Clinical Comparison of Three Indirect Pulp Capping Restorative Protocols: A Randomized Controlled Prospective Study

OBJECTIVES

The objective of this prospective double-blind clinical trial was to compare clinical outcomes of indirect pulp capping restorative protocols on permanent teeth over a 12-month period.

METHODS AND MATERIALS

Deep carious lesions in permanent teeth (90) were randomly assigned to three indirect pulp capping protocols (n=30: TheraCal LC, Dycal, and no liner). All teeth were restored with resin composite. The outcome measures were pain (VAS scale) and success rate (pulp vitality based on percussion, palpation, cold test, and radiographic findings), collected at screening, intervention, and 24-hour, 7-day, 3-month, 6-month, and 12-month follow-up visits.

RESULTS

There was no statistically significant difference in tooth sensitivity among the three indirect pulp capping protocols nor in success rates among the restorative protocols after 1 year of follow-up (p>0.1).The respective success rates, as defined by the tooth remaining vital, after 1 year were: 96.2% for TheraCal LC, 100% for Dycal, and 100% for no liner.

CONCLUSIONS

After 12-month evaluation, the success rate of indirect pulp capping therapy on permanent teeth was not affected by the pulp capping restorative protocol.

Non-linear models for black carbon exposure modelling using air pollution datasets

Black carbon (BC) is a product of incomplete combustion, present in urban aerosols and sourcing mainly from road traffic. Epidemiological evidence reports positive associations between BC and cardiovascular and respiratory disease. Despite this, BC is currently not regulated by the EU Air Quality Directive, and as a result BC data are not available in urban areas from reference air quality monitoring networks in many countries. To fill this gap, a machine learning approach is proposed to develop a BC proxy using air pollution datasets as an input. The proposed BC proxy is based on two machine learning models, support vector regression (SVR) and random forest (RF), using observations of particle mass and number concentrations (N), gaseous pollutants and meteorological variables as the input. Experimental data were collected from a reference station in Barcelona (Spain) over a 2-year period (2018-2019). Two months of additional data were available from a second urban site in Barcelona, for model validation. BC concentrations estimated by SVR showed a high degree of correlation with the measured BC concentrations (R² = 0.828) with a relatively low error (RMSE = 0.48 μg/m³). Model performance was dependent on seasonality and time of the day, due to the influence of new particle formation events. When validated at the second station, performance indicators decreased (R² = 0.633; RMSE = 1.19 μg/m³) due to the lack of N data and PM_2.5 and the smaller size of the dataset (2 months). New particle formation events critically impacted model performance, suggesting that its application would be optimal in environments where traffic is the main source of ultrafine particles. Due to its flexibility, it is concluded that the model can act as a BC proxy, even based on EU-regulatory air quality parameters only, to complement experimental measurements for exposure assessment in urban areas.

E-waste dismantling as a source of personal exposure and environmental release of fine and ultrafine particles

Electronic waste (WEEE; from TV screens to electric toothbrushes) is one of the fastest growing waste streams in the world. Prior to recycling, e-waste components (metals, wood, glass, etc.) are processed by shredding, grinding and chainsaw cutting. These activities generate fine and ultrafine particle emissions, containing metals as well as organics (e.g., flame retardants), which have high potential for human health impacts as well as for environmental release. In this work, release of fine and ultrafine particles, and their exposure impacts, was assessed in an e-waste recycling facility under real-world operating conditions. Parameters monitored were black carbon, particle mass concentrations, ultrafine particles, and aerosol morphology and chemical composition. Potential health impacts were assessed in terms of cytotoxicity (cell viability) and oxidative stress (ROS) on <2 μm particles collected in liquid suspension. Environmental release of WEEE aerosols was evidenced by the higher particle concentrations monitored outside the facility when compared to the urban background (43 vs.11 μgPM2.5/m³, respectively, or 2.4 vs. 0.2 μgCa/m³). Inside the facility, concentrations were higher in the top than on the ground floor (PM2.5 = 147 vs. 78 μg/m³, N = 15.4 ∗ 104 vs. 8.7 ∗ 104/cm³, BC = 12.4 vs. 7.2 μg/m³). Ventilation was a key driver of human exposure, in combination with particle emissions. Key chemical tracers were Ca (from plastic fillers) and Fe (from wiring and other metal components). Y, Zr, Cd, Pb, P and Bi were markers of cathode TV recycling, and Li and Cr of grinding activities. While aerosols did not evidence cytotoxic effects, ROS generation was detected in 4 out of the 12 samples collected, associated to the ultrafine fraction. We conclude on the need for studies on aerosol emissions from WEEE facilities, especially in Europe, due to their demonstrable environmental and human health impacts and the rapidly growing generation of this type of waste.

Exposure of e-waste dismantlers from a formal recycling facility in Spain to inhalable organophosphate and halogenated flame retardants

Concentration levels of 16 organophosphate esters (OPEs) and 18 halogenated flame retardants (HFRs) were measured in airborne fine particulate matter (PM_2.5) from an e-waste dismantling facility in Catalonia (Spain) to assess their occurrence, profiles and potential health risks. Three different areas from the facility were studied, including an area for cathodic ray-tube (CRT) TV dismantling, a grinding area, and the outdoor background. OPEs and HFRs were detected in all samples, with concentrations between 10.4 and 110 ng/m³ for OPEs and from 0.72 to 2213 ng/m³ for HFRs. The compounds with highest concentrations in both working areas were triphenyl phosphate (TPHP) and tris(2-chloroisopropyl) phosphate (TCIPP) for OPEs and decabromodiphenyl ether (BDE-209) for HFRs. Higher concentration levels were found in the CRT area compared to the grinding one, probably due to the lower ventilation and different types of e-waste being processed. OPEs were also detected in the solid e-waste from the facility, highlighting the need to evaluate pollutant levels in e-waste before proceeding to its re-use. Estimated daily intakes via inhalation during workday were calculated, as well as carcinogenic and non-carcinogenic health risks, these being 25 and 50 times lower than threshold risk values in the worst cases, respectively. However, this calculated risk only considers the workday exposure via inhalation, while other routes of exposure (e.g., ingestion, dermal) could bring these values closer to threshold values.

Particle release from refit operations in shipyards: Exposure, toxicity and environmental implications

European harbours are known to contribute to air quality degradation. While most of the literature focuses on emissions from stacks or logistics operations, ship refit and repair activities are also relevant aerosol sources in EU harbour areas. Main activities include abrasive removal of filler and spray painting with antifouling coatings/primers/topcoats. This work aimed to assess ultrafine particle (UFP) emissions from ship maintenance activities and their links with exposure, toxicity and health risks for humans and the aquatic environment. Aerosol emissions were monitored during mechanical abrasion of surface coatings under real-world operating conditions in two scenarios in the Mallorca harbour (Spain). Different types of UFPs were observed: (1) highly regular (triangular, hexagonal) engineered nanoparticles (Ti-, Zr-, Fe-based), embedded as nano-additives in the coatings, and (2) irregular, incidental particles emitted directly or formed during abrasion. Particle number concentrations monitored were in the range of industrial activities such as drilling or welding (up to 5 ∗ 10⁵/cm³, mean diameters <30 nm). The chemical composition of PM₄ aerosols was dominated by metallic tracers in the coatings (Ti, Al, Ba, Zn). In vitro toxicity of PM₂ aerosols evidenced reduced cell viability and a moderate potential for cytotoxic effects. While best practices (exhaust ventilation, personal protective equipment, dust removal) were in place, it is unlikely that exposures and environmental release can be fully avoided at all times. Thus, it is advisable that health and safety protocols should be comprehensive to minimise exposures in all types of locations (near- and far-field) and periods (activity and non-activity). Potential release to coastal surface waters of metallic engineered and incidental nanomaterials, as well as fine and coarse particles (in the case of settled dust), should be assessed and avoided.

Characterizing the Chemical Profile of Incidental Ultrafine Particles for Toxicity Assessment Using an Aerosol Concentrator

Incidental ultrafine particles (UFPs) constitute a key pollutant in industrial workplaces. However, characterizing their chemical properties for exposure and toxicity assessments still remains a challenge. In this work, the performance of an aerosol concentrator (Versatile Aerosol Concentration Enrichment System, VACES) was assessed to simultaneously sample UFPs on filter substrates (for chemical analysis) and as liquid suspensions (for toxicity assessment), in a high UFP concentration scenario. An industrial case study was selected where metal-containing UFPs were emitted during thermal spraying of ceramic coatings. Results evidenced the comparability of the VACES system with online monitors in terms of UFP particle mass (for concentrations up to 95 µg UFP/m3) and between filters and liquid suspensions, in terms of particle composition (for concentrations up to 1000 µg/m3). This supports the applicability of this tool for UFP collection in view of chemical and toxicological characterization for incidental UFPs. In the industrial setting evaluated, results showed that the spraying temperature was a driver of fractionation of metals between UF (<0.2 µm) and fine (0.2-2.5 µm) particles. Potentially health hazardous metals (Ni, Cr) were enriched in UFPs and depleted in the fine particle fraction. Metals vaporized at high temperatures and concentrated in the UF fraction through nucleation processes. Results evidenced the need to understand incidental particle formation mechanisms due to their direct implications on particle composition and, thus, exposure. It is advisable that personal exposure and subsequent risk assessments in occupational settings should include dedicated metrics to monitor UFPs (especially, incidental).

[Ability of ophthalmic technicians to identify a normal ophthalmological examination]

INTRODUCTION

Ophthalmology care has been growing for several years. Since ophthalmic technicians have the opportunity to perform delegated procedures, it is important to evaluate their training.

OBJECTIVE

To evaluate the ability of 3rd year ophthalmic technician students and graduates to assess the normality of an ophthalmological examination and to determine a proposed time delay for seeing an ophthalmologist.

MATERIALS AND METHODS

One hundred records including ophthalmology examinations were shown to 8 ophthalmic technician students in their third year of study and to 3 graduated technicians. Three ophthalmologists determined the content of the files, the pathological nature or not of the case, as well as the proposed time for seeing an ophthalmologist. We calculated the sensitivity and specificity to recognize the normality of the case, as well as the concordance between the proposed time for seeing an ophthalmologist.

RESULTS

For recognition of a normal case, the sensitivity was 80%, and the specificity was 83% in the group of technician students, and 81% versus 80% respectively in the group of graduated technicians. For the proposed time of consultation for seeing an ophthalmologist, the kappa agreement coefficient was 0.30 in the group of students and 0.41 in the group of graduates (low and moderate agreement respectively).

CONCLUSION

The study showed a good ability of technicians to recognize the normality or not of clinical cases, but their ability to judge the appropriate timing of treatment by an ophthalmologist remains insufficient.

Evaluation of the Semi-Continuous OCEC analyzer performance with the EUSAAR2 protocol

This work evaluates the applicability of the reference protocol EUSAAR2 in the Semi-Continuous OCEC analyzer under two environments, an urban background site influenced by traffic emissions and a regional background site. The comparison of the 24-h averaged OC and EC measurements of the Semi-Continuous analyzer with the OC and EC concentrations determined offline in PM_2.5 24 h filters yielded very good agreement for both denuded and undenuded samples. In the urban background site, the regression for EC yielded a slope of 0.93 and 1.04 (b = 0.07 and 0.05, R² = 0.83 and 0.84), for denuded and undenuded samples respectively. The slopes of OC regressions were 0.99 (b = -0.18, R2 = 0.81) for the low volume and 0.93 (b = 0.12, R² = 0.84) for the high volume samples. In the regional background site, the slopes of the EC regression with the denuded and undenuded samples was 0.91 and 1.02 correspondingly (b = 0 and - 0.03, R² = 0.77 and 0.89). The regression of OC had slopes close to 1; 1.03 for the high volume and 0.95 for the low volume sampler (b = 0.08 and 0.26, R² = 0.78 and 0.78). BC measurements obtained by an aethalometer and MAAP were in very good agreement with EC at both sampling sites. BC levels were consistently higher than EC (slope of the regression aethalometer BC vs EC slope a = 1.2, intercept b = 0.19, R² = 0.79, for the urban background site and a = 1.9, b = -0.04, R2 = 0.94, for the regional site, slope MAAP BC vs EC a = 1.2, b = 0.06, R² = 0.94, for the urban background site and 1.7, b = -0.03, R² = 0.96, for the regional site). This confirms the need of using the site-specific mass absorption cross section (MAC) instead of the ones provided by manufacturers for the conversion of absorption units into BC mass concentration. BC data correlated very well with the optical EC obtained from the semi-continuous OCEC analyzer (a = 1.3, b = 0.16, R² = 0.80 for the urban background site and a = 1.7, b = 0.009, R² = 0.94 for the regional site, respectively). The comparison of OC concentrations by the Semi-Continuous Sunset analyzer with organic aerosol online measurements by ACSM showed strong correlations. The ratio OA/OC was 1.9 and 2.3 for the urban background and regional sites. The accumulation of refractory material on the filter, because of prolonged periods of sampling, caused a shift of the split point to the inert mode and changes on PC formation and evolution. Extreme dust outbreaks lead to the overestimation of OC due to the evolution of carbonate in the He mode. Generally, the Sunset Semi-Continuous OCEC analyzer with EUSAAR2 provided robust and consistent measurements with offline thermal-optical analysis.

Air quality mitigation in European cities: Status and challenges ahead

Cities are currently at the core of air quality (AQ) improvement. The present work provides an overview of AQ management strategies and outcomes in 10 European cities (Antwerp, Berlin, Dublin, Madrid, Malmö, Milan, Paris, Plovdiv, Prague, Vienna) in 2018, and their evolution since 2013 (same cities, plus Ploiesti and Vilnius), based on first-hand input from AQ managers. The status of AQ mitigation in 2018, and its evolution since 2013, were assessed. While results evidenced that the majority of mitigation strategies targeted road traffic, emerging sources such as inland shipping, construction/demolition and recreational wood burning were identified. Several cities had in 2018 the ambition to continue decreasing air pollution concentrations to meet WHO guidelines, an ambition which had not yet been identified in 2013. Specific needs identified by all of the cities assessed were tools to quantify the effectiveness of mitigation strategies and for cost-benefit analysis, as well as specific and up to date technical guidance on real-world road vehicle emissions. The cities also requested guidance to identify mitigation measures promoting co-benefits, e.g., in terms of AQ, climate change, and noise. Support from administrations at local-regional-national-EU scales, and especially involving local policy-makers early on in the air quality management process, was considered essential. This work provides insight into the drivers of successful/unsuccessful AQ policies as well as on the challenges faced during their implementation. We identify knowledge gaps and provide input to the research and policy-making communities as to specific needs of cities.

Visual snow syndrome: a comparison between an Italian and British population

BACKGROUND AND PURPOSE

Visual snow manifests as a pan-field, dynamic visual disturbance described as continuous television static-like tiny flickering dots. Current diagnostic criteria further require at least two additional symptoms for visual snow syndrome (VSS) from: palinopsia (afterimages and trailing); entoptic phenomena (floaters, blue field entoptic phenomenon, photopsia, self-light of the eye); photophobia and nyctalopia. Our objective was to compare the phenotype of VSS in an Italian and British population.

METHODS

Patients with VSS were characterized clinically using the current criteria. An online survey was prepared in collaboration with the patient group Eye-on-Vision. Patients were directed to the site if they contacted us by email asking to be involved in research. After data collection, we compared the phenotypic characteristics of a subgroup of British versus Italian patients taking part in the survey. As we expected more responses from the UK, we matched 100 UK patients for gender and age with our Italian cohort.

RESULTS

Patients were enrolled from the UK (n = 100) and Italy (n = 100). The populations had similar demography. After multiple correction testing there were no differences in VSS features between the two groups. The same was true for the prevalence of migraine and previous use of recreational drugs.

CONCLUSION

This is the first study comparing the phenotype of VSS between two distinct populations. Our findings suggest that the visual snow phenotype, as well as migraine comorbidity, is similar across the two groups.

Estimated health impacts from maritime transport in the Mediterranean region and benefits from the use of cleaner fuels

Ship traffic emissions degrade air quality in coastal areas and contribute to climate impacts globally. The estimated health burden of exposure to shipping emissions in coastal areas may inform policy makers as they seek to reduce exposure and associated potential health impacts. This work estimates the PM2.5-attributable impacts in the form of premature mortality and cardiovascular and respiratory hospital admissions, from long-term exposure to shipping emissions. Health impact assessment (HIA) was performed in 8 Mediterranean coastal cities, using a baseline conditions from the literature and a policy case accounting for the MARPOL Annex VI rules requiring cleaner fuels in 2020. Input data were (a) shipping contributions to ambient PM2.5 concentrations based on receptor modelling studies found in the literature, (b) population and health incidence data from national statistical registries, and (c) geographically-relevant concentration-response functions from the literature. Long-term exposure to ship-sourced PM2.5 accounted for 430 (95% CI: 220-650) premature deaths per year, in the 8 cities, distributed between groups of cities: Barcelona and Athens, with >100 premature deaths/year, and Nicosia, Brindisi, Genoa, Venice, Msida and Melilla, with tens of premature deaths/year. The more stringent standards in 2020 would reduce the number of PM2.5-attributable premature deaths by 15% on average. HIA provided a comparative assessment of the health burden of shipping emissions across Mediterranean coastal cities, which may provide decision support for urban planning with a special focus on harbour areas, and in view of the reduction in sulphur content of marine fuels due to MARPOL Annex VI in 2020.

Poor patient awareness and frequent misdiagnosis of migraine: findings from a large transcontinental cohort

BACKGROUND AND PURPOSE

Although migraine is the second most disabling condition worldwide, there is poor awareness of it. The objective was to assess the awareness of migraine and previous diagnostic and therapeutic consultations and treatments in a large international population of migraineurs.

METHODS

This was a multicentre study conducted in 12 headache centres in seven countries. Each centre recruited up to 100 patients referred for a first visit and diagnosed with migraine. Subjects were given a structured clinical questionnaire-based interview about the perceptions of the type of headache they suffered from, its cause, previous diagnoses, investigations and treatments.

RESULTS

In all, 1161 patients completed the study. Twenty-eight per cent of participants were aware that they suffered from migraine. Sixty-four per cent called their migraine 'headache'; less commonly they used terms such as 'cervical pain' (4%), tension headache (3%) and sinusitis (1%). Eight per cent of general practitioners and 35% of specialists (of whom 51% were neurologists and/or headache specialists) consulted for migraine formulated the correct diagnosis. Before participating in the study, 50% of patients had undergone X-ray, computed tomography and/or magnetic resonance imaging of the cervical spine and 76% underwent brain and/or cervical spine imaging for migraine. Twenty-eight per cent of patients had received symptomatic migraine-specific medications and 29% at least one migraine preventive medication.

CONCLUSIONS

Although migraine is a very common disease, poor awareness of it amongst patients and physicians is still an issue in several countries. This highlights the importance of the promotion of migraine awareness to reduce its burden and limit direct and indirect costs and the risk of exposure to useless investigations.

Vertical and horizontal fall-off of black carbon and NO2 within urban blocks

While exposure to traffic pollutants significantly decreases with distance from the curb, very dense urban architectures hamper such dispersion. Moreover, the building height reduces significantly the dispersion of pollutants. We have investigated the horizontal variability of Black Carbon (BC) and the vertical variability of NO₂ and BC within the urban blocks. Increasing the distance from road BC concentrations decreased following an exponential curve reaching halving distances at 25 m (median), although with a wide variability among sites. Street canyons showed sharper fall-offs than open roads or roads next to a park. Urban background concentrations were achieved at 67 m distance on average, with higher distances found for more trafficked roads. Vertical fall-off of BC was less pronounced than the horizontal one since pollutants homogenize quickly vertically after rush traffic hours. Even shallower vertical fall-offs were found for NO₂. For both pollutants, background concentrations were never reached within the building height. A street canyon effect was also found exacerbating concentrations at the lowest floors of the leeward side of the road. These inputs can be useful for assessing population exposure, air quality policies, urban planning and for models validation.

Health risk assessment from exposure to particles during packing in working environments

Packing of raw materials in work environments is a known source of potential health impacts (respiratory, cardiovascular) due to exposure to airborne particles. This activity was selected to test different exposure and risk assessment tools, aiming to understand the effectiveness of source enclosure as a strategy to mitigate particle release. Worker exposure to particle mass and number concentrations was monitored during packing of 7 ceramic materials in 3 packing lines in different settings, with low (L), medium (M) and high (H) degrees of source enclosure. Results showed that packing lines L and M significantly increased exposure concentrations (119-609 μg m^-3 respirable, 1150-4705 μg m^-3 inhalable, 24,755-51,645 cm^-3 particle number), while non-significant increases were detected in line H. These results evidence the effectiveness of source enclosure as a mitigation strategy, in the case of packing of ceramic materials. Total deposited particle surface area during packing ranged between 5.4 and 11.8 × 10⁵ μm² min^-1, with particles depositing mainly in the alveoli (51-64%) followed by head airways (27-41%) and trachea bronchi (7-10%). The comparison between the results from different risk assessment tools (Stoffenmanager, ART, NanoSafer) and the actual measured exposure concentrations evidenced that all of the tools overestimated exposure concentrations, by factors of 1.5-8. Further research is necessary to bridge the current gap between measured and modelled health risk assessments.

Testing the performance of sensors for ozone pollution monitoring in a citizen science approach

Tropospheric ozone (O₃) is an environmental pollutant of growing concern, especially in suburban and rural areas where the density of air quality monitoring stations is not high. In this type of areas citizen science strategies can be useful tools for awareness raising, but sensor technologies must be validated before sensor data are communicated to the public. In this work, the performance under field conditions of two custom-made types of ozone sensing devices, based on metal-oxide and electrochemical sensors, was tested. A large array of 132 metal-oxide (Sensortech MICS 2614) and 11 electrochemical (Alphasense) ozone sensors, built into 44 sensing devices, was co-located at reference stations in Italy (4 stations) and Spain (5). Mean R² between sensor and reference data was 0.88 (0.78-0.96) and 0.89 (0.73-0.96) for Captor (metal-oxide) and Raptor (electrochemical) nodes. The metal-oxide sensors showed an upper limit (approximately 170 μg/m³) implying that these sensors may be useful to communicate mean ozone concentrations but not peak episodes. The uncertainty of the nodes was 10% between 100 and 150 μg/m³ and 20% between 150 and 200 μg/m³, for Captors, and 10% for >100 μg/m³ for Raptors. Operating both types of nodes up to 5 months did not evidence any clear influence of drifts. The use of these sensors in citizen science can be a useful tool for awareness raising. However, significant data processing efforts are required to ensure high data quality, and thus machine learning strategies are advisable. Relative uncertainties should always be reported when communicating ozone concentration data from sensing nodes.

Particle-phase concentrations and sources of legacy and novel flame retardants in outdoor and indoor environments across Spain

Levels of particle-phase legacy polybrominated diphenyl ethers (PBDEs), and novel brominated and chlorinated flame retardants, such as decabromodiphenyl ethane (DBDPE) and Dechlorane Plus (DP), were measured in ambient outdoor air, indoor workplace air and indoor dust, in different locations across Spain. PBDE concentrations were generally higher in outdoor ambient air samples than in indoor air, ranging between 1.18 and 28.6 pg m^-3, while DP was the main flame retardant (FR) in indoor air (2.90-42.6 pg m^-3). A different behavior of legacy versus novel FRs was observed in all the environments and matrices considered, which seemed to indicate a progressive replacement of the former. Although the emission sources could not be fully identified, certain evidences suggested that high outdoor PBDE concentrations could be associated with old goods in landfills and recycling centers, while high indoor DP concentrations were linked to the presence of new electronic devices. A direct impact of land use on outdoor atmospheric DP concentrations was observed, with DP concentrations correlating with high density of buildings within a city. In addition, DP concentrations outdoors correlated with inorganic species with FR properties (e.g., Cr, Cu). Significant differences in the fraction of anti-DP to the total DP (F_anti ratio) were observed between indoor air (PM_2.5) and dust (PM₁₀), which could be related with: a) a dependence on particle size, suggesting a higher relative abundance of the anti-isomer in PM₁₀ than in PM_2.5, while similar concentrations were recorded for the syn-isomer; b) a higher deposition rate of the anti-isomer compared to the syn-isomer; and/or c) a more accentuated preferential degradation of the anti-isomer linked to artificial light or other agents coexisting in the air. The detectable presence of all the FR families analyzed in indoor air and dust points to the importance of monitoring these compounds in order to minimize human exposure.

Current Prophylactic Medications for Migraine and Their Potential Mechanisms of Action

A relatively high number of different medications is currently used for migraine prevention in clinical practice. Although these compounds were initially developed for other indications and differ in their mechanisms of action, some general themes can be identified from the mechanisms at play. Efficacious preventive drugs seem to either suppress excitatory nervous signaling via sodium and/or calcium receptors, facilitate GABAergic inhibition, reduce neuronal sensitization, block cortical spreading depression and/or reduce circulating levels of CGRP. We here review such mechanisms for the different compounds.

Particle-related exposure, dose and lung cancer risk of primary school children in two European countries

Schools represent a critical microenvironment in terms of air quality due to the proximity to outdoor particle sources and the frequent lack of proper ventilation and filtering systems. Moreover, the population exposed in schools (i.e. children) represents a susceptible population due to their age. Air quality-based studies involving students' exposure at schools are still scarce and often limited to mass-based particle metrics and may thus underestimate the possible effect of sub-micron particles and particle toxicity. To this purpose, the present paper aims to evaluate the exposure to different airborne particle metrics (including both sub- and super-micron particles) and attached carcinogenic compounds. Measurements in terms of particle number, lung-deposited surface area, and PM fraction concentrations were measured inside and outside schools in Barcelona (Spain) and Cassino (Italy). Simultaneously, PM samples were collected and chemically analysed to obtain mass fractions of carcinogenic compounds. School time airborne particle doses received by students in classrooms were evaluated as well as their excess lung cancer risk due to a five-year primary school period. Median surface area dose received by students during school time in Barcelona and Cassino resulted equal to 110mm² and 303mm², respectively. The risk related to the five-year primary school period was estimated as about 2.9×10^-5 and 1.4×10^-4 for students of Barcelona and Cassino, respectively. The risk in Barcelona is slightly higher with respect to the maximum tolerable value (10^-5, according to the U.S. Environmental Protection Agency), mainly due to toxic compounds on particles generated from anthropogenic emissions (mainly industry). On the other hand, the excess lung cancer risk in Cassino is cause of concern, being one order of magnitude higher than the above-mentioned threshold value due to the presence of biomass burning heating systems and winter thermal inversion that cause larger doses and great amount of toxic compounds on particles.

Workplace exposure and release of ultrafine particles during atmospheric plasma spraying in the ceramic industry

Atmospheric plasma spraying (APS) is a frequently used technique to produce enhanced-property coatings for different materials in the ceramic industry. This work aimed to characterise and quantify the impact of APS on workplace exposure to airborne particles, with a focus on ultrafine particles (UFPs, <100nm) and nanoparticles (<50nm). Particle number, mass concentrations, alveolar lung deposited surface area concentration, and size distributions, in the range 10nm-20μm were simultaneously monitored at the emission source, in the potential worker breathing zone, and in outdoor air. Different input materials (known as feedstock) were tested: (a) micron-sized powders, and (b) suspensions containing submicron- or nano-sized particles. Results evidenced significantly high UFP concentrations (up to 3.3×10⁶/cm³) inside the spraying chamber, which impacted exposure concentrations in the worker area outside the spraying chamber (up to 8.3×10⁵/cm³). Environmental release of UFPs was also detected (3.9×10⁵/cm³, outside the exhaust tube). Engineered nanoparticle (ENP) release to workplace air was also evidenced by TEM microscopy. UFP emissions were detected during the application of both micron-sized powder and suspensions containing submicron- or nano-sized particles, thus suggesting that emissions were process- (and not material-) dependent. An effective risk prevention protocol was implemented, which resulted in a reduction of UFP exposure in the worker area. These findings demonstrate the potential risk of occupational exposure to UFPs during atmospheric plasma spraying, and raise the need for further research on UFP formation mechanisms in high-energy industrial processes.

[Ecchymosis as the presenting manifestation of Wilson disease: A case report]

INTRODUCTION

The presence of a psychiatric disorder during the course of an organic disease is a common cause of delayed diagnosis.

CASE REPORT

We report a 16-year-old girl who was admitted with thrombocytopenia and had a two-year history of neuropsychiatric disorder which was attributed to a difficult family situation. Neurological examination showed a frontal lobe disorder and extrapyramidal manifestations. The thrombocytopenia was attributed to liver cirrhosis. These neurological and hepatic injuries were consistent with a metabolic disease, most likely Wilson disease. This was supported by the presence of a corneal Kayser-Fleischer ring and a decreased ceruloplasmin concentration. An urgent liver transplantation was required due to worsening neurological symptoms.

CONCLUSION

Wilson disease is a rare genetic disease caused by copper toxicity. It is characterized by combined hepatic and neurologic damage to varying degrees and can develop at any age. Urgent treatment is required, but the diagnosis may be delayed by prevailing psychiatric symptoms.

Process-generated nanoparticles from ceramic tile sintering: Emissions, exposure and environmental release

The ceramic industry is an industrial sector in need of significant process changes, which may benefit from innovative technologies such as laser sintering of ceramic tiles. Such innovations result in a considerable research gap within exposure assessment studies for process-generated ultrafine and nanoparticles. This study addresses this issue aiming to characterise particle formation, release mechanisms and their impact on personal exposure during a tile sintering activity in an industrial-scale pilot plant, as a follow-up of a previous study in a laboratory-scale plant. In addition, possible particle transformations in the exhaust system, the potential for particle release to the outdoor environment, and the effectiveness of the filtration system were also assessed. For this purpose, a tiered measurement strategy was conducted. The main findings evidence that nanoparticle emission patterns were strongly linked to temperature and tile chemical composition, and mainly independent of the laser treatment. Also, new particle formation (from gaseous precursors) events were detected, with nanoparticles <30nm in diameter being formed during the thermal treatment. In addition, ultrafine and nano-sized airborne particles were generated and emitted into workplace air during sintering process on a statistically significant level. These results evidence the risk of occupational exposure to ultrafine and nanoparticles during tile sintering activity since workers would be exposed to concentrations above the nano reference value (NRV; 4×10(4)cm(-3)), with 8-hour time weighted average concentrations in the range of 1.4×10(5)cm(-3) and 5.3×10(5)cm(-3). A potential risk for nanoparticle and ultrafine particle release to the environment was also identified, despite the fact that the efficiency of the filtration system was successfully tested and evidenced a >87% efficiency in particle number concentrations removal.

Variability of the characteristics of a migraine attack within patients

Background

Migraine attacks may present different features in different patients and also within the same patient. The percentage of patients reporting stereotyped attacks and those reporting attacks with different phenotypes has not been the object of specific investigations.

Objective

The objective of this article is to evaluate the percentage of migraine patients reporting the same characteristics, in terms of phenotype and response to symptomatic medications on three consecutive migraine attacks.

Methods

Thirty patients with migraine without aura prospectively recorded the features of three consecutive attacks in a headache diary. Characteristics recorded were: pain intensity, presence of nausea, vomiting, photophobia, phonophophia, osmophobia, allodynia, cranial autonomic symptoms (at least one), and premonitory symptoms. Patients were allowed to take frovatriptan as symptomatic medication, whose efficacy was evaluated as the two hours pain-free status.

Results

None of the patients presented identical characteristics on the three studied attacks. This was still the case if we reduced the number of variables evaluated from 11 to seven of the eight core features indicated by the ICHD. Considering just six variables: unilaterality and quality of pain, presence/absence of nausea, vomiting, photophobia and phonophobia, only two patients (6%) had identical features on three consecutive attacks. With respect to the response to frovatriptan, 39% of patients had the same response, either positive (i.e. pain free after two hours) or negative (i.e. not pain free after two hours) on three consecutive attacks.

Conclusion

Migraine attacks show a high variability not just among patients, but also within the same patient. Our data indicate that stereotypy of attacks is uncommon, and reinforces the underlying logic of the current operational classification system.

Psychological factors associated with failure of detoxification treatment in chronic headache associated with medication overuse

Aim

The aim of this study was to evaluate the psychological factors associated with a negative outcome following detoxification in a 2-month follow-up in medication-overuse headache.

Methods

All consecutive patients entering the detoxification program were analysed in a prospective, non-randomised fashion. Psychiatric conditions and personality characteristics were assessed using the Structured Clinical Interview for DSM-IV Disorders (SCID-I) and the Minnesota Multiphasic Personality Inventory (MMPI)-2. χ2 tests, one-way analyses of variance, and odds ratios (ORs) were used.

Results

A total of 248 patients completed the follow-up: 156 stopped overuse and their headaches reverted to an episodic pattern (Group A); 23 kept overusing without any benefit on headache frequency (Group B); and 51 stopped overuse without any benefit on headache frequency (Group C). The prognostic factors for the outcome of Group B were higher scores on the correction (OR 1.128; p = 0.036), depression (OR 1.071; p = 0.05), hysteria (OR 1.106; p = 0.023), and overcontrolled hostility (OR 1.182; p = 0.04) MMPI-2 scales, whereas those for Group C were psychiatric comorbidities (OR 1.502; p = 0.021) and higher scores on the hysteria scale (OR 1.125; p = 0.004).

Conclusions

The outcome of detoxification is influenced by psychological factors that should be considered when considering treatment strategies.

Spatiotemporally resolved black carbon concentration, schoolchildren's exposure and dose in Barcelona

At city level, personal monitoring is the best way to assess people's exposure. However, it is usually estimated from a few monitoring stations. Our aim was to determine the exposure to black carbon (BC) and BC dose for 45 schoolchildren with portable microaethalometers and to evaluate the relationship between personal monitoring and fixed stations at schools (indoor and outdoor) and in an urban background (UB) site. Personal BC concentra-tions were 20% higher than in fixed stations at schools. Linear mixed-effect models showed low R(2) between personal measurements and fixed stations at schools (R(2)  ≤ 0.28), increasing to R(2)  ≥ 0.70 if considering only periods when children were at schools. For the UB station, the respective R(2) were 0.18 and 0.45, indicating the importance of the distance to the monitoring station when assessing exposure. During the warm season, the fixed stations agreed better with personal measurements than during the cold one. Children spent 6% of their time on commuting but received 20% of their daily BC dose, due to co-occurrence with road traffic rush hours and the close proximity to the source. Children received 37% of their daily-integrated BC dose at school. Indoor environments (classroom and home) were responsible for the 56% BC dose.

Industrial sources of primary and secondary organic aerosols in two urban environments in Spain

In urban areas, primary and secondary organic aerosols are typically considered to originate from vehicular traffic emissions. However, industrial emissions within or in the vicinity of urban areas may also be significant contributors to carbonaceous aerosol concentrations. This hypothesis was tested and validated in two urban areas in Spain. The observed unusual dominance of organic carbon (OC) over elemental carbon (EC), the analysis of the variability of OC, EC and OC/EC and their correlation with transport patterns suggested the presence of OC sources associated with industrial activities. A methodology based on chemical speciation of particulate matter (PM) followed by the application of receptor modelling techniques allowed for the identification of the specific industrial sources of OC, which were linked to primary OC emissions from a grain drying plant (cereal) and to secondary OC formation from paper production activities (paper mills), as well as from urban sources and biogenic emissions. This work presents an integrated approach to identifying and characterizing of industrial sources of carbonaceous aerosols in urban areas, aiming to improve the scarce body of literature currently available on this topic.

Environmental and health benefits from designating the Marmara Sea and the Turkish Straits as an emission control area (ECA)

Ship emissions degrade air quality and affect human health, and are increasingly becoming a matter of concern. Sulfur emission control areas (ECA), specific coastal regions where only low-sulfur fuels may be consumed by ocean-going ships, have proven to be useful tools to reduce ship-sourced air pollution along the North American, Canadian, and European North and Baltic Sea coastlines. The present work assesses the environmental and health benefits which would derive from designating an ECA in the Marmara Sea and the Turkish Straits (50 000 ships/year; 23 million inhabitants). Results show evidence that implementing an ECA would be technically viable and that it would reduce ship-sourced PM10 and PM2.5 ambient concentrations in Istanbul by 67%, and SO2 by 90%. The reduction of the air pollution burden on health was quantified as 210 hospital admissions from exposure to PM10, 290 hospital admissions from exposure to SO2, and up to 30 premature deaths annually due to ECA emission controls. Consequently, the designation of an ECA in the Marmara Sea and the Turkish Straits is evaluated as a positive, technically viable and real-world measure to reduce air pollution from ships in Turkey.

Outdoor and indoor UFP in primary schools across Barcelona

Indoor and outdoor measurements of real-time ultrafine particles (UFP; N10-700 in this study) number concentration and average diameter were collected twice at 39 primary schools located in Barcelona (Spain), with classrooms naturally ventilated under warm weather conditions. Simultaneous outdoor N concentration measurements at schools under different traffic exposures showed the important role of this source, with higher levels by 40% on average at schools near heavy traffic, highlighting thus the increased exposure of children due to urban planning decisions. A well-defined spatial pattern of outdoor UFP levels was observed. Midday increases in outdoor N levels mainly attributed to nucleation processes have been recorded both at high and low temperatures in several of the outdoor school sites (increasing levels by 15%-70%). The variation of these increases also followed a characteristic spatial pattern, pointing at schools' location as a key variable in terms of UFP load owing to the important contribution of traffic emissions. Indoor N concentrations were to some extent explained by outdoor N concentrations during school hours, together with average temperatures, related with natural ventilation. Outdoor midday increases were generally mimicked by indoor N concentrations, especially under warm temperatures. At specific cases, indoor concentrations during midday were 30%-40% higher than outdoor. The time scale of these observations evidenced the possible role of: a) secondary particle formation enhanced by indoor precursors or conditions, maybe related with surface chemistry reactions mediated by O3, and/or b) UFP from cooking activities. Significant indoor N increases were detected after school hours, probably associated with cleaning activities, resulting in indoor N concentrations up to 3 times higher than those in outdoor. A wide variability of indoor/outdoor ratios of N concentrations and mean UFP sizes was detected among schools and measurement periods, which seems to be partly associated with climatic conditions and O3 levels, although further research is required.

Sources of indoor and outdoor PM2.5 concentrations in primary schools

Children spend a third of their day in the classroom, where air pollution levels may differ substantially from those outdoors due to specific indoor sources. Air pollution exposure assessments based on atmospheric particle mass measured outdoors may therefore have little to do with the daily PM dose received by school children. This study aims to investigate outdoor and indoor sources of PM2.5 measured at 39 primary schools in Barcelona during 2012. On average 47% of indoor PM2.5 measured concentrations was found to be generated indoors due to continuous resuspension of soil particles (13%) and a mixed source (34%) comprising organic (skin flakes, clothes fibers, possible condensation of VOCs) and Ca-rich particles (from chalk and building deterioration). Emissions from seven outdoor sources penetrated easily indoors being responsible for the remaining 53% of measured PM2.5 indoors. Unpaved playgrounds were found to increase mineral contributions in classrooms by 5-6 μg/m(3) on average with respect to schools with paved playgrounds. Weekday traffic contributions varied considerably across Barcelona within ranges of 1-14 μg/m(3) outdoor and 1-10 μg/m(3) indoor. Indoors, traffic contributions were significantly higher (more than twofold) for classrooms with windows oriented directly to the street, rather than to the interior of the block or to playgrounds. This highlights the importance of urban planning in order to reduce children's exposure to traffic emissions.

2001-2012 trends on air quality in Spain

This study aims at interpreting the 2001-2012 trends of major air pollutants in Spain, with a major focus on evaluating their relationship with those of the national emission inventories (NEI) and policy actions. Marked downward concentration trends were evidenced for PM10, PM2.5 and CO. Concentrations of NO2 and NOx also declined but in a lesser proportion at rural and traffic sites. At rural sites O3 has been kept constant, whereas it clearly increased at urban and industrial sites. Comparison of the air quality trends and major inflection points with those from NEIs, the National Energy Consumption and the calendar of the implementation of major policy actions allowed us to clearly identify major benefits of European directives on power generation and industrial sources (such as the Large Combustion Plants and the Integrated Pollution Prevention and Control Directives). This, together with a sharp 2007-2008 decrease of coal consumption has probably caused the marked parallel decline of SO2, NOx and for PM2.5 concentrations. Also the effect of the EURO 4 and 5 vehicle emission standards on decreasing emissions of PM and CO from vehicles is noticeable. The smooth decline in NO2-NOx levels is mostly attributed to the low efficiency of EURO 4 and 5 standards in reducing real life urban driving NO2 emissions. The low NOx decrease together with the complexity of the reactions of O3 formation is responsible for the constant O3 concentrations, or even the urban increase. The financial crisis has also contributed to the decrease of the ambient concentration of pollutants; however this caused a major reduction of the primary energy consumption from 2008 to 2009, and not from 2007 to 2008 when ambient air PM and SO2 sharply decreased. The meteorological influence was characterized by a 2008-2012 period favorable to the dispersion of pollutants when compared to the 2001-2007.

Child exposure to indoor and outdoor air pollutants in schools in Barcelona, Spain

Proximity to road traffic involves higher health risks because of atmospheric pollutants. In addition to outdoor air, indoor air quality contributes to overall exposure. In the framework of the BREATHE study, indoor and outdoor air pollution was assessed in 39 schools in Barcelona. The study quantifies indoor and outdoor air quality during school hours of the BREATHE schools. High levels of fine particles (PM2.5), nitrogen dioxide (NO2), equivalent black carbon (EBC), ultrafine particle (UFP) number concentration and road traffic related trace metals were detected in school playgrounds and indoor environments. PM2.5 almost doubled (factor of 1.7) the usual urban background (UB) levels reported for Barcelona owing to high school-sourced PM2.5 contributions: [1] an indoor-generated source characterised mainly by organic carbon (OC) from organic textile fibres, cooking and other organic emissions, and by calcium and strontium (chalk dust) and; [2] mineral elements from sand-filled playgrounds, detected both indoors and outdoors. The levels of mineral elements are unusually high in PM2.5 because of the breakdown of mineral particles during playground activities. Moreover, anthropogenic PM components (such as OC and arsenic) are dry/wet deposited in this mineral matter. Therefore, PM2.5 cannot be considered a good tracer of traffic emissions in schools despite being influenced by them. On the other hand, outdoor NO2, EBC, UFP, and antimony appear to be good indicators of traffic emissions. The concentrations of NO2 are 1.2 times higher at schools than UB, suggesting the proximity of some schools to road traffic. Indoor levels of these traffic-sourced pollutants are very similar to those detected outdoors, indicating easy penetration of atmospheric pollutants. Spatial variation shows higher levels of EBC, NO2, UFP and, partially, PM2.5 in schools in the centre than in the outskirts of Barcelona, highlighting the influence of traffic emissions. Mean child exposure to pollutants in schools in Barcelona attains intermediate levels between UB and traffic stations.

Functional polymorphisms in COMT and SLC6A4 genes influence the prognosis of patients with medication overuse headache after withdrawal therapy

BACKGROUND AND PURPOSE

It is currently unknown if common genetic variants influence the prognosis of patients with medication overuse headache (MOH). Here the role of two common single nucleotide polymorphisms in the COMT gene (rs4680 and rs6269), as well as the STin2 variable number tandem repeat (VNTR) polymorphism in the SLC6A4 gene, were evaluated as predictors for long-term outcomes of MOH patients after withdrawal therapy.

METHODS

Genotyping was conducted by polymerase chain reaction (PCR), PCR restriction fragment length polymorphism analysis or real-time PCR allelic discrimination assay on genomic DNA extracted from peripheral blood. Gene variants association was evaluated by logistic regression analysis adjusted for clinical confounding factors, and the threshold of statistical significance for multiple testing was set at P < 0.012.

RESULTS

Sixty-five MOH patients with unsuccessful detoxification and 83 MOH patients with effective drug withdrawal therapy were available for the analysis. rs4680G allele carriers or the COMT rs6269G-rs4680G haplotype were found to be associated with a lower risk of relapse within the first year after successful detoxification therapy, in comparison with homozygous rs4680A allele carriers [odds ratio (OR) 0.17, 95% confidence interval (CI) 0.05-0.61, P = 0.007] or with the COMT rs6269A-rs4680A haplotype (OR 0.19, 95% CI 0.06-0.54, P = 0.003), respectively. In addition, carriers of the STin2 VNTR short allele were found at higher odds for the composite poor outcome including unsuccessful withdrawal therapy and relapse within 12 months of follow-up after successful detoxification (OR 2.81, 95%CI 1.26-6.25, P = 0.009).

CONCLUSIONS

Our results indicate that genotyping for COMT rs4680 and SLC6A4 STin2 VNTR could be useful for the identification of MOH patients at higher risk of poor prognosis after drug withdrawal.

Natural sources of atmospheric aerosols influencing air quality across Europe

Atmospheric aerosols are emitted by natural and anthropogenic sources. Contributions from natural sources to ambient aerosols vary widely with time (inter-annual and seasonal variability) and as a function of the distance to source regions. This work aims to identify the main natural sources of atmospheric aerosols affecting air quality across Europe. The origin, frequency, magnitude, and spatial and temporal variability of natural events were assessed for the years 2008 and 2009. The main natural sources of atmospheric aerosols identified were African dust, sea spray and wildfires. Primary biological particles were not included in the present work. Volcanic eruptions did not affect air quality significantly in Europe during the study period. The impact of natural episodes on air quality was significant in Southern and Western Europe (Cyprus, Spain, France, UK, Greece, Malta, Italy and Portugal), where they contributed to surpass the PM10 daily and annual limit values. In Central and Northern Europe (Germany, Austria and Latvia) the impact of these events was lower, as it resulted in the exceedance of PM daily but not annual limit values. Contributions from natural sources to mean annual PM10 levels in 2008 and 2009 ranged between 1 and 2 μg/m(3) in Italy, France and Portugal, between 1 and 4 μg/m(3) in Spain (10 μg/m(3) when including the Canary Islands), 5 μg/m(3) in UK, between 3 and 8 μg/m(3) in Greece, and reached up to 13 μg/m(3) in Cyprus. The evaluation of the number of monitoring stations per country reporting natural exceedances of the daily limit value (DLV) is suggested as a potential tool for air quality monitoring networks to detect outliers in the assessment of natural contributions. It is strongly suggested that a reference methodology for the identification and quantification of African dust contributions should be adopted across Europe.

Investigation on Detergent Tablet Stability: from Raw Materials to Tablet Properties

The aim of this study is to investigate the functional characteristics (mechanical strength, disintegration and dissolution) of effervescent detergent tablets with chlorine provider under various storage conditions. The contribution of surfactant to the tablet stability was studied by comparing tablets without and with surfactant. After one year of storage in polypropylene tubes, the properties were modified for both formulas but the way to reach the end-point was different. In order to precise the influence of relative humidity, the tablets were exposed to controlled humidity levels, after a preliminary drying stage: with the surfactant, stability was better at lower humidity but for higher relative humidity, tablet properties were affected to a larger extent, compared to the formula without surfactant. Raman spectroscopy pointed out modifications of effervescent couple with humidity indicating i) a beginning of effervescence in the tablets and ii) the limiting effect of the surfactant on this phenomenon.

Health effects from Sahara dust episodes in Europe: literature review and research gaps

The adverse consequences of particulate matter (PM) on human health have been well documented. Recently, special attention has been given to mineral dust particles, which may be a serious health threat. The main global source of atmospheric mineral dust is the Sahara desert, which produces about half of the annual mineral dust. Sahara dust transport can lead to PM levels that substantially exceed the established limit values. A review was undertaken using the ISI web of knowledge database with the objective to identify all studies presenting results on the potential health impact from Sahara dust particles. The review of the literature shows that the association of fine particles, PM₂.₅, with total or cause-specific daily mortality is not significant during Saharan dust intrusions. However, regarding coarser fractions PM₁₀ and PM₂.₅₋₁₀ an explicit answer cannot be given. Some of the published studies state that they increase mortality during Sahara dust days while other studies find no association between mortality and PM₁₀ or PM₂.₅₋₁₀. The main conclusion of this review is that health impact of Saharan dust outbreaks needs to be further explored. Considering the diverse outcomes for PM₁₀ and PM₂.₅₋₁₀, future studies should focus on the chemical characterization and potential toxicity of coarse particles transported from Sahara desert mixed or not with anthropogenic pollutants. The results of this review may be considered to establish the objectives and strategies of a new European directive on ambient air quality. An implication for public policy in Europe is that to protect public health, anthropogenic sources of particulate pollution need to be more rigorously controlled in areas highly impacted by the Sahara dust.

Assessing feasibility and acceptability of home-care based rehabilitation from the perspective of stroke patients and their informal caregivers

Purpose

To report on stroke patients and their informal caregivers’ perceptions and experiences regarding feasibility and acceptability of home-care based rehabilitation, in the context of the implementation of an EHSD procedure.

Theory

EHSD procedures are considered promising alternatives to conventional care in stroke rehabilitation, as they seem to be able to reduce costs with illness and to accrue important benefits to patients and their informal caregivers. The literature in this area provides some guidelines of how to organize and assess this type of intervention, regarding the impact on patient’s functionality and related costs. Less investigated are the perspectives of patients and their informal caregivers, namely, their perceptions and experiences regarding feasibility and acceptability of home-care based rehabilitation.

Methods

Data were collected using focus group discussion. We conducted two focus groups with key-informants, selected patients and caregivers, chosen due to the diversity and deepness of their cases, aiming at improving both evidence-based knowledge and theoretical framework. A group of three researchers with specific roles joined each focus group, namely a moderator, a recorder and a coordinator. During the sessions, participants were encouraged to speak until all views were expressed. The data were recorded, transcribed and analyzed. The content analysis was performed with NVivo 9 which allowed us to identify the main themes of each topic under discussion.

Results and conclusions

Home-care based rehabilitation seems to be feasible and acceptable for patients and their caregivers. Our results point out the advantages of home-care over traditional models. Moreover, patients and their caregivers identified aspects that can be improved in home-based services.

Care transition and network activation in Portugal

Purpose

Theory

Methods

Results and conclusions

Multidisciplinary home training for stroke patients in Portugal: the perspective of care professionals

Purpose

To systematize the content of home-care interventions for stroke patients in Portugal and assess their relevance, feasibility and acceptability from the perspective of care professionals.

Theory

Research seems to show that Integrated Home Care (IHC) is an excellent form of rehabilitation as the domicile is the place where the patient feels safe, participate most and have direct feedback from ADL training [1]. Moreover, recent results show that IHC has the potential to lower the costs of post-stroke rehabilitation [2]. Cost-effectiveness analysis would then be an important tool for decision-makers regarding alternative IHC interventions. However, in practice the realization of the potential benefits of IHC has to overcome serious barriers and the dissemination of IHC in the European Union will depend “on the upgrade of health professionals from a defensive kind of monodisciplinary professionalism towards an open-ended multidisciplinary professionalism” [1]. Therefore, it is fundamental to assess health professionals’ perceptions and experiences regarding the relevance, feasibility and acceptability of home-based rehabilitation and their willingness to participate.

Methods

In Portugal, the home rehabilitation teams include a gerontologist which is the case manager, a physiotherapist, an occupational therapist and a psychologist. A mixed method was used to analyse the teams’ interventions at home. Information about each session was recorded by all professionals in a standardized form. Additionally, case managers have written qualitative reports, according to a pre-defined minimum structure and the psychologist has written patient specific psychology reports. We analysed the sessions’ reports of 80 patients who have received rehabilitation services at home. This information was coded, keyed into a database and analyzed with PASW Statistics 18. In the qualitative phase, we have explored health professional’s perceptions on experiences with home-care rehabilitation process. Data were collected within a focus group composed by two physiotherapists, two occupational therapists, a psychologist and two gerontologists. A group of three researchers with specific roles joined the focus group, namely a moderator, a recorder and a coordinator. The session’s content was recorded, transcript and analyzed with NVivo 9.

Results and conclusions

Quantitative results consist on the average number of sessions at home per specialty, the duration of sessions, the reasons for therapeutic rehabilitation, the type of intervention executed by the professionals, the specific content of treatments in home care and strategies used by professionals in this type of rehabilitation. Qualitative results include health professionals individual and collective understanding of patients’ achievements and effort required from the professionals and their assessment of the measures used to evaluate the results.

Biomass burning contributions to urban aerosols in a coastal Mediterranean city

Mean annual biomass burning contributions to the bulk particulate matter (PM(X)) load were quantified in a southern-European urban environment (Barcelona, Spain) with special attention to typical Mediterranean winter and summer conditions. In spite of the complexity of the local air pollution cocktail and the expected low contribution of biomass burning emissions to PM levels in Southern Europe, the impact of these emissions was detected at an urban background site by means of tracers such as levoglucosan, K(+) and organic carbon (OC). The significant correlation between levoglucosan and OC (r(2)=0.77) and K(+) (r(2)=0.65), as well as a marked day/night variability of the levoglucosan levels and levoglucosan/OC ratios was indicative of the contribution from regional scale biomass burning emissions during night-time transported by land breezes. In addition, on specific days (21-22 March), the contribution from long-range transported biomass burning aerosols was detected. Quantification of the contribution of biomass burning aerosols to PM levels on an annual basis was possible by means of the Multilinear Engine (ME). Biomass burning emissions accounted for 3% of PM(10) and PM(2.5) (annual mean), while this percentage increased up to 5% of PM(1). During the winter period, regional-scale biomass burning emissions (agricultural waste burning) were estimated to contribute with 7±4% of PM(2.5) aerosols during night-time (period when emissions were clearly detected). Long-range transported biomass burning aerosols (possibly from forest fires and/or agricultural waste burning) accounted for 5±2% of PM(2.5) during specific episodes. Annually, biomass burning emissions accounted for 19%-21% of OC levels in PM(10), PM(2.5) and PM(1). The contribution of this source to K(+) ranged between 48% for PM(10) and 97% for PM(1) (annual mean). Results for K(+) from biomass burning evidenced that this tracer is mostly emitted in the fine fraction, and thus coarse K(+) could not be taken as an appropriate tracer of biomass burning.

AMP-activated protein kinase mediates effects of oxidative stress on embryo gene expression in a mouse model of diabetic embryopathy

AIMS/HYPOTHESIS

Neural tube defects (NTDs) are a common malformation associated with diabetic embryopathy. Maternal hyperglycaemia-induced oxidative stress inhibits the expression of Pax3, a gene that is essential for neural tube closure, and increases the incidence of NTDs. Because oxidative stress can stimulate AMP-activated kinase (AMPK) activity, and AMPK can regulate gene transcription, we hypothesised that increased AMPK activity would mediate the adverse effects of maternal hyperglycaemia-induced oxidative stress on Pax3 expression and NTDs.

METHODS

Pregnant mice were made transiently hyperglycaemic by glucose injection, or hypoxic by housing in a hypoxic chamber, or were treated with antimycin A to induce oxidative stress, and AMPK activity in the embryos was assayed. The effects of stimulating AMPK activity with 5-aminoimidazole-4-carboxamide-1-beta-4-ribofuranoside (AICAR) on Pax3 expression and NTDs were determined. Vitamin E or glutathione ethyl ester was used to reduce oxidative stress, and compound C was used to inhibit AMPK activation. Murine embryonic stem cells were employed as an in vitro model to study the effects of oxidative stress on AMPK activity and the effects of AMPK stimulation on Pax3 expression.

RESULTS

Maternal hyperglycaemia stimulated AMPK activity, and stimulation of AMPK with AICAR inhibited Pax3 expression (in vivo and in vitro) and increased NTDs (in vivo). Stimulation of AMPK by hyperglycaemia, hypoxia or antimycin A was inhibited by antioxidants. The AMPK inhibitor compound C blocked the effects of hyperglycaemia or AA on Pax3 expression and NTDs.

CONCLUSIONS/INTERPRETATION

Stimulation of AMPK in embryos during a diabetic pregnancy mediates the effects of hyperglycaemia-induced oxidative stress to disturb the expression of the critical Pax3 gene, thereby causing NTDs.

Implication of low level inflammation in the insulin resistance of adipose tissue at late pregnancy

Insulin resistance is a characteristic of late pregnancy, and adipose tissue is one of the tissues that most actively contributes to the reduced maternal insulin sensitivity. There is evidence that pregnancy is a condition of moderate inflammation, although the physiological role of this low-grade inflammation remains unclear. The present study was designed to validate whether low-grade inflammation plays a role in the development of insulin resistance in adipose tissue during late pregnancy. To this end, we analyzed proinflammatory adipokines and kinases in lumbar adipose tissue of nonpregnant and late pregnant rats at d 18 and 20 of gestation. We found that circulating and tissue levels of adipokines, such as IL-1β, plasminogen activator inhibitor-1, and TNF-α, were increased at late pregnancy, which correlated with insulin resistance. The observed increase in adipokines coincided with an enhanced activation of p38 MAPK in adipose tissue. Treatment of pregnant rats with the p38 MAPK inhibitor SB 202190 increased insulin-stimulated tyrosine phosphorylation of the insulin receptor (IR) and IR substrate-1 in adipose tissue, which was paralleled by a reduction of IR substrate-1 serine phosphorylation and an enhancement of the metabolic actions of insulin. These results indicate that activation of p38 MAPK in adipose tissue contributes to adipose tissue insulin resistance at late pregnancy. Furthermore, the results of the present study support the hypothesis that physiological low-grade inflammation in the maternal organism is relevant to the development of pregnancy-associated insulin resistance.