Differential Developmental Neurotoxicity and Tissue Uptake of the Per- and Polyfluoroalkyl Substance Alternatives, GenX and PFBS

Per- and polyfluoroalkyl substances (PFAS) are a class of synthetic chemicals with several applications. Multiple adverse health effects are reported for longer carbon chain (≤C8) PFAS. Shorter carbon chain PFAS, [e.g., hexafluoropropylene oxide dimer acid (HFPO-DA; GenX) and perfluorobutanesulfonic acid (PFBS)] were introduced as alternatives. Past studies indicate that longer-chain PFAS are neurotoxic targeting the dopamine pathway, but it is not known if shorter-chain PFAS act similarly. This study aimed to evaluate developmental neurotoxicity and tissue uptake of GenX and PFBS using the zebrafish (Danio rerio). First, acute toxicity was assessed by measuring LC50 at 120 h postfertilization (hpf). Body burden was determined after embryonic exposure (1-72 hpf) to sublethal concentrations of GenX or PFBS by LC-ESI-MS/MS. Locomotor activity using a visual motor response assay at 120 hpf and dopamine levels at 72 hpf was assessed after embryonic exposure. PFBS was more acutely toxic and bioaccumulative than GenX. GenX and PFBS caused hyperactivity at 120 hpf, but stronger behavioral alterations were observed for PFBS. An increase in whole organism dopamine occurred at 40 ppb of GenX, while a decrease was observed at 400 ppb of PFBS. Differences detected in dopamine for these two PFAS indicate differential mechanisms of developmental neurotoxicity.

Toxicities of Legacy and Current-Use PFAS in an Anuran: Do Larval Exposures Influence Responses to a Terrestrial Pathogen Challenge?

Legacy polyfluoroalkyl substances (PFAS) [perfluorooctanesulfonate (PFOS) and perfluorooctanoic acid (PFOA)] are being replaced by various other fluorinated compounds, such as hexafluoropropylene oxide dimer acid (GenX). These alternatives are thought to be less bioaccumulative and, therefore, less toxic than legacy PFAS. Contaminant exposures occur concurrently with exposure to natural stressors, including the fungal pathogen Batrachocytrium dendrobatidis (Bd). Despite evidence that other pollutants can increase the adverse effects of Bd on anurans, no studies have examined the interactive effects of Bd and PFAS. This study tested the growth and developmental effects of PFOS, PFOA, and GenX on gray treefrog (Hyla versicolor) tadpoles, followed by a Bd challenge after metamorphosis. Despite PFAS exposure only occurring during the larval stage, carry-over effects on growth were observed post metamorphosis. Further, PFAS interacted with Bd exposure to influence growth; Bd-exposed animals had significantly shorter SVL [snout-vent length (mm)] with significantly increased body condition, among other time-dependent effects. Our data suggest that larval exposure to PFAS can continue to impact growth in the juvenile stage after exposure has ended. Contrary to predictions, GenX affected terrestrial performance more consistently than its legacy congener, PFOA. Given the role of Bd in amphibian declines, further investigation of interactions of PFAS with Bd and other environmentally relevant pathogens is warranted.

Reconnaissance Survey of Organic Contaminants of Emerging Concern in the Kabul and Swat Rivers of Pakistan

The Swat and Kabul rivers of northern Pakistan are within an important regional watershed that supports river-based livelihoods and is impacted by untreated effluent discharges and municipal solid waste. Evidence indicates that fish populations are decreasing in these rivers. One potential cause of poor aquatic health is pollution; therefore, we investigated the presence of contaminants of emerging concern (CECs) in the river systems. Water samples were collected in the Kabul River (n = 9) and Swat River (n = 10) during seasons of high (summer 2018) and low (winter 2019) river flow. Agrochemicals, pharmaceuticals, plasticizers, chemicals in personal care products, and hormones were quantified via liquid chromatography high-resolution mass spectrometry. In the Swat River, caffeine (18-8452 ng/L), N,N-diethyl-meta-toluamide (DEET; 16-56 ng/L), and plasticizers (13-7379 ng/L) were detected at all sites during both seasons, while butachlor (16-98 ng/L) was detected only during high flow. In the Kabul River, caffeine (12-2081 ng/L) and several plasticizers (91-722 ng/L) were detected at all sites during both seasons, while DEET (up to 97 ng/L) was detected only during high flow. During low flow, pharmaceuticals (analgesics and nonsteroidal anti-inflammatory drugs) were quantified in both rivers (up to 823 ng/L), with detection frequencies from 70% to 100% and 0% to 78% in the Swat and Kabul Rivers, respectively. Intermittent-use and natural seasonal processes (increased runoff and dilution from rainfall and snowmelt) yielded higher agrochemical concentrations and lower concentrations of continuous-use compounds (e.g., caffeine) during high flow. The present study provides the first insight into CEC concentrations in the Swat River, additional insight into the Kabul River stressors, and, overall, contaminant risks to aquatic life. Environ Toxicol Chem 2023;42:2599-2613. © 2023 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Electric Field-Assisted Nanofiltration for PFOA Removal with Exceptional Flux, Selectivity, and Destruction

Per- and polyfluoroalkyl substances (PFAS) pose significant environmental and human health risks and thus require solutions for their removal and destruction. However, PFAS cannot be destroyed by widely used removal processes like nanofiltration (NF). A few scarcely implemented advanced oxidation processes can degrade PFAS. In this study, we apply an electric field to a membrane system by placing a nanofiltration membrane between reactive electrodes in a crossflow configuration. The performance of perfluorooctanoic acid (PFOA) rejection, water flux, and energy consumption were evaluated. The reactive and robust SnO2-Sb porous anode was created via a sintering and sol-gel process. The characterization and analysis techniques included field emission scanning electron microscopy (FE-SEM), X-ray photoelectron spectroscopy (XPS), X-ray diffraction (XRD), ion chromatography, mass spectroscopy, porosimeter, and pH meter. The PFOA rejection increased from 45% (0 V) to 97% (30 V) when the electric field and filtration were in the same direction, while rejection capabilities worsened in opposite directions. With saline solutions (1 mM Na2SO4) present, the induced electro-oxidation process could effectively mineralize PFOA, although this led to unstable removal and water fluxes. The design achieved an exceptional performance in the nonsaline feed of 97% PFOA rejection and water flux of 68.4 L/m2 hr while requiring only 7.31 × 10-5 kWh/m3/order of electrical energy. The approach's success is attributed to the proximity of the electrodes and membrane, which causes a stronger electric field, weakened concentration polarization, and reduced mass transfer distances of PFOA near the membrane. The proposed electric field-assisted nanofiltration design provides a practical membrane separation method for PFAS removal from water.

Chronic Exposure to a PFAS Mixture Resembling AFFF-Impacted Surface Water Decreases Body Size in Northern Leopard Frogs (Rana pipiens)

Per- and polyfluoroalkyl substances (PFAS) occur in the environment as mixtures, yet mixture toxicity remains poorly understood. Aqueous film-forming foams (AFFFs) are a common source of PFAS. Our objective was to examine chronic effects of a complex PFAS mixture on amphibian growth and development. We tested toxicity of a five-chemical PFAS mixture summing to 10 μg/L and that accounts for >90% of the PFAS in AFFF-affected surface waters: perfluorooctane sulfonate (PFOS, 40%), perfluorohexane sulfonic acid (PFHxS, 30%), perflurooctanoic acid (PFOA, 12.5%), perfluorohexanoic acid (PFHxA, 12.5%), and perfluoropentanoic acid (PFPeA, 5%). We also included treatments to determine whether PFOS drove mixture toxicity and whether PFOS and mixture components act additively. We exposed Northern leopard frog (Rana pipiens) larvae through metamorphosis (∼130 d) in outdoor mesocosms. After 21 days of exposure, the larval body condition fell ∼5% relative to controls in the 4 μg/L PFOS treatment and mixtures lacking PFOS. At metamorphosis, the full 5-component 10 μg/L PFAS mixture reduced mass by 16% relative to controls. We did not observe effects on development. Our results indicate that toxicity of PFOS and other PFAS mixtures typical of AFFF sites act additively and that PFOS is not more inherently toxic than other mixture components.

Per- and polyfluoroalkyl substances in water treatment residuals: Occurrence and desorption

Per- and polyfluoroalkyl substances (PFAS) in surface and ground waters supplying municipal drinking water are a growing concern. However, PFAS concentrations in water treatment residuals (WTRs)-a solid by-product of water treatment-have yet to be explored. In a first of its kind assessment, we examine PFAS occurrence in seven calcium (Ca)-, iron-, and aluminum-based drinking water treatment residuals (DWTRs) and one wastewater effluent treatment residual (WWETR) produced using aluminum chlorohydrate (ACH). Only perfluoroalkyl acids (PFAAs) were detected, with total PFAA concentrations in the seven DWTRs produced from naturally recharged water sources ranging from 0 to ∼3.3 μg kg-1 ; no PFAS were detected in either of the Ca-DWTRs. The ACH-WWETR contained the highest number and concentration of PFAAs (34 μg kg-1 ). Desorption of resident PFAAs from the WTRs was negligible for the carboxylates (PFCAs). Some desorption of the sulfonates (PFSAs) was detected, particularly for PFOS which had the highest concentration among all resident PFAAs. The ACH-WWETR was further evaluated for its potential to attenuate additional PFAAs (3500 μg mL-1 total PFAAs) in a biosolid-derived porewater matrix. Sorption was highest for long-chain PFAAs and subsequent desorption of the adsorbed PFAAs ranged from 0% to no more than 26%, with the WWETR mass added strongly affecting both PFSA and PFCA sorption/desorption. These findings suggest that WTRs, if introduced into the environment, are unlikely to be a major source of PFAS. Also, the use of particular WTRs as amendments may provide a beneficial reduction in PFAS mobility.

A blood-based metabolomic signature predictive of risk for pancreatic cancer

Emerging evidence implicates microbiome involvement in the development of pancreatic cancer (PaCa). Here, we investigate whether increases in circulating microbial-related metabolites associate with PaCa risk by applying metabolomics profiling to 172 sera collected within 5 years prior to PaCa diagnosis and 863 matched non-subject sera from participants in the Prostate, Lung, Colorectal, and Ovarian (PLCO) cohort. We develop a three-marker microbial-related metabolite panel to assess 5-year risk of PaCa. The addition of five non-microbial metabolites further improves 5-year risk prediction of PaCa. The combined metabolite panel complements CA19-9, and individuals with a combined metabolite panel + CA19-9 score in the top 2.5th percentile have absolute 5-year risk estimates of >13%. The risk prediction model based on circulating microbial and non-microbial metabolites provides a potential tool to identify individuals at high risk of PaCa that would benefit from surveillance and/or from potential cancer interception strategies.

High Persistence of Novel Polyfluoroalkyl Betaines in Aerobic Soils

Some contemporary aqueous film-forming foams (AFFFs) contain n:3 and n:1:2 fluorotelomer betaines (FTBs), which are often detected at sites impacted by AFFFs. As new chemical replacements, little is known about their environmental fate. For the first time, we investigated the biotransformation potential of 5:3 and 5:1:2 FTBs and a commercial AFFF that mainly contains n:3 and n:1:2 FTBs (n = 5, 7, 9, 11, and 13). Although some polyfluoroalkyl compounds are precursors to perfluoroalkyl acids, 5:3 and 5:1:2 FTBs exhibited high persistence, with no significant changes even after 120 days of incubation. While the degradation of 5:3 FTB into suspected products such as fluorotelomer acids or perfluoroalkyl carboxylic acids (PFCAs) could not be conclusively confirmed, we did identify a potential biotransformation product, 5:3 fluorotelomer methylamine. Similarly, 5:1:2 FTB did not break down or produce short-chain hydrogen-substituted polyfluoroalkyl acids (n:2 H-FTCA), hydrogen-substituted PFCA (2H-PFCA), or any other products. Incubating the AFFF in four soils with differing properties and microbial communities resulted in 0.023-0.25 mol % PFCAs by day 120. Most of the products are believed to be derived from n:2 fluorotelomers, minor components of the AFFF. Therefore, the findings of the study cannot be fully explained by the current understanding of structure-biodegradability relationships.

Perfluoroalkyl acid transformation and mitigation by nNiFe-activated carbon nanocomposites in steady-state flow column studies

The ongoing contamination of groundwater with per- and polyfluoroalkyl substances (PFAS) has resulted in a global and rapidly growing interest in PFAS groundwater remediation. Preferred technologies that lead to PFAS destruction are often limited by not addressing all PFAS, being energy-intensive or not being suited for in-situ application. We developed nNiFe-activated carbon (AC) nanocomposites and demonstrated varying degrees of PFAS reduction and fluoride generation with these nanocomposites in batch reactors for several PFAS. Here we explore nNiFe-AC's effectiveness to transform perfluoroalkyl acid acids (PFAAs) under steady-state flow (0.0044 to 0.15 mL/min) in nNiFe-AC:sand packed columns. Column experiments included, two perfluorooctane sulfonate (PFOS) in deionized water and two PFAA mixtures in deionized water or bicarbonate buffer containing five perfluoroalkyl carboxylates (PFCAs, C5-C9) and three perfluoroalkyl sulfonates (PFSAs, C4, C6 and C8) at temperatures of 50 or 60°C were evaluated. PFOS transformation was similar in PFOS-only and PFAA mixture column experiments. Overall, % PFAA transformation under flow conditions exceeded what we observed previously in batch reactors with up to 53% transformation of a PFAA mixture with ∼ 8% defluorination. Longer chain PFAS dominated the PFAAs transformed and a bicarbonate matrix appeared to reduce overall transformation. PFAA breakthrough was slower than predicted from only sorption due to transformation; some longer chain PFAS like PFOS did not breakthrough. Here, nNiFe-AC technology with both in-situ and ex-situ potential application was shown to be a plausible part of a treatment train needed to address the ongoing challenge for cleaning up PFAS-contaminated waters.

PFAS release from wastewater residuals as a function of composition and production practices

Per- and polyfluoroalkyl substances (PFAS) are a class of highly persistent contaminants that have been linked to human health effects at low exposure concentrations. Public concerns exist that land-application of biosolids may result in the release of PFAS into terrestrial and aquatic ecosystems. The relative importance of inorganic constituents such as Fe and Al, which are known to impact PFAS retention/release behavior in soils, on PFAS release from wastewater residuals (WWRs, i.e., biosolids and sewage sludges) is not well understood. Here, we examine native concentrations and WWR-water partition coefficients of a range of PFAS in the context of WWRs characteristics including oxalate-extractable Fe and Al, organic matter (OM), dissolved organic carbon, and total protein content. Total PFAS concentrations, which included perfluoroalkyl carboxylates, perfluoroalkyl sulfonates, fluorotelomer sulfonates and some sulfonamides, ranged from ∼480 to 3500 μg PFAS kg-1 dry weight. PFAS WWR-water partition coefficients ranged from ∼10 to 20,000 L kg-1, consistent with the literature. PFAS partitioning was significantly correlated to oxalate extractable Al and Fe as well as bulk OM and protein content. These results have important implications for wastewater treatment facilities that recycle Al- and Fe-based drinking water treatment residuals in terms of both PFAS retention and loading.

Occurrence and implications of per and polyfluoroalkyl substances in animal feeds used in laboratory toxicity testing

The exceptional thermal and chemical stability and the amphiphilicity of per- and polyfluoroalkyl substances (PFAS) have resulted in widespread use and subsequent contamination in environmental media and biota. Concerns surrounding toxicity have led to numerous animal-based toxicity studies. Due to the ubiquity of PFAS and the low parts per trillion (ppt) health advisory levels for drinking water, several contamination elimination protocols have been implemented. In addition, it is urgently necessary to perform low-dose experiments, but due to unknown pathways for entry of unwanted PFAS, low-dose studies are extremely challenging to conduct. However, animal feed sources are a likely route that could introduce unwanted PFAS into experiments, yet investigations of PFAS in common animal feeds are lacking. Here, we report the examination of PFAS levels in eighteen different animal feeds, representing a range of diets fed to diverse taxa. We evaluated whether PFAS levels in feeds were correlated with ingredient composition (plant versus animal-based) or dietary habits of lab animals (amphibian, fish, invertebrate, mammal). PFOS, PFHxS, PFOA, and short-chain perfluoroalkyl carboxylic acids had the highest detection levels and frequencies across all samples. Different food ingredients led to different PFAS profiles. No meaningful levels of PFAS precursors were detected. We demonstrate that PFAS contamination in animal feed is pervasive. Reducing food-sourced PFAS is a critical, albeit challenging task to improve interpretability of in vivo exposures.

Abstract P076: Contribution of the microbiome to a metabolomic signature predictive of risk for pancreatic cancer

Purpose: Emerging evidence implicates the microbiome in the development of pancreatic cancer. We investigated whether increased levels of microbial-related metabolites in circulation are associated with pancreatic cancer risk. Methods: We applied metabolomics profiling to sera from the Prostate, Lung, Colorectal and Ovarian (PLCO) Cohort to quantify and build a model based on 14 microbial-related metabolites. The study involved samples collected from 172 subjects within five years prior to diagnosis and 863 matched controls. Data from five PLCO centers were used for training and from two centers for validation and model selection. The model was subsequently tested using samples from three independent centers. The contributions of non-microbial-associated metabolites as well as CA19-9 was also assessed. Results: A 3-marker microbial-related metabolite panel yielded in the PLCO testing set an AUC of 0.64 (95% CI: 0.53-0.76) for 5-year probability of pancreatic cancer. Five additional non-microbial metabolites were identified that when combined with the microbiome panel yielded an AUC of 0.79 (95% CI: 0.71-0.88) for 5-year probability of pancreatic cancer in the PLCO testing set. The combined metabolite panel and CA19-9 yielded an AUC of 0.86 (95% CI: 0.77-0.95) for 2-year probability of pancreatic cancer in the PLCO testing set, which was improved compared to CA19-9 alone (AUC: 0.70 (95% CI: 0.57-0.82), p< 0.001). Conclusion: We developed a metabolite panel derived in part from the microbiome for risk assessment of pancreatic cancer, which has relevance to prevention and early detection.

Citation Format: Johannes F. Fahrmann, Ehsan Irajizad, Ana Kenney, Tiffany Tang, Jody Vykoukal, Ranran Wu, Jennifer B. Dennison, Marta Sans Escofet, James P. Long, Maureen Loftus, John A. Chabot, Michael D. Kluger, Fay Kastrinos, Lauren Brais, Ana Babic, Kunal Jajoo, Linda S. Lee, Thomas E. Clancy, Kimmie Ng, Andrea Bullock, Jeanine M. Genkinger, Anirban Maitra, Kim-Anh Do, Bin Yu, Brian M. Wolpin, Samir Hanash. Contribution of the microbiome to a metabolomic signature predictive of risk for pancreatic cancer. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P076.

An Environmentally Relevant Mixture of Perfluorooctanesulfonic Acid and Perfluorohexanesulfonic Acid Does Not Conform to Additivity in Northern Leopard Frogs Exposed Through Metamorphosis

Per- and polyfluoroalkyl substances (PFAS) are chemicals associated with adverse health effects. At aqueous film-forming foam sites, they occur as mixtures, with perfluorooctanesulfonic acid (PFOS) and perfluorohexanesulfonic acid (PFHxS) commonly co-occurring in the highest concentrations. Although PFOS and PFHxS toxicities have been studied, few studies have tested their potential interaction. Using Rana pipiens, the present study compared toxicities of a 1:1 PFOS:PFHxS mixture to PFOS and PFHxS individually with the prediction that responses would be additive. Gosner stage 25 (GS 25) tadpoles were exposed through metamorphosis (GS 46) to 0.5 and 1 ppb PFOS or PFHxS alone or to a mixture of 0.5 ppb PFOS and 0.5 ppb PFHxS. Tadpoles were weighed and measured (snout-vent length [SVL]) at day 31, metamorphic climax (GS 42), and GS 46. These values were used to calculate the scaled mass index (SMI), a measure of body condition. Body burdens were quantified on day 31 and at GS 46. The PFOS and PFHxS body burdens were elevated relative to controls at GS 46. No effects were observed on survival, SVL, or mass. Single PFAS effects included a 17% reduction in SMI at day 31 (0.5 ppb PFHxS) and a 1.1-day longer metamorphic period (1 ppb PFHxS) relative to controls. Mixture results deviated from additivity-SMIs were higher than expected on day 31 and lower than expected at GS 42. In addition, time to GS 42 in the PFAS mixture exceeded expected additivity by 12 days. Results from a chronic exposure to a 1:1 PFOS:PFHxS mixture resulted in changes in body condition and length of metamorphosis that deviated from additivity. More PFAS mixture toxicity studies conducted at relevant ratios and concentrations are needed. Environ Toxicol Chem 2022;41:3007-3016. © 2022 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Effects of Per- and Polyfluoroalkyl Substance Mixtures on the Susceptibility of Larval American Bullfrogs to Parasites

Per- and polyfluoroalkyl substances (PFAS) are persistent environmental contaminants known to adversely affect health and development in many taxa. Although PFAS generally occur as mixtures in the environment, little is known about the effects of PFAS mixtures on organisms compared to single chemical exposures. Moreover, PFAS exposure in nature occurs alongside biotic factors such as parasitism. Even though host-parasite interactions are common in natural systems, there is little information about how PFAS affect these interactions. Here, we examined the effects of PFAS mixtures on the susceptibility of larval American bullfrogs (Rana catesbeiana) to echinostomes. Our PFAS treatments included perfluorooctanesulfonic acid (PFOS) at 4 and 10 ppb, two mixtures without PFOS as a component at 6 and 10 ppb total PFAS, and a mixture containing PFOS at 10 ppb total PFAS. We found that a 62-day PFAS exposure increased parasite loads by 42-100% in all treatments relative to the control. Additionally, we found that the singular exposure to PFOS increased parasite loads by ∼40% compared to a mixture containing PFOS suggesting antagonism among PFAS in mixtures. Our results highlight the need for further investigation into the effects of PFAS mixtures on organisms and how PFAS affect common ecological interactions.

Limited liver resections in the posterosuperior segments: international multicentre propensity score-matched and coarsened exact-matched analysis comparing the laparoscopic and robotic approaches

Background

Limited liver resections (LLRs) for tumours located in the posterosuperior segments of the liver are technically demanding procedures. This study compared outcomes of robotic (R) and laparoscopic (L) LLR for tumours located in the posterosuperior liver segments (IV, VII, and VIII).

Methods

This was an international multicentre retrospective analysis of patients who underwent R-LLR or L-LLR at 24 centres between 2010 and 2019. Patient demographics, perioperative parameters, and postoperative outcomes were analysed; 1 : 3 propensity score matching (PSM) and 1 : 1 coarsened exact matching (CEM) were performed.

Results

Of 1566 patients undergoing R-LLR and L-LLR, 983 met the study inclusion criteria. Before matching, 159 R-LLRs and 824 L-LLRs were included. After 1 : 3 PSM of 127 R-LLRs and 381 L-LLRs, comparison of perioperative outcomes showed that median blood loss (100 (i.q.r. 40–200) versus 200 (100–500) ml; P = 0.003), blood loss of at least 500 ml (9 (7.4 per cent) versus 94 (27.6 per cent); P < 0.001), intraoperative blood transfusion rate (4 (3.1 per cent) versus 38 (10.0 per cent); P = 0.025), rate of conversion to open surgery (1 (0.8 per cent) versus 30 (7.9 per cent); P = 0.022), median duration of Pringle manoeuvre when applied (30 (20–46) versus 40 (25–58) min; P = 0.012), and median duration of operation (175 (130–255) versus 224 (155–300); P < 0.001) were lower in the R-LLR group compared with the L-LLR group. After 1 : 1 CEM of 104 R-LLRs with 104 L-LLRs, R-LLR was similarly associated with significantly reduced blood loss and a lower rate of conversion to open surgery.

Conclusion

Based on a matched analysis of well selected patients, both robotic and laparoscopic access could be undertaken safely with good outcomes for tumours in the posterosuperior liver segments.

The Multicenter Cancer of Pancreas Screening Study: Impact on Stage and Survival

PURPOSE

To report pancreas surveillance outcomes of high-risk individuals within the multicenter Cancer of Pancreas Screening-5 (CAPS5) study and to update outcomes of patients enrolled in prior CAPS studies.

METHODS

Individuals recommended for pancreas surveillance were prospectively enrolled into one of eight CAPS5 study centers between 2014 and 2021. The primary end point was the stage distribution of pancreatic ductal adenocarcinoma (PDAC) detected (stage I v higher-stage). Overall survival was determined using the Kaplan-Meier method.

RESULTS

Of 1,461 high-risk individuals enrolled into CAPS5, 48.5% had a pathogenic variant in a PDAC-susceptibility gene. Ten patients were diagnosed with PDAC, one of whom was diagnosed with metastatic PDAC 4 years after dropping out of surveillance. Of the remaining nine, seven (77.8%) had a stage I PDAC (by surgical pathology) detected during surveillance; one had stage II, and one had stage III disease. Seven of these nine patients with PDAC were alive after a median follow-up of 2.6 years. Eight additional patients underwent surgical resection for worrisome lesions; three had high-grade and five had low-grade dysplasia in their resected specimens. In the entire CAPS cohort (CAPS1-5 studies, 1,731 patients), 26 PDAC cases have been diagnosed, 19 within surveillance, 57.9% of whom had stage I and 5.2% had stage IV disease. By contrast, six of the seven PDACs (85.7%) detected outside surveillance were stage IV. Five-year survival to date of the patients with a screen-detected PDAC is 73.3%, and median overall survival is 9.8 years, compared with 1.5 years for patients diagnosed with PDAC outside surveillance (hazard ratio [95% CI]; 0.13 [0.03 to 0.50], P = .003).

CONCLUSION

Most pancreatic cancers diagnosed within the CAPS high-risk cohort in the recent years have had stage I disease with long-term survival.

Acute Toxicity of Eight Aqueous Film-Forming Foams to 14 Aquatic Species

Researchers have developed numerous per- and polyfluoroalkyl substances (PFAS)-free aqueous film-forming foam (AFFF) formulations to replace PFAS-containing AFFF used for fire suppression. As part of the Department of Defense's Strategic Environmental Research and Development Program (SERDP), we examined the direct lethal effects of seven PFAS-free AFFF and a PFAS-containing AFFF on 14 aquatic species using a series of lethal concentration (LC50) tests. We assessed the LC10, LC50, and LC90 values using log-logistic and logit analyses. Across all aquatic species tested, we discovered that exposure to at least one PFAS-free AFFF was more or as toxic as exposure to the PFAS-containing AFFF. For most cases, National Foam Avio F3 Green KHC 3% and Buckeye Platinum Plus C6MILSPEC 3% were the most and least toxic formulations, respectively. Moreover, we found consistency among results from multiple experiments using the same minnow species (Pimephales promelas) and among closely related taxa (e.g., daphnids, amphibians). Lastly, the LC50 values for AFFF formulations trended lower for tested marine species as compared to those of freshwater species. These results dramatically increase the current knowledge on the potentially toxic effects of AFFF but also highlight the need for additional research and the development of new PFAS-free AFFF that are more "ecologically friendly" than those containing persistent PFAS.

Current updates and future directions in diagnosis and management of gastroenteropancreatic neuroendocrine neoplasms

Gastroenteropancreatic neuroendocrine neoplasms are a heterogenous group of rare neoplasms that are increasingly being discovered, often incidentally, throughout the gastrointestinal tract with varying degrees of activity and malignant potential. Confusing nomenclature has added to the complexity of managing these lesions. The term carcinoid tumor and embryonic classification have been replaced with gastroenteropancreatic neuroendocrine neoplasm, which includes gastrointestinal neuroendocrine and pancreatic neuroendocrine neoplasms. A comprehensive multidisciplinary approach is important for clinicians to diagnose, stage and manage these lesions. While histological diagnosis is the gold standard, recent advancements in endoscopy, conventional imaging, functional imaging, and serum biomarkers complement histology for tailoring specific treatment options. In light of developing technology, our review sets out to characterize diagnostic and therapeutic advancements for managing gastroenteropancreatic neuroendocrine tumors, including innovations in radiolabeled peptide imaging, circulating biomarkers, and endoscopic treatment approaches adapted to different locations throughout the gastrointestinal system.

State-of-the-Art Update of Pancreatic Cysts

Andrew Canakis.

Machine learning in endoscopic ultrasonography and the pancreas: The new frontier?

Pancreatic diseases have a substantial burden on society which is predicted to increase further over the next decades. Endoscopic ultrasonography (EUS) remains the best available diagnostic method to assess the pancreas, however, there remains room for improvement. Artificial intelligence (AI) approaches have been adopted to assess pancreatic diseases for over a decade, but this methodology has recently reached a new era with the innovative machine learning algorithms which can process, recognize, and label endosonographic images. Our review provides a targeted summary of AI in EUS for pancreatic diseases. Included studies cover a wide spectrum of pancreatic diseases from pancreatic cystic lesions to pancreatic masses and diagnosis of pancreatic cancer, chronic pancreatitis, and autoimmune pancreatitis. For these, AI models seemed highly successful, although the results should be evaluated carefully as the tasks, datasets and models were greatly heterogenous. In addition to use in diagnostics, AI was also tested as a procedural real-time assistant for EUS-guided biopsy as well as recognition of standard pancreatic stations and labeling anatomical landmarks during routine examination. Studies thus far have suggested that the adoption of AI in pancreatic EUS is highly promising and further opportunities should be explored in the field.

Environmental Sources, Chemistry, Fate, and Transport of Per- and Polyfluoroalkyl Substances: State of the Science, Key Knowledge Gaps, and Recommendations Presented at the August 2019 SETAC Focus Topic Meeting

A Society of Environmental Toxicology and Chemistry (SETAC) Focused Topic Meeting (FTM) on the environmental management of per- and polyfluoroalkyl substances (PFAS) convened during August 2019 in Durham, North Carolina (USA). Experts from around the globe were brought together to critically evaluate new and emerging information on PFAS including chemistry, fate, transport, exposure, and toxicity. After plenary presentations, breakout groups were established and tasked to identify and adjudicate via panel discussions overarching conclusions and relevant data gaps. The present review is one in a series and summarizes outcomes of presentations and breakout discussions related to (1) primary sources and pathways in the environment, (2) sorption and transport in porous media, (3) precursor transformation, (4) practical approaches to the assessment of source zones, (5) standard and novel analytical methods with implications for environmental forensics and site management, and (6) classification and grouping from multiple perspectives. Outcomes illustrate that PFAS classification will continue to be a challenge, and additional pressing needs include increased availability of analytical standards and methods for assessment of PFAS and fate and transport, including precursor transformation. Although the state of the science is sufficient to support a degree of site-specific and flexible risk management, effective source prioritization tools, predictive fate and transport models, and improved and standardized analytical methods are needed to guide broader policies and best management practices. Environ Toxicol Chem 2021;40:3234-3260. © 2021 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Updates in diagnosis and management of pancreatic cysts

Incidental pancreatic cysts are commonly encountered with some cysts having malignant potential. The most common pancreatic cystic neoplasms include serous cystadenoma, mucinous cystic neoplasm and intraductal papillary mucinous neoplasm. Risk stratifying pancreatic cysts is important in deciding whether patients may benefit from endoscopic ultrasound (EUS) or surgical resection. Surgery should be reserved for patients with malignant cysts or cysts at high risk for developing malignancy as suggested by various risk features including solid mass, nodule and dilated main pancreatic duct. EUS may supplement magnetic resonance imaging findings for cysts that remain indeterminate or have concerning features on imaging. Various cyst fluid markers including carcinoembryonic antigen, glucose, amylase, cytology, and DNA markers help distinguish mucinous from nonmucinous cysts. This review will guide the practicing gastroenterologist in how to evaluate incidental pancreatic cysts and when to consider referral for EUS or surgery. For presumed low risk cysts, surveillance strategies will be discussed. Managing pancreatic cysts requires an individualized approach that is directed by the various guidelines.

Prospective evaluation of an assessment tool for technical performance of duodenoscopes

OBJECTIVE

While single-use and detachable-tip duodenoscopes have been recently developed to overcome risks of infection transmission, there are no reliable tools to objectively assess their technical performance. We evaluated the reliability and validity of a newly developed tool to assess the technical performance of reusable duodenoscopes.

METHODS

An assessment tool was developed to measure duodenoscope performance based on three distinct criteria: maneuverability, mechanical/imaging characteristics and ability to perform requisite interventions. The assessment tool was tested prospectively on duodenoscopes used in endoscopic retrograde cholangiopancreatography (ERCP) procedures at nine academic medical centers over a 6-month period. The main outcome was reliability of the duodenoscope assessment tool, which was estimated using Cronbach's coefficient alpha (α). The secondary outcome was validity of the assessment tool.

RESULTS

The assessment tool evaluated technical performance of reusable duodenoscopes in 1080 ERCP procedures. Indications were biliary in 92.8% and pancreatic in 7.2% procedures. The overall Cronbach's coefficient α for maneuverability was 0.81, assessment of mechanical/imaging characteristics was 0.92, and ability to perform requisite interventions was 0.87. On multiple linear regression analysis, prolonged procedure duration, older patient age and pancreatic interventions were significantly positively associated with higher (worse) scores.

CONCLUSIONS

The newly developed assessment tool appears reliable and valid for evaluating the technical performance of duodenoscopes. Registration: ClinicalTrials.gov Identifier: NCT04004533.

COVID-19 related pancreatic cancer surveillance disruptions amongst high-risk individuals

BACKGROUND

COVID-19 pandemic-related disruptions to EUS-based pancreatic cancer surveillance in high-risk individuals remain uncertain.

METHODS

Analysis of enrolled participants in the CAPS5 Study, a prospective multicenter study of pancreatic cancer surveillance in high-risk individuals.

RESULTS

Amongst 693 enrolled high-risk individuals under active surveillance, 108 (16%) had an EUS scheduled during the COVID-19 pandemic-related shutdown (median length of 78 days) in the spring of 2020, with 97% of these procedures being canceled. Of these canceled surveillance EUSs, 83% were rescheduled in a median of 4.1 months, however 17% were not rescheduled after 6 months follow-up. Prior history of cancer was associated with increased likelihood of rescheduling. To date no pancreatic cancer has been diagnosed among those whose surveillance was delayed.

CONCLUSIONS

COVID-19 delayed pancreatic cancer surveillance with no adverse outcomes in efficiently rescheduled individuals. However, 1 in 6 high-risk individuals had not rescheduled surveillance, indicating the need for vigilance to ensure timely surveillance rescheduling.

Dietary exposure and accumulation of per- and polyfluoroalkyl substances alters growth and reduces body condition of post-metamorphic salamanders

Per- and polyfluoroalkyl substances (PFAS) are contaminants of concern due to their persistence, potential to bioaccumulate, and toxicity. While dietary exposure is the primary route of exposure for terrestrial species, data on dietary PFAS uptake and adverse effects are largely restricted to mammals. As such, substantial data gaps exist that hinder ecological risk assessment, including environmentally relevant exposure levels and taxa. Using a 30-d laboratory experiment, we examined the effects of dietary PFAS-exposure on post-metamorphic tiger salamanders (Ambystoma tigrinum). We fed salamanders crickets exposed to perfluorooctanoic acid (PFOA), perfluorooctane sulfonate (PFOS), perfluorohexane sulfonate (PFHxS), or 6:2 fluorotelomer sulfonate (6:2 FTS) at low (<1.0), medium (2-5), or high (16-62) ng PFAS/g/d (wet weight) dose rates. We found that only PFOS resulted in substantial biomagnification. Despite limited evidence for biomagnification, PFAS altered growth and generally reduced body condition. Salamanders with the highest burdens of PFOS grew less and had lower body conditions, while burdens of PFHxS and PFOA were only associated with reduced growth. There was no evidence that environmentally relevant doses of PFAS increase liver size in salamanders. Our results demonstrate that dietary exposure and accumulation of PFAS can impact fitness-related traits in amphibians and contribute to trophic transfer in terrestrial food webs.

Persistence of three bisphenols and other trace organics of concern in anaerobic sludge under methanogenic conditions

The degradation and distribution of bisphenol A (BPA), bisphenol S (BPS) and bisphenol AF (BPAF) were evaluated in dilute anaerobic sludge slurries amended with a single bisphenol or a mixture of all three and maintained under methanogenic conditions over a 28-d period. No significant degradation of the bisphenols was observed in methane-generating microcosms. Rapid sorption to sludge particles was the primary removal process with sorption observed: BPAF > BPA > BPS. Several other trace organic chemicals of concern in the sludge were detected using quadrupole time of flight mass spectrometry. Of those detected, triclosan and triclocarban had sufficiently high intensities to quantify changes over the 28-d period in the bisphenol-amended microcosms. Similar to the bisphenols, triclosan and triclocarban concentrations also did not significantly change over the 28-d period with concentrations quantified at 2021 ± 627 and 1864 ± 769 μg/kg dry weight, respectively. Findings exemplify that methane-generating microcosms do not appear conducive to significant degradation of trace organics of concern in anaerobic sludge digesters.

Sublethal Effects of Dermal Exposure to Poly- and Perfluoroalkyl Substances on Postmetamorphic Amphibians

Studies of the toxicity of poly- and perfluoroalkyl substances (PFAS) on amphibians, especially after metamorphosis, are limited. We examined effects of dermal PFAS exposure (30 d) on survival and growth of juvenile American toads (Anaxyrus americanus), eastern tiger salamanders (Ambystoma tigrinum), and northern leopard frogs (Rana pipiens). Chemicals included perfluorooctanoic acid, perfluorooctane sulfonate (PFOS), perfluorohexane sulfonate (PFHxS), and 6:2 fluorotelomer sulfonate (6:2 FTS) at 0, 80, 800, or 8000 ppb on a moss dry weight basis. Exposure to PFAS influenced final snout-vent length (SVL) and scaled mass index (SMI), a measure of relative body condition. Observed effects depended on species and chemical, but not concentration. Anurans exposed to PFOS, PFHxS (frogs only), and 6:2 FTS demonstrated reduced SVL versus controls, whereas salamanders exposed to 6:2 FTS showed increased SVL. Frogs exposed to PFHxS and 6:2 FTS and toads exposed to PFOS had increased SMI compared to controls; salamanders did not demonstrate effects. Concentrations of 6:2 FTS in substrate decreased substantially by 30 d, likely driven by microbial action. Perfluorooctane sulfonate had notable biota-sediment accumulation factors, but was still <1. Although a no-observable-effect concentration could not generally be determined, the lowest-observable-effect concentration was 50 to 120 ppb. Survival was not affected. The present study demonstrates that PFAS bioaccumulation from dermal exposures and sublethal effects are dependent on species, chemical, and focal trait. Environ Toxicol Chem 2021;40:717-726. © 2020 SETAC.

Lead-Time Trajectory of CA19-9 as an Anchor Marker for Pancreatic Cancer Early Detection

BACKGROUND & AIMS

There is substantial interest in liquid biopsy approaches for cancer early detection among subjects at risk, using multi-marker panels. CA19-9 is an established circulating biomarker for pancreatic cancer; however, its relevance for pancreatic cancer early detection or for monitoring subjects at risk has not been established.

METHODS

CA19-9 levels were assessed in blinded sera from 175 subjects collected up to 5 years before diagnosis of pancreatic cancer and from 875 matched controls from the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. For comparison of performance, CA19-9 was assayed in blinded independent sets of samples collected at diagnosis from 129 subjects with resectable pancreatic cancer and 275 controls (100 healthy subjects; 50 with chronic pancreatitis; and 125 with noncancerous pancreatic cysts). The complementary value of 2 additional protein markers, TIMP1 and LRG1, was determined.

RESULTS

In the PLCO cohort, levels of CA19-9 increased exponentially starting at 2 years before diagnosis with sensitivities reaching 60% at 99% specificity within 0 to 6 months before diagnosis for all cases and 50% at 99% specificity for cases diagnosed with early-stage disease. Performance was comparable for distinguishing newly diagnosed cases with resectable pancreatic cancer from healthy controls (64% sensitivity at 99% specificity). Comparison of resectable pancreatic cancer cases to subjects with chronic pancreatitis yielded 46% sensitivity at 99% specificity and for subjects with noncancerous cysts, 30% sensitivity at 99% specificity. For prediagnostic cases below cutoff value for CA19-9, the combination with LRG1 and TIMP1 yielded an increment of 13.2% in sensitivity at 99% specificity (P = .031) in identifying cases diagnosed within 1 year of blood collection.

CONCLUSION

CA19-9 can serve as an anchor marker for pancreatic cancer early detection applications.

Comparison of zebrafish in vitro and in vivo developmental toxicity assessments of perfluoroalkyl acids (PFAAs)

Perfluoroalkyl acids (PFAAs) are persistent environmental contaminants that are associated with various adverse health outcomes. Perfluorooctanoic acid (PFOA) is one of the most prominently detected PFAAs in the environment, which is now replaced with shorter chain carbon compounds including perfluorohexanoic acid (PFHxA) and perfluorobutyric acid (PFBA). The aim of this study was to compare the toxicity of four PFAAs as a function of chain length and head group (carboxylate versus sulfonate) with in vitro and in vivo zebrafish assessments, which were subsequently compared to other cell and aquatic models. Mortality rate increased with chain length (PFOA > PFHxA ≫ PFBA) in both whole embryo/larvae and embryonic cell models. The sulfonate group enhanced toxicity with perfluorobutane sulfonate (PFBS) showing higher toxicity than PFBA and PFHxA in both larvae and cells. Toxicity trends were similar among different aquatic models, but sensitivities varied. Discrepancies with other zebrafish studies were confirmed to be associated with a lack of neutralization of acidic pH of dosing solutions in these other investigations, demonstrating the need for rigor in reporting pH of exposure solutions in all experiments. The zebrafish embryonic cell line was also found to be similar to most other cell lines regardless of exposure length. Overall, results agree with findings in other cell lines and organisms where longer chain length and sulfonate group increase toxicity, except in investigations not neutralizing the exposure solutions for these acidic compounds.

Clinical decision support system, using expert consensus-derived logic and natural language processing, decreased sedation-type order errors for patients undergoing endoscopy

OBJECTIVE

Determination of appropriate endoscopy sedation strategy is an important preprocedural consideration. To address manual workflow gaps that lead to sedation-type order errors at our institution, we designed and implemented a clinical decision support system (CDSS) to review orders for patients undergoing outpatient endoscopy.

MATERIALS AND METHODS

The CDSS was developed and implemented by an expert panel using an agile approach. The CDSS queried patient-specific historical endoscopy records and applied expert consensus-derived logic and natural language processing to identify possible sedation order errors for human review. A retrospective analysis was conducted to evaluate impact, comparing 4-month pre-pilot and 12-month pilot periods.

RESULTS

22 755 endoscopy cases were included (pre-pilot 6434 cases, pilot 16 321 cases). The CDSS decreased the sedation-type order error rate on day of endoscopy (pre-pilot 0.39%, pilot 0.037%, Odds Ratio = 0.094, P-value < 1e-8). There was no difference in background prevalence of erroneous orders (pre-pilot 0.39%, pilot 0.34%, P = .54).

DISCUSSION

At our institution, low prevalence and high volume of cases prevented routine manual review to verify sedation order appropriateness. Using a cohort-enrichment strategy, a CDSS was able to reduce number of chart reviews needed per sedation-order error from 296.7 to 3.5, allowing for integration into the existing workflow to intercept rare but important ordering errors.

CONCLUSION

A workflow-integrated CDSS with expert consensus-derived logic rules and natural language processing significantly reduced endoscopy sedation-type order errors on day of endoscopy at our institution.

Reductive transformation of perfluorooctanesulfonate by nNiFe0-Activated carbon

Degradation of linear (L) and branched (Br) perfluorooctanesulfonate (PFOS) using nNiFe° particles supported on activated carbon (AC) and heat is demonstrated for the first time and with several lines of evidence. At 60 °C, PFOS degradation plateaued at 50 ± 6%, while at 50 °C, 94 ± 4.1 % PFOS transformed. The accelerated iron corrosion at the higher temperature is attributed to the lower PFOS transformation at 60 °C. However, at both temperatures, ≥ 97 % of the PFOS transformed was accounted for by the moles of fluoride generated. At 60 °C, PFOS degradation rates were estimated at 0.028 ± 0.003 h^-1 and fluoride and sulfite generation rates of 0.70 ± 0.165 h^-1 and 0.62 ± 0.157 h^-1, respectively, with no differences between L-PFOS and total Br-PFOS. Using time-of-flight mass spectrometry, some organic products were identified in the particle extracts from the 60 °C reaction. Products included single-bonded C8 polyfluoroalkyl sulfonates (F₁₆ to F₇) and alkyl acids (PFCAs, C₄-C₈) and one perfluorinated C₈ desulfonated product supporting both defluorination and desulfonation pathways. Most of the organic products were gone after the first 25 h. High PFOS mineralization using nNiFe°-AC technology warrants further investigation for its use in permeable reactive barriers.

Characterizing and Comparing Per- and Polyfluoroalkyl Substances in Commercially Available Biosolid and Organic Non-Biosolid-Based Products

There is increasing concern over the presence of per- and polyfluoroalkyl substances (PFAS) in biosolids, while sales in commercially available biosolid-based products used as soil amendments are also increasing. Here, the occurrence of 17 perfluoroalkyl acids (PFAAs) present in 13 commercially available biosolid-based products, six organic composts (manure, mushroom, peat, and untreated wood), and one food and yard waste compost were studied. The PFAA concentration ranges observed are as follows: biosolid-based products (9.0-199 μg/kg) > food and yard waste (18.5 μg/kg) > other organic products (0.1-1.1 μg/kg). Analysis of 2014, 2016, and 2018 bags produced from one product line showed a temporal decrease in the total PFAAs (181, 101, and 74 μg/kg, respectively). The total oxidizable precursor (TOP) assay revealed the presence of PFAA precursors in the biosolid-based products at much higher levels, when the soluble carbon was removed by the ENVI-Carb clean-up prior to the TOP assay. Time-of-flight mass spectrometry confirmed the presence of three sulfonamides, two fluorotelomer sulfonates, and several polyfluoroalkyl phosphate diesters. Pore-water concentrations of water-saturated products were primarily of short-chain PFAAs and increased with increasing PFAA concentrations in the products. A strong positive log-linear correlation between organic carbon (OC)-normalized PFAA partition coefficients and the number of CF_n units indicates that OC is a good predictor of PFAA release concentrations.

Evaluation of endoscopic ultrasound fine-needle aspiration versus fine-needle biopsy and impact of rapid on-site evaluation for pancreatic masses

Background and study aims  Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is traditionally considered a first-line strategy for diagnosing pancreatic lesions; however, given less than ideal accuracy rates, fine-needle biopsy (FNB) has been recently developed to yield histological tissue. The aim of this study was to compare diagnostic yield and safety between EUS-FNA and EUS-FNB in sampling of pancreatic masses. Patients and methods  This was a multicenter retrospective study to evaluate efficacy and safety of EUS-FNA and EUS-FNB for pancreatic lesions. Baseline characteristics including sensitivity, specificity, and accuracy, were evaluated. Rapid on-site evaluation (ROSE) diagnostic adequacy, cell-block accuracy, and adverse events were analyzed. Subgroup analyses comparing FNA versus FNB route of tissue acquisition and comparison between methods with or without ROSE were performed. Multivariable logistic regression was also performed. Results  A total of 574 patients (n = 194 FNA, n = 380 FNB) were included. Overall sensitivity, specificity, and accuracy of FNB versus FNA were similar [(89.09 % versus 85.62 %; P  = 0.229), (98.04 % versus 96.88 %; P  = 0.387), and 90.29 % versus 87.50 %; P  = 0.307)]. Number of passes for ROSE adequacy and cell-block accuracy were comparable for FNA versus FNB [(3.06 ± 1.62 versus 3.04 ± 1.88; P  = 0.11) and (3.08 ± 1.63 versus 3.35 ± 2.02; P  = 0.137)]. FNA + ROSE was superior to FNA alone regarding sensitivity and accuracy [91.96 % versus 70.83 %; P  < 0.001) and (91.80 % versus 80.28 %; P  = 0.020)]. Sensitivity of FNB + ROSE and FNB alone were superior to FNA alone [(92.17 % versus 70.83 %; P  < 0.001) and (87.44 % versus 70.83 %; P  < 0.001)]. There was no difference in sensitivity though improved accuracy between FNA + ROSE versus FNB alone [(91.96 % versus 87.44 %; P  = 0.193) and (91.80 % versus 80.72 %; P  = 0.006)]. FNB + ROSE was more accurate than FNA + ROSE (93.13 % versus 91.80 % ; P  = 0.001). Multivariate analysis showed ROSE was a significant predictor of accuracy [OR 2.60 (95 % CI, 1.41-4.79)]. One adverse event occurred after FNB resulting in patient death. Conclusion  EUS-FNB allowed for more consistent cell-block evaluation as compared to EUS-FNA. EUS-FNA + ROSE was found to have a similar sensitivity to EUS-FNB alone suggesting a reduced need for ROSE as part of the standard algorithm of pancreatic sampling. While FNB alone produced similar diagnostic findings to EUS-FNA + ROSE, FNB + ROSE still was noted to increase diagnostic yield. This finding may favor a unique role for FNB + ROSE, suggesting it may be useful in cases when previous EUS-guided sampling may have been indeterminate.

Evaluating perfluorooctanesulfonate oxidation in permanganate systems

Permanganate (PM) has shown to be able to oxidize a range of organic contaminants including perfluorooctane sulfonate (PFOS). However, mechanisms of PFOS removal by PM have been questioned. To provide clarity to what may be happening to PFOS in PM systems, here we evaluated the ability of PM on PFOS destruction by conducting studies similar to previous studies that reported PFOS destruction which included PM solutions and PM combined with persulfate (PS). We also evaluated if addition of various soluble catalysts could enhance PM's potential to breakdown PFOS. We observed no PFOS destruction by PM. We also show that the F^- and SO₄^2- generation reported in a published study as evidence that PM was breaking bonds in PFOS were found below or not significantly higher than reported limits of quantitation and that SO₄^2- impurities in technical PM approach the reported SO₄^2- levels. For PM-PS systems, heterogeneous PFOS distribution was observed when subsampling reaction vessels at different depths and "salting-out" of PFOS was evident. In addition, subsequent sonication and filtering of the samples led to the apparent disappearance of most of the PFOS, which was an artifact arising from the behavior of PFOS aggregates or potential hemi-micelle formation. Given these findings, addition of salts may have application for collecting or concentrating PFOS and other PFAAs in a remediation or water treatment strategy.

Best Practices in Teaching Endoscopy Based on a Delphi Survey of Gastroenterology Program Directors and Experts in Endoscopy Education

BACKGROUND AND AIMS

Teaching endoscopy is a key objective of gastroenterology (GI) fellowship programs but the best approach is not known. We sought to characterize which teaching competencies experts considered most critical for endoscopy education.

METHODS

We developed and refined 18 endoscopy teaching competencies based on literature review, personal experience, and interviews with experts. We invited GI fellowship program directors and endoscopy education experts to participate in a Delphi process to rate each proposed competency as essential, important but not essential, or not important using a 70% agreement threshold for consensus. Thirty-four GI fellowship program directors and 2 experts in endoscopy education participated (n = 36).

RESULTS

Most survey participants were male (61.8%), associate professors (55.9%), and had performed at least a quarter of procedures with fellows (80.6%). Survey response rates were 94% (34 of 36) for round 1 and 91% (31 of 34) for round 2 (overall 31 of 36; 86.1%). After 2 rounds we achieved the predefined consensus level for most competencies. Fourteen of 18 competencies (77.8%) reached consensus after round 2: 10 (55.6%) were deemed essential and 4 (22.2%) were deemed important but not essential. Essential competencies included the following: discusses patient history and plans for procedure with trainee (100%), assumes control of procedure when trainee is unable to progress or if patient safety concerns arise (100%), maintains attention throughout the case (96.8%), and discusses the next steps in management for the patient (96.8%).

CONCLUSIONS

In a national Delphi survey of endoscopy education experts, we identified 10 essential endoscopy teaching competencies. These can be used to frame faculty development and standardize GI fellowship programs to promote high-quality endoscopy education.

Determination of Aflatoxins in Agricultural Products: Use of Aqueous Acetone for Extraction

An analytical procedure originally developed for the determination of aflatoxins in cottonseed products has been modified for application to many agricultural materials. Aflatoxins are rapidly extracted free of lipid contamination with 70% acetone. Many interfering pigments are removed from the crude extract by precipitation as insoluble lead derivatives, transfer of aflatoxins into chloroform, and further purification of the chloroform extract with silica gel.

The procedure was compared with four recently proposed methods for the analysis of peanut products. This technique is capable of detecting as little as 0.3 ppb of aflatoxin Bi in peanuts and peanut butters. Adequate recovery of added aflatoxins was obtained when this method was applied to numerous different agricultural products.

Endoscopic Ultrasound Fine-Needle Aspiration versus Fine-Needle Biopsy for Lymph Node Diagnosis: A Large Multicenter Comparative Analysis

Background/Aims

Endoscopic ultrasound fine-needle aspiration (EUS-FNA) is preferred for sampling of lymph nodes (LNs) adjacent to the gastrointestinal wall; however, fine-needle biopsy (FNB) may provide improved diagnostic outcomes. This study aimed to evaluate the comparative efficacy and safety of FNA versus FNB for LN sampling.

Methods

This was a multicenter retrospective study of prospectively collected data to evaluate outcomes of EUS-FNA and EUS-FNB for LN sampling. Characteristics analyzed included sensitivity, specificity, accuracy, the number of needle passes, diagnostic adequacy of rapid on-site evaluation (ROSE), cell-block analysis, and adverse events.

Results

A total of 209 patients underwent EUS-guided LN sampling. The mean lesion size was 16.22±8.03 mm, with similar sensitivity and accuracy between FNA and FNB ([67.21% vs. 75.00%, respectively, p=0.216] and [78.80% vs. 83.17%, respectively, p=0.423]). The specificity of FNB was better than that of FNA (100.00% vs. 93.62%, p=0.01). The number of passes required for diagnosis was not different. Abdominal and peri-hepatic LN location demonstrated FNB to have a higher sensitivity (81.08% vs. 64.71%, p=0.031 and 80.95% vs. 58.33%, p=0.023) and accuracy (88.14% vs. 75.29%, p=0.053 and 88.89% vs. 70.49%, p=0.038), respectively. ROSE was a significant predictor for accuracy (odds ratio, 5.16; 95% confidence interval, 1.15–23.08; p=0.032). No adverse events were reported in either cohort.

Conclusions

Both EUS-FNA and EUS-FNB are safe for the diagnosis of LNs. EUS-FNB is preferred for abdominal LN sampling. EUS-FNA+ ROSE was similar to EUS-FNB alone, showing better diagnosis for EUS-FNB than traditional FNA. While ROSE remained a significant predictor for accuracy, due to its poor availability in most centers, its use may be limited to cases with previous inconclusive diagnoses.

Per- and polyfluoroalkyl substances in commercially available biosolid-based products: The effect of treatment processes

Per- and polyfluoroalkyl substances (PFAS) have been used in a variety of consumer and industrial products and are known to accumulate in sewage sludge due to sorption and their recalcitrant nature. Treatment processes ensure safe and high-quality biosolids by reducing the potential for adverse environmental impacts such as pathogen levels; however, they have yet to be evaluated for their impact on the fate of PFAS. The objective of this study was to compare PFAS concentrations in four commercially available biosolid-based products that received different types of treatments: heat treatment, composting, blending, and thermal hydrolysis. Seventeen perfluoroalkyl acids (PFAAs) were quantified using liquid chromatography with tandem quadrupole time-of-flight mass spectrometry followed by screening for 30 PFAA precursors. Treatment processes did not reduce PFAA loads except for blending, which served only to dilute concentrations. Several PFAA precursors were identified with 6:2 and 8:2 fluorotelomer phosphate diesters in all samples pre- and post-treatment. PRACTITIONER POINTS: Heat treatment and composting increased perfluoroalkyl acid (PFAA) concentrations. Only dilution from blending with non-PFAS material decreased PFAA concentrations. Thermal hydrolysis process had no apparent effect on PFAA concentrations. PFAS sources are a greater driver of PFAS loads in biosolid-based products than treatment processes.

Perfluorooctane Sulfonate (PFOS) Produces Dopaminergic Neuropathology in Caenorhabditis elegans

Perfluorooctane sulfonate (PFOS) has been widely utilized in numerous industries. Due to long environmental and biological half-lives, PFOS is a major public health concern. Although the literature suggests that PFOS may induce neurotoxicity, neurotoxic mechanisms, and neuropathology are poorly understood. Thus, the primary goal of this study was to determine if PFOS is selectively neurotoxic and potentially relevant to specific neurological diseases. Nematodes (Caenorhabditis elegans) were exposed to PFOS or related per- and polyfluoroalkyl substances (PFAS) for 72 h and tested for evidence of neuropathology through examination of cholinergic, dopaminergic, gamma-amino butyric acid (GABA)ergic, and serotoninergic neuronal morphologies. Dopaminergic and cholinergic functional analyses were assessed through 1-nonanol and Aldicarb assay. Mechanistic studies assessed total reactive oxygen species, superoxide ions, and mitochondrial content. Finally, therapeutic approaches were utilized to further examine pathogenic mechanisms. Dopaminergic neuropathology occurred at lower exposure levels (25 ppm, approximately 50 µM) than required to produce neuropathology in GABAergic, serotonergic, and cholinergic neurons (100 ppm, approximately 200 µM). Further, PFOS exposure led to dopamine-dependent functional deficits, without altering acetylcholine-dependent paralysis. Mitochondrial content was affected by PFOS at far lower exposure level than required to induce pathology (≥1 ppm, approximately 2 µM). Perfluorooctane sulfonate exposure also enhanced oxidative stress. Further, mutation in mitochondrial superoxide dismutase rendered animals more vulnerable. Neuroprotective approaches such as antioxidants, PFAS-protein dissociation, and targeted (mitochondrial) radical and electron scavenging were neuroprotective, suggesting specific mechanisms of action. In general, other tested PFAS were less neurotoxic. The primary impact is to prompt research into potential adverse outcomes related to PFAS-induced dopaminergic neurotoxicity in humans.

Building Social Capital to Foster Interprofessional Education: The Interprofessional Educator Academy

Interprofessional education (IPE) is promoted as a necessary precursor to the implementation of the collaborative practices in patient care thought to improve teamwork and communication among health care providers, patients, their families, and communities. Yet barriers to IPE persist, due largely to a lack of understanding on the part of health care team members about the norms and practices of health professions outside their own. A by-product of social interactions within groups and networks, social capital is a collective asset that contributes to the development of trust, innovation, and coordination of efforts toward mutual goals. Duke AHEAD (Academy for Health Professions Education and Academic Development), an interprofessional educator academy, is examined through the lens of social capital theory as a viable means of breaking down barriers to IPE, thereby improving patient care.

Larval amphibians rapidly bioaccumulate poly- and perfluoroalkyl substances

Poly- and perfluoroalkyl substances (PFAS) are ubiquitous contaminants that can bioaccumulate in aquatic taxa. Amphibians are particularly vulnerable to contaminants and sensitive to endocrine disruptors during their aquatic larval stage. However, few studies have explored PFAS uptake rates in amphibians, which is critical for designing ecotoxicology studies and assessing the potential for bioaccumulation. Uptake rates of perfluorooctane sulfonate (PFOS) and perfluorooctanoic acid (PFOA) were measured for larval northern leopard frogs (Rana pipiens), American toads (Anaxyrus americanus), and eastern tiger salamanders (Ambystoma tigrinum) during a 240-h exposure to 10 and 1000 μg/L concentrations. We measured body burden and calculated bioconcentration factor (BCF) every 48 h during the experiments. For all species and exposures, body burdens often reached steady state within 48-96 h of exposure. Steady-state body burdens for PFOA and PFOS ranged from 3819 to 16,481 ng/g dry weight (BCF = 0.46-2.5) and 6955-489,958 ng/g dry weight (47-259 BCFs), respectively. Therefore, PFAS steady state occurs rapidly in the larval amphibians we studied and particularly for PFOS. This result reflects a high potential for PFAS trophic transfer because amphibians are often low in trophic position and are important prey for many aquatic and terrestrial species.

Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice

BACKGROUND & AIMS

It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence.

METHODS

We performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs.

RESULTS

By the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET and 116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate).

CONCLUSIONS

In this prospective multicenter study, we found that although competence cannot be confirmed for all AETs at the end of training, most meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms the effectiveness of training programs. Clinicaltrials.gov ID NCT02509416.

Sorption, Aerobic Biodegradation, and Oxidation Potential of PFOS Alternatives Chlorinated Polyfluoroalkyl Ether Sulfonic Acids

Global phase out of perfluorooctanesulfonic acid (PFOS) has led to increasing production of alternatives such as the chlorinated polyfluoroalkyl ether sulfonic acids (Cl-PFESAs) for which little is known on their environmental fate. In this study, sorption by soils, aerobic soil biodegradation, and oxidation potential of 6:2 Cl-PFESA (9-chlorohexadecafluoro-3-oxanonane-1-sulfonate) and 8:2 Cl-PFESA (9-chlorooctadecafluoro-3-oxanonane-1-sulfonate) were evaluated. 6:2 Cl-PFESA sorption was quantified for aqueous and acetone/water solutions, whereas 8:2 PFESA could only be accurately measured in acetone/water solutions. The log-linear cosolvency model was applied and validated to estimate sorption of 8:2 Cl-PFESA. Only soil organic carbon (OC, 0.76-4.30%) was highly and positively correlated to sorption of the Cl-PFESAs ( R² > 0.96). The resulting log K_oc values (OC-normalized sorption coefficients) are 4.01 ± 0.09 ( n = 6) and 5.54 ± 0.05 ( n = 4) L kg^-1 for 6:2 Cl-PFESA and 8:2 Cl-PFESA, respectively. Aerobic biodegradation in a loam soil at 24 ± 0.5 °C showed negligible degradation of both Cl-PFESAs. Cl-PFESAs also remained unchanged in an unbuffered heat (50 °C)-activated 42 mM persulfate oxidation treatment. Therefore, Cl-PFESAs are equally recalcitrant as PFOS in addition to being more sorptive, thus with a higher bioaccumulation potential for a similar alkyl chain length.