severity and progression at follow up.

Basal ganglia activation in Parkinson's disease

The objective of this study was to compare basal ganglia activation in patients with Parkinson's disease to that of healthy controls, using functional MRI (fMRI). Six mildly-affected patients, off antiparkinsonian medications for at least 12h, and seven age-matched controls performed a unilateral motor switching task during fMRI data acquisition. Clear differences in basal ganglia activation were seen, with control subjects showing greater activation during both the left and right movement sessions. We observed activation of right sided basal ganglia structures in both groups, particularly with right sided movements, with caudate activation noted most frequently. This observation is consistent with right caudate involvement in the learning of new tasks and in association with externally paced movements.

Studies on the putative interactions between the organophosphorus insecticide Phosmet and recombinant mouse PrP and its implication in the BSE epidemic

It has been suggested that exposure of cattle to the ectoparasiticide Phosmet in the 1980s caused a conformational change in the cellular prion protein (PrP(C)) to form the BSE prion (PrP(SC)), which initiated the epidemic of bovine spongiform encephalopathy (BSE). Recombinant mouse cellular prion (r[mouse]PrP(C)) was exposed to the organophosphorus pesticide Phosmet in vitro and the conformation of the prion before and after exposure was monitored using circular dichroism (CD) spectroscopy, utilizing synchrotron radiation at the Council for the Central Laboratory of the Research Councils (CLRC) facilities at Daresbury, UK. Metabolites of Phosmet, generated in situ by rat microsomes, were investigated in the same way, to determine whether they might initiate the conformational change due to their high chemical reactivity. Our studies showed that exposure of r[mouse]PrP(C) to Phosmet or microsomes-generated metabolites of Phosmet did not result in the conformational change in the protein from alpha-helix to beta-pleated sheet that is characteristic of the PrP(C) to PrP(SC) conversion and, therefore, Phosmet is very unlikely to have initiated the BSE epidemic by a simple direct mechanism of conformational change in the prion protein.

Inflammatory pseudotumour of the liver

A case of inflammatory pseudotumour of the liver is presented. The clinical, radiological and pathological findings are described and a brief discussion of this rare but important condition is presented.