Where the rubber meets the road: Emerging environmental impacts of tire wear particles and their chemical cocktails

About 3 billion new tires are produced each year and about 800 million tires become waste annually. Global dependence upon tires produced from natural rubber and petroleum-based compounds represents a persistent and complex environmental problem with only partial and often-times, ineffective solutions. Tire emissions may be in the form of whole tires, tire particles, and chemical compounds, each of which is transported through various atmospheric, terrestrial, and aquatic routes in the natural and built environments. Production and use of tires generates multiple heavy metals, plastics, PAH's, and other compounds that can be toxic alone or as chemical cocktails. Used tires require storage space, are energy intensive to recycle, and generally have few post-wear uses that are not also potential sources of pollutants (e.g., crumb rubber, pavements, burning). Tire particles emitted during use are a major component of microplastics in urban runoff and a source of unique and highly potent toxic substances. Thus, tires represent a ubiquitous and complex pollutant that requires a comprehensive examination to develop effective management and remediation. We approach the issue of tire pollution holistically by examining the life cycle of tires across production, emissions, recycling, and disposal. In this paper, we synthesize recent research and data about the environmental and human health risks associated with the production, use, and disposal of tires and discuss gaps in our knowledge about fate and transport, as well as the toxicology of tire particles and chemical leachates. We examine potential management and remediation approaches for addressing exposure risks across the life cycle of tires. We consider tires as pollutants across three levels: tires in their whole state, as particulates, and as a mixture of chemical cocktails. Finally, we discuss information gaps in our understanding of tires as a pollutant and outline key questions to improve our knowledge and ability to manage and remediate tire pollution.

Anaesthetic subspecialties and sustainable healthcare: a narrative review

The principles of environmentally sustainable healthcare as applied to anaesthesia and peri-operative care are well documented. Associated recommendations focus on generic principles that can be applied to all areas of practice. These include reducing the use of inhalational anaesthetic agents and carbon dioxide equivalent emissions of modern peri-operative care. However, four areas of practice have specific patient, surgical and anaesthetic factors that present barriers to the implementation of some of these principles, namely: neuroanaesthesia; obstetric; paediatric; and cardiac anaesthesia. This narrative review describes these factors and synthesises the available evidence to highlight areas of sustainable practice clinicians can address today, as well as posing several unanswered questions for the future. In neuroanaesthesia, improvements can be made by undertaking awake surgery, moving towards more reusables and embracing telemedicine in quaternary services. Obstetric anaesthesia continues to present questions regarding how services can move away from nitrous oxide use or limit its release to the environment. The focus for paediatric anaesthesia is addressing the barriers to total intravenous and regional anaesthesia. For cardiac anaesthesia, a significant emphasis is determining how to focus the substantial resources required on those who will benefit from cardiac interventions, rather than universal implementation. Whilst the landscape of evidence-based sustainable practice is evolving, there remains an urgent need for further original evidence in healthcare sustainability targeting these four clinical areas.

ALGORITHMS, ADDICTION, AND ADOLESCENT MENTAL HEALTH: An Interdisciplinary Study to Inform State-level Policy Action to Protect Youth from the Dangers of Social Media

A recent Wall Street Journal investigation revealed that TikTok floods child and adolescent users with videos of rapid weight loss methods, including tips on how to consume less than 300 calories a day and promoting a "corpse bride diet," showing emaciated girls with protruding bones. The investigation involved the creation of a dozen automated accounts registered as 13-year-olds and revealed that TikTok algorithms fed adolescents tens of thousands of weight-loss videos within just a few weeks of joining the platform. Emerging research indicates that these practices extend well beyond TikTok to other social media platforms that engage millions of U.S. youth on a daily basis.Social media algorithms that push extreme content to vulnerable youth are linked to an increase in mental health problems for adolescents, including poor body image, eating disorders, and suicidality. Policy measures must be taken to curb this harmful practice. The Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED), a research program based at the Harvard T.H. Chan School of Public Health and Boston Children's Hospital, has assembled a diverse team of scholars, including experts in public health, neuroscience, health economics, and law with specialization in First Amendment law, to study the harmful effects of social media algorithms, identify the economic incentives that drive social media companies to use them, and develop strategies that can be pursued to regulate social media platforms' use of algorithms. For our study, we have examined a critical mass of public health and neuroscience research demonstrating mental health harms to youth. We have conducted a groundbreaking economic study showing nearly $11 billion in advertising revenue is generated annually by social media platforms through advertisements targeted at users 0 to 17 years old, thus incentivizing platforms to continue their harmful practices. We have also examined legal strategies to address the regulation of social media platforms by conducting reviews of federal and state legal precedent and consulting with stakeholders in business regulation, technology, and federal and state government.While nationally the issue is being scrutinized by Congress and the Federal Trade Commission, quicker and more effective legal strategies that would survive constitutional scrutiny may be implemented by states, such as the Age Appropriate Design Code Act recently adopted in California, which sets standards that online services likely to be accessed by children must follow. Another avenue for regulation may be through states mandating that social media platforms submit to algorithm risk audits conducted by independent third parties and publicly disclose the results. Furthermore, Section 230 of the federal Communications Decency Act, which has long shielded social media platforms from liability for wrongful acts, may be circumvented if it is proven that social media companies share advertising revenues with content providers posting illegal or harmful content.Our research team's public health and economic findings combined with our legal analysis and resulting recommendations, provide innovative and viable policy actions that state lawmakers and attorneys general can take to protect youth from the harms of dangerous social media algorithms.

Quaternary Ammonium Compounds: A Chemical Class of Emerging Concern

Quaternary ammonium compounds (QACs), a large class of chemicals that includes high production volume substances, have been used for decades as antimicrobials, preservatives, and antistatic agents and for other functions in cleaning, disinfecting, personal care products, and durable consumer goods. QAC use has accelerated in response to the COVID-19 pandemic and the banning of 19 antimicrobials from several personal care products by the US Food and Drug Administration in 2016. Studies conducted before and after the onset of the pandemic indicate increased human exposure to QACs. Environmental releases of these chemicals have also increased. Emerging information on adverse environmental and human health impacts of QACs is motivating a reconsideration of the risks and benefits across the life cycle of their production, use, and disposal. This work presents a critical review of the literature and scientific perspective developed by a multidisciplinary, multi-institutional team of authors from academia, governmental, and nonprofit organizations. The review evaluates currently available information on the ecological and human health profile of QACs and identifies multiple areas of potential concern. Adverse ecological effects include acute and chronic toxicity to susceptible aquatic organisms, with concentrations of some QACs approaching levels of concern. Suspected or known adverse health outcomes include dermal and respiratory effects, developmental and reproductive toxicity, disruption of metabolic function such as lipid homeostasis, and impairment of mitochondrial function. QACs' role in antimicrobial resistance has also been demonstrated. In the US regulatory system, how a QAC is managed depends on how it is used, for example in pesticides or personal care products. This can result in the same QACs receiving different degrees of scrutiny depending on the use and the agency regulating it. Further, the US Environmental Protection Agency's current method of grouping QACs based on structure, first proposed in 1988, is insufficient to address the wide range of QAC chemistries, potential toxicities, and exposure scenarios. Consequently, exposures to common mixtures of QACs and from multiple sources remain largely unassessed. Some restrictions on the use of QACs have been implemented in the US and elsewhere, primarily focused on personal care products. Assessing the risks posed by QACs is hampered by their vast structural diversity and a lack of quantitative data on exposure and toxicity for the majority of these compounds. This review identifies important data gaps and provides research and policy recommendations for preserving the utility of QAC chemistries while also seeking to limit adverse environmental and human health effects.

The KMT2A recombinome of acute leukemias in 2023

Chromosomal rearrangements of the human KMT2A/MLL gene are associated with de novo as well as therapy-induced infant, pediatric, and adult acute leukemias. Here, we present the data obtained from 3401 acute leukemia patients that have been analyzed between 2003 and 2022. Genomic breakpoints within the KMT2A gene and the involved translocation partner genes (TPGs) and KMT2A-partial tandem duplications (PTDs) were determined. Including the published data from the literature, a total of 107 in-frame KMT2A gene fusions have been identified so far. Further 16 rearrangements were out-of-frame fusions, 18 patients had no partner gene fused to 5'-KMT2A, two patients had a 5'-KMT2A deletion, and one ETV6::RUNX1 patient had an KMT2A insertion at the breakpoint. The seven most frequent TPGs and PTDs account for more than 90% of all recombinations of the KMT2A, 37 occur recurrently and 63 were identified so far only once. This study provides a comprehensive analysis of the KMT2A recombinome in acute leukemia patients. Besides the scientific gain of information, genomic breakpoint sequences of these patients were used to monitor minimal residual disease (MRD). Thus, this work may be directly translated from the bench to the bedside of patients and meet the clinical needs to improve patient survival.

Triclosan and Methyl Triclosan in Prey Fish in a Wastewater-Influenced Estuary

While the antimicrobial ingredient triclosan has been widely monitored in the environment, much less is known about the occurrence and toxicity of its major transformation product, methyl triclosan. An improved method was developed and validated to effectively extract and quantify both contaminants in fish tissue and used to characterize concentrations in small prey fish in areas of San Francisco Bay where exposure to triclosan via municipal wastewater discharges was expected to be highest. Concentrations of triclosan (0.44-57 ng/g wet wt, median 1.9 ng/g wet wt) and methyl triclosan (1.1-200 ng/g wet wt, median 36 ng/g wet wt) in fish tissue decreased linearly with concentrations of nitrate in site water, used as indicators of wastewater influence. The total concentrations of triclosan and methyl triclosan measured in prey fish were below available toxicity thresholds for triclosan, but there are few ecotoxicological studies to evaluate impacts of methyl triclosan. Methyl triclosan represented up to 96% of the total concentrations observed. These results emphasize the importance of monitoring contaminant transformation products, which can be present at higher levels than the parent compound. Environ Toxicol Chem 2023;42:620-627. © 2023 SETAC.

Optimizing Chemicals Management in the United States and Canada through the Essential-Use Approach

Chemicals have improved the functionality and convenience of industrial and consumer products, but sometimes at the expense of human or ecological health. Existing regulatory systems have proven to be inadequate for assessing and managing the tens of thousands of chemicals in commerce. A different approach is urgently needed to minimize ongoing production, use, and exposures to hazardous chemicals. The premise of the essential-use approach is that chemicals of concern should be used only in cases in which their function in specific products is necessary for health, safety, or the functioning of society and when feasible alternatives are unavailable. To optimize the essential-use approach for broader implementation in the United States and Canada, we recommend that governments and businesses (1) identify chemicals of concern for essentiality assessments based on a broad range of hazard traits, going beyond toxicity; (2) expedite decision-making by avoiding unnecessary assessments and strategically asking up to three questions to determine whether the use of the chemical in the product is essential; (3) apply the essential-use approach as early as possible in the process of developing and assessing chemicals; and (4) engage diverse experts in identifying chemical uses and functions, assessing alternatives, and making essentiality determinations and share such information broadly. If optimized and expanded into regulatory systems in the United States and Canada, other policymaking bodies, and businesses, the essential-use approach can improve chemicals management and shift the market toward safer chemistries that benefit human and ecological health.

New definition of hypotension in patients with reflex syncope using 24-hour ambulatory blood pressure monitoring (SynABPM Study)

Background

Diagnostic criteria for ambulatory blood pressure monitoring (ABPM) in patients with suspected reflex syncope are lacking.

Purpose

We hypothesized that patients with reflex syncope have a higher prevalence of systolic blood pressure (SBP) drops on ABPM than control subjects and we aimed to define the SBP cut-off values that allow identification of patients with hypotensive susceptibility.

Methods

We compared ABPM data from reflex syncope patients and controls, matched by average 24-hour SBP, age, sex and hypertension. Patients with constitutional hypotension, orthostatic hypotension, predominant cardioinhibition or competing causes of syncope were excluded. Daytime and night-time SBP drops (<110, 100, 90, 80 mmHg) were assessed. Findings were validated in an independent sample.

Results

In the Derivation cohort, daytime SBP drops were significantly more common in 158 syncope patients than 329 controls. One or more daytime drop <90 mmHg provided the best diagnostic yield (91% specificity, 32% sensitivity, Odds Ratio [OR]=4.6, p=0.001). Two or more-daytime drops <100 mmHg achieved 84% specificity and 40% sensitivity (OR=3.5, p=0.001). Results were confirmed in the Validation cohort: one or more daytime SBP drop <90 mmHg provided 94% specificity and 29% sensitivity (OR=6.2, p<0.001), while two or more daytime SBP drops <100 mmHg achieved 83% specificity and 35% sensitivity (OR=2.6, p<0.001) (Figure 1).

Conclusion

SBP drops during ABPM are more common in reflex syncope patients than in controls. Cut-off values that may be applied in clinical practice are defined. This study expands the current indications for ABPM to patients with reflex syncope.

Funding Acknowledgement

Type of funding sources: None.

Suspect Screening and Chemical Profile Analysis of Storm-Water Runoff Following 2017 Wildfires in Northern California

The combustion of structures and household materials as well as firefighting during wildfires lead to releases of potentially hazardous chemicals directly into the landscape. Subsequent storm-water runoff events can transport wildfire-related contaminants to downstream receiving waters, where they may pose water quality concerns. To evaluate the environmental hazards of northern California fires on the types of contaminants in storm water discharging to San Francisco Bay and the coastal marine environment, we analyzed storm water collected after the northern California wildfires (October 2017) using a nontargeted analytical (NTA) approach. Liquid chromatography quadrupole time-of-flight mass spectrometric analysis was completed on storm-water samples (n = 20) collected from Napa County (impacted by the Atlas and Nuns fires), the city of Santa Rosa, and Sonoma County (Nuns and Tubbs fires) during storm events that occurred in November 2017 and January 2018. The NTA approach enabled us to establish profiles of contaminants based on peak intensities and chemical categories found in the storm-water samples and to prioritize significant chemicals within these profiles possibly attributed to the wildfire. The results demonstrated the presence of a wide range of contaminants in the storm water, including surfactants, per- and polyfluoroalkyl substances, and chemicals from consumer and personal care products. Homologs of polyethylene glycol were found to be the major contributor to the contaminants, followed by other widely used surfactants. Nonylphenol ethoxylates, typically used as surfactants, were detected and were much higher in samples collected after Storm Event 1 relative to Storm Event 2. The present study provides a comprehensive approach for examining wildfire-impacted storm-water contamination of related contaminants, of which we found many with potential ecological risk. Environ Toxicol Chem 2022;41:1824-1837. © 2022 SETAC.

Occurrence and risk assessment of organophosphate esters and bisphenols in San Francisco Bay, California, USA

Organophosphate esters (OPEs) and bisphenols are two classes of industrial chemicals that are ubiquitously detected in environmental matrices due to high global production and widespread use, particularly in the manufacture of plastic products. In 2017, water samples collected throughout the highly urbanized San Francisco Bay were analyzed for 22 OPEs and 16 bisphenols using liquid chromatography-electrospray ionization-Q Trap-mass spectrometry. Fifteen of the 22 OPEs were detected, with highest median concentrations in the order TCPP (42 ng/L) > TPhP (9.5 ng/L) > TBOEP (7.6 ng/L) > TnBP (7.5 ng/L) > TEP (6.7 ng/L) > TDCIPP (6.2 ng/L). In contrast, only two of 16 bisphenols, BPA and BPS, were quantified, with concentrations ranging from <0.7-35 ng/L and <1-120 ng/L, respectively. BPA and a few OPEs (EHDPP and TEHP) were primarily present in the particulate phase, while BPS and all other observed OPEs were predominantly found in the dissolved phase. Pairwise correlation analysis revealed several strong, positive correlations among OPEs, and few weak, negative correlations between OPEs and BPA, suggesting differences between the two classes with respect to their sources, pathways, and/or fate in the environment. Concentrations of OPEs and bisphenols observed in this study were generally consistent with reported concentrations in other estuarine and marine settings globally. TDCIPP exceeded existing predicted no-effect concentrations (PNECs) at some sites, and six other compounds (TCrP, IDDPP, EHDPP, TPhP, TBOEP, and BPA) were observed at levels approaching individual compound PNECs (not considering mixture effects), indicating potential risks to Bay biota. These results emphasize the need to control releases of these contaminants in order to protect the ecosystem. Periodic monitoring can be used to maintain vigilance in the face of potential regrettable substitutions.

Framework for nontargeted investigation of contaminants released by wildfires into stormwater runoff: Case study in the northern San Francisco Bay area

Wildfires can be extremely destructive to communities and ecosystems. However, the full scope of the ecological damage is often hard to assess, in part due to limited information on the types of chemicals introduced to affected landscapes and waterways. The objective of this study was to establish a sampling, analytical, and interpretive framework to effectively identify and monitor contaminants of emerging concern in environmental water samples impacted by wildfire runoff. A nontargeted analysis consisting of comprehensive two-dimensional gas chromatography coupled to time-of-flight mass spectrometry (GC × GC/TOF-MS) was conducted on stormwater samples from watersheds in the City of Santa Rosa and Sonoma and Napa Counties, USA, after the three most destructive fires during the October 2017 Northern California firestorm. Chemicals potentially related to wildfires were selected from the thousands of chromatographic features detected through a screening method that compared samples from fire-impacted sites versus unburned reference sites. This screening led to high confidence identifications of 76 potentially fire-related compounds. Authentic standards were available for 48 of these analytes, and 46 were confirmed by matching mass spectra and GC × GC retention times. Of these 46 compounds, 37 had known commercial and industrial uses as intermediates or ingredients in plastics, personal care products, pesticides, and as food additives. Nine compounds had no known uses or sources and may be oxidation products resulting from burning of natural or anthropogenic materials. Preliminary examination of potential toxicity associated with the 46 compounds, conducted via online databases and literature review, indicated limited data availability. Regional comparison suggested that more structural damage may yield a greater number of unique, potentially wildfire-related compounds. We recommend further study of post-wildfire runoff using the framework described here, which includes hypothesis-driven site selection and nontargeted analysis, to uncover potentially significant stormwater contaminants not routinely monitored after wildfires and inform risk assessment. Integr Environ Assess Manag 2021;17:1179-1193. © 2021 SETAC.

Lifelong and mature-onset syncope in older adults may have different mechanisms

Background

Syncope is a common clinical problem with a sharp rise in the incidence after 70 years. In older patients, syncope is often a diagnostic challenge. It is unclear whether the age at which patients experience syncope for the first time impacts the results of syncope investigation.

Purpose

To study the influence of early-onset vs. mature-onset syncope on clinical characteristics and final head-up tilt (HUT) diagnosis in a large sample of unexplained syncope patients.

Methods

Consecutive patients (n=1928) with unexplained syncope after initial evaluation examined with a standard HUT protocol in a syncope unit were stratified into age groups below and above 60 years. Clinical characteristics and the final HUT diagnosis were analysed in relation to self-reported age at first syncope and age at investigation. The distribution of age at first syncope was bimodal with peaks at 15 and 70 years (Figure 1). In the present analysis, patients aged &gt;60 years (n=836) with early-onset (&lt;30 years) and mature-onset (&gt;60 years) syncope were compared.

Results

Vasovagal syncope (VVS) was more common in early-onset syncope, 39% vs 19% (p&lt;0.001), (Figure 2). Orthostatic hypotension (OH) was more common in mature-onset syncope, 23% vs 7% (p&lt;0.001), as was hypertension, 59% vs 40% (p=0.001). The frequency of carotid sinus syndrome (CSS) was not affected by age at first syncope in patients aged &gt;60 years.Complex syncope etiology (findings suggesting overlap between VVS, OH and/or CSS) was more common among patients with early-onset syncope, 37% vs 26% (p=0.023). No definite HUT-derived diagnosis was more common in mature-onset syncope, 23% vs 13% (p=0.023). Heart failure, 9% vs 2% (p=0.024) and atrial fibrillation, 20% vs 9% (p=0.013) were more common in mature-onset syncope. Prodromes were less common in mature-onset syncope, 26% vs 52% (p&lt;0.001), however there was no significant difference in reported palpitations preceding syncope and dizziness on standing.

Conclusions

Mature-onset syncope was more often associated with absence of prodromes, orthostatic hypotension, inconclusive HUT findings and presence of heart failure and atrial fibrillation suggesting cardiac syncope to be the likely cause. Early-onset syncope was associated with presence of prodromes, vasovagal reflex mechanism and complex syncope diagnosis. Lifelong and mature-onset unexplained syncope may have different pathophysiological mechanisms in older patients and aetiologies other than vasovagal syncope should be carefully considered in patients with first-ever syncope in later life.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swedish heart and lung foundationCrafoord foundation

Association of incident fragility fractures in patients hospitalised due to unexplained syncope and orthostatic hypotension

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The study was funded by The Swedish Heart-Lung Foundation, The Greta and Johan Kock Foundation, and an Agreement for Medical Education and Research (ALF) grant by Swedish Research Council funding for clinical research in medicine.

Background

Fragility fractures are caused by low-energy insults such as falls from standing height or less and pose a growing health challenge as their incidence rises with increasing age. Impaired orthostatic blood pressure response and a number of cardiovascular biomarkers have been previously identified as risk factors for fractures. It is likely that severe episodes of syncope and orthostatic hypotension increase the risk of subsequent fragility fractures, however this relationship has not been thoroughly examined.

Purpose

To investigate the relationship of hospital admissions due to unexplained syncope and OH with incident fragility fractures in a middle-aged population.

Methods

We analysed a large population-based prospective cohort of 30,446 middle-aged individuals (age, 57.5 ± 7.6; men, 39.8%). We included patients hospitalised due to unexplained syncope and OH. Cox regression analysis adjusted for age, sex, prevalent fractures, body mass index (BMI) were applied to assess the impact of unexplained syncope/OH hospitalisations on subsequent incident fragility fractures. Prevalent fractures occurring before syncope/OH hospitalisation were excluded (n = 39) as well as cases with no follow-up time after the event of syncope/OH (n= 8).

Results

The mean follow-up from baseline to first incident fracture or end of follow-up was 17.8 + 6.5 years, and 8201 (27%) suffered incident fracture. The mean age of patients with unexplained syncope (n = 493) and OH patients (n = 406) at baseline was 61.5 ± 7.1 years (50.1%, male) and 62.6 ± 6.6 years (49.8% male), respectively. The mean time between baseline and first admission for syncope and OH was 12.3 ± 4.5 years, and the mean age at first hospitalisation was 74.4 ± 7.6 years. In the multivariable-adjusted Cox regression, the risk of subsequent incident fractures was increased among patients hospitalised due to unexplained syncope (HR: 1.20; 95% CI 1.03–1.40; p &lt; 0.02) and OH (HR: 1.40; 95% CI 1.20–1.64; p &lt; 0.001), respectively (Kaplan-Meier curves; Figure 1).

Conclusions

Patients hospitalised due to unexplained syncope and OH demonstrate increased risk of subsequent fragility fractures. We suggest that patients who are hospitalised for unexplained syncope and OH should be clinically assessed for true syncope aetiology, systematically treated against fall risk, and evaluated for additional risk factors for fragility fractures. Abstract Figure 1. Kaplan-Meier curves

Effect of aging on cerebral tissue oxygenation in relation to reflex syncope

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Swedish Heart and Lung Foundation, The Swedish Heart and Lung Association, ALF funds, Skåne University Hospital Funds, The Crafoord Foundation.

Background

There is an increased susceptibility to syncope with aging attributed to age-related physiological impairments. Cerebral oximetry non-invasively measures cerebral tissue oxygenation (SctO2) and has been shown to be valuable in syncope evaluation. SctO2 has been found to decrease with aging but it is unknown whether the decrease in SctO2 is related to increased susceptibility to syncope during orthostatic provocation. By measuring SctO2 during head up tilt test (HUT) we can study age-related differences in SctO2 and their impact on developing reflex syncope.

Purpose

To investigate the effect of age on the cerebral tissue oxygenation threshold for syncope and presyncope among patients with vasovagal syncope.

Methods

Non-invasive haemodynamic monitoring and near-infrared spectroscopy (NIRS) were applied during head-up tilt (HUT) in 139 vasovagal syncope patients (mean [SD] 45[17] years, 60% female), and 82 control patients with a normal response to HUT (45[18] years, 61% female). Group differences in SctO2 and systolic blood pressure (SBP) during HUT in supine position, after 3 and 10 min of HUT, 30 seconds prior to syncope ("presyncopal phase") and during syncope in different age groups (&lt;30, 30-60 and  &gt;60 years) were compared using one-way ANOVA and Tukey"s multiple comparison test. Associations between age and SctO2 were studied using linear regression models adjusted for sex and concurrent SBP.

Results

Lower SctO2 in supine position was associated with increasing age among controls (B=-0.085, p = 0.010) but not among VVS patients (B=-0.036, p = 0.114). No age-related differences in SctO2 were found after 3 and 10 minutes of HUT and during syncope.  Mean SctO2 (%) during the presyncopal phase decreased over the advancing age groups (&lt;30: 66.9 ± 6.2, 30-60: 64.5 ± 6.1, &gt;60: 62.2 ± 5.8; p = 0.009 for inter-group comparison). In contrast, mean SBP during the presyncopal phase did not differ by age groups (&lt;30: 85.6 ± 21.8, 30-60: 77.6 ± 19.7, &gt;60: 77.6 ± 20.8 mmHg, p = 0.133). Age was associated with lower SctO2 during the presyncopal phase after adjusting for sex and SBP (B = 0.096, p = 0.001).

Conclusion

Older VVS patients have lower cerebral tissue oxygenation in the presyncopal phase compared with younger patients independently of systolic blood pressure. These results suggest either that with imminent reflex syncope cerebral tissue oxygenation diminishes more with advancing age or that cerebral deoxygenation is better tolerated by older reflex syncope patients. Abstract Figure.

Recommended best practices for collecting, analyzing, and reporting microplastics in environmental media: Lessons learned from comprehensive monitoring of San Francisco Bay

Microplastics are ubiquitous and persistent contaminants in the ocean and a pervasive and preventable threat to the health of marine ecosystems. Microplastics come in a wide variety of shapes, sizes, and plastic types, each with unique physical and chemical properties and toxicological impacts. Understanding the magnitude of the microplastic problem and determining the highest priorities for mitigation require accurate measures of microplastic occurrence in the environment and identification of likely sources. The field of microplastic pollution is in its infancy, and there are not yet widely accepted standards for sample collection, laboratory analyses, quality assurance/quality control (QA/QC), or reporting of microplastics in environmental samples. Based on a comprehensive assessment of microplastics in San Francisco Bay water, sediment, fish, bivalves, stormwater, and wastewater effluent, we developed recommended best practices for collecting, analyzing, and reporting microplastics in environmental media. We recommend factors to consider in microplastic study design, particularly in regard to site selection and sampling methods. We also highlight the need for standard QA/QC practices such as collection of field and laboratory blanks, use of methods beyond microscopy to identify particle composition, and standardized reporting practices, including suggested vocabulary for particle classification.

Assessment of emerging polar organic pollutants linked to contaminant pathways within an urban estuary using non-targeted analysis

A comprehensive, non-targeted analysis of polar organic pollutants using high resolution/accurate mass (HR/AM) mass spectrometry approaches has been applied to water samples from San Francisco (SF) Bay, a major urban estuary on the western coast of the United States, to assess occurrence of emerging contaminants and inform future monitoring and management activities. Polar Organic Chemical Integrative Samplers (POCIS) were deployed selectively to evaluate the influence of three contaminant pathways: urban stormwater runoff (San Leandro Bay), wastewater effluent (Coyote Creek, Lower South Bay), and agricultural runoff (Napa River). Grab samples were collected before and after deployment of the passive samplers to provide a quantitative snapshot of contaminants for comparison. Composite samples of wastewater effluent (24 hours) were also collected from several wastewater dischargers. Samples were analyzed using liquid-chromatography coupled to high resolution mass spectrometry. Resulting data were analyzed using a customized workflow designed for high-fidelity detection, prioritization, identification, and semi-quantitation of detected molecular features. Approximately 6350 compounds were detected in the combined data set, with 424 of those compounds tentatively identified through high quality spectral library match scores. Compounds identified included ethoxylated surfactants, pesticide and pharmaceutical transformation products, polymer additives, and rubber vulcanization agents. Compounds identified in samples were reflective of the apparent sources and pathways of organic pollutant inputs, with stormwater-influenced samples dominated by additive chemicals likely derived from plastics and vehicle tires, as well as ethoxylated surfactants.

A ubiquitous tire rubber-derived chemical induces acute mortality in coho salmon

In U.S. Pacific Northwest coho salmon (Oncorhynchus kisutch), stormwater exposure annually causes unexplained acute mortality when adult salmon migrate to urban creeks to reproduce. By investigating this phenomenon, we identified a highly toxic quinone transformation product of N-(1,3-dimethylbutyl)-N'-phenyl-p-phenylenediamine (6PPD), a globally ubiquitous tire rubber antioxidant. Retrospective analysis of representative roadway runoff and stormwater-affected creeks of the U.S. West Coast indicated widespread occurrence of 6PPD-quinone (<0.3 to 19 micrograms per liter) at toxic concentrations (median lethal concentration of 0.8 ± 0.16 micrograms per liter). These results reveal unanticipated risks of 6PPD antioxidants to an aquatic species and imply toxicological relevance for dissipated tire rubber residues.

Methods Matter: Methods for Sampling Microplastic and Other Anthropogenic Particles and Their Implications for Monitoring and Ecological Risk Assessment

To inform mitigation strategies and understand how microplastics affect wildlife, research is focused on understanding the sources, pathways, and occurrence of microplastics in the environment and in wildlife. Microplastics research entails counting and characterizing microplastics in nature, which is a labor-intensive process, particularly given the range of particle sizes and morphologies present within this diverse class of contaminants. Thus, it is crucial to determine appropriate sampling methods that best capture the types and quantities of microplastics relevant to inform the questions and objectives at hand. It is also critical to follow protocols with strict quality assurance and quality control (QA/QC) measures so that results reflect accurate estimates of microplastic contamination. Here, we assess different sampling procedures and QA/QC strategies to inform best practices for future environmental monitoring and assessments of exposure. We compare microplastic abundance and characteristics in surface-water samples collected using different methods (i.e., manta and bulk water) at the same sites, as well as duplicate samples for each method taken at the same site and approximate time. Samples were collected from 9 sampling sites within San Francisco Bay, California, USA, using 3 different sampling methods: 1) manta trawl (manta), 2) 1-L grab (grab), and 3) 10-L bulk water filtered in situ (pump). Bulk water sampling methods (both grab and pump) captured more microplastics within the smaller size range (<335 µm), most of which were fibers. Manta samples captured a greater diversity of morphologies but underestimated smaller-sized particles. Inspection of pump samples revealed high numbers of particles from procedural contamination, stressing the need for robust QA/QC, including sampling and analyzing laboratory blanks, field blanks, and duplicates. Choosing the appropriate sampling method, combined with rigorous, standardized QA/QC practices, is essential for the future of microplastics research in marine and freshwater ecosystems. Integr Environ Assess Manag 2021;17:282-291. © 2020 SETAC.

Downregulation of growth hormone in postural orthostatic tachycardia syndrome: insights from the SYSTEMA cohort

Background

Postural orthostatic tachycardia syndrome (POTS) is a variant of cardiovascular autonomic disorder occurring predominantly in young women. POTS is characterized by an excessive heart rate increase when assuming upright posture accompanied by symptoms of orthostatic intolerance. The pathophysiology of POTS has not been fully established and is believed to be multifactorial.

Purpose

We aimed to investigate the alterations in circulating growth hormone level in POTS.

Methods

We conducted an age-matched case-control study enrolling 42 patients with POTS (age 31±9 years; 36 women) verified by positive head-up tilt testing and cardiovascular autonomic tests, and 46 controls (32±9 years; 35 women) with negative active standing test and no history of syncope, orthostatic intolerance and endocrine disease. We measured plasma levels of growth hormone using a high-sensitivity chemiluminescence immunoassay in relation to presence of POTS diagnosis. All study participants completed the validated Orthostatic Hypotension Questionnaire (OHQ), consisting of two components: the symptoms assessment scale (OHSA) and daily activity scale (OHDAS) to evaluate the burden of symptoms. We applied standard statistical tests for group differences. Growth hormone values were log-transformed and standardized before the group comparison.

Results

POTS patients had significantly lower plasma levels of growth hormone (ng/mL) (median=0.53, IQR, 0.10–2.83 vs. median=2.33, IQR, 0.26–7.2, p=0.04) than controls. Levels of growth hormone were reversely related to OHDAS (p=0.049) among POTS patients. Supine heart rate was significantly higher in POTS patients (69.0±11.1 beats/min vs. 63.3±10.8 beats/min, p=0.02), as well as diastolic blood pressure (72.9±9.1 mmHg vs. 69.0±8.5 mmHg, p=0.04). We observed no significant difference in supine systolic blood pressure (116.6±13.3 mmHg vs. 115.2±10.0 mmHg, p=0.60). POTS patients had a significantly higher composite OHQ score than controls (60.0±18.6 vs. 4.2±7.5, p&lt;0.001), as well as OHSA (36.2±10.0 vs. 3.6±6.4, p&lt;0.001) and OHDAS (23.8±9.7 vs. 0.6±1.3, p&lt;0.001).

Conclusion(s)

Our study shows that patients with POTS have significantly reduced plasma levels of circulating growth hormone. Lower growth hormone levels among POTS patients are associated with increased impairment of daily life activities. Further studies are necessary to confirm our findings in the independent populations and explain the mechanisms behind this alteration.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Crafoord Foundation, Swedish Heart and Lung Foundation

Multi-box mass balance model of PFOA and PFOS in different regions of San Francisco Bay

We present a model to predict the long-term distribution and concentrations of perfluorooctanoic acid (PFOA) and perfluorooctanesulfonic acid (PFOS) in estuaries comprising multiple intercommunicated sub-embayments. To that end, a mass balance model including rate constants and time-varying water inputs was designed to calculate levels of these compounds in water and sediment for every sub-embayment. Subsequently, outflows and tidal water exchanges were used to interconnect the different regions of the estuary. To calculate plausible risks to population, outputs of the model were used as inputs in a previously designed model to simulate concentrations of PFOA and PFOS in a sport fish species (Cymatogaster aggregata). The performance of the model was evaluated by applying it to the specific case of San Francisco Bay, (California, USA), using 2009 sediment and water sampled concentrations of PFOA and PFOS in North, Central and South regions. Concentrations of these compounds in the Bay displayed exponential decreasing trends, but with different shapes depending on region, compound, and compartment assessed. Nearly stable PFOA concentrations were reached after 50 years, while PFOS needed close to 500 years to stabilize in sediment and fish. Afterwards, concentrations stabilize between 4 and 23 pg/g in sediment, between 0.02 and 44 pg/L in water, and between 7 and 104 pg/g wet weight in fish, depending on compound and region. South Bay had the greatest final concentrations of pollutants, regardless of compartment. Fish consumption is safe for most scenarios, but due to model uncertainty, limitations in monthly intake could be established for North and South Bay catches.

P6223Relationship between platelet indices and future cardiovascular events: results from a population-based cohort study

Background

Studies evaluating the relationship between platelet indices and cardiovascular outcome yielded conflicting results. In particular, the evidence from large, population-based, prospective studies with extended follow-up duration is scarce.

Purpose

We investigated the incidence of major adverse events in relation to baseline values of platelet count, mean platelet volume (MPV) and platelet distribution width (PDW) in the prospective cohort of the Malmö Diet and Cancer Study.

Methods

A total of 30,314 middle-aged individuals (mean age 57±8 years; 40% men) were overall included and followed up for a median of 16 years (in total, 468,490 person-years). The following outcome measures were considered: all-cause death, myocardial infarction (MI) and ischemic stroke.

Results

There was no relationship between increase in MPV or PDW values and adverse events during follow-up. In particular, the incidence of all-cause death, MI and stroke in patients in the 4thquartile of MPV was 19.8% (vs. 20.7% in the 1stquartile; p=0.08), 8.5% (vs. 8.2%; p=0.78) and 7.9% (vs. 7.1%; p=0.09), respectively. The rates of all-cause death, MI and stroke in patients in the 4thquartile of PDW were 20.1% (vs. 20.7% in the 1stquartile; p=0.16), 8.7% (vs. 8.1%; p=0.30) and 8.1% (vs. 7.2%; p=0.09), respectively. There was a significant rise in mortality by platelet count increase (log-rank p<0.001). In multivariable analysis, patients in the 4thquartile of platelet count (>264 x 109/L) showed a significantly higher incidence of all-cause death (HR 1.17, 95% CI 1.07–1.28; p=0.001), MI (HR 1.24, 95% CI 1.08–1.43; p=0.003) and stroke (HR 1.20, 95% CI 1.04–1.39; p=0.014) vs the 1stquartile. The higher mortality in the 4thquartile of platelet count was independent of the history of previous stroke, was significant in patients without prior MI (HR 1.18, 95% CI 1.08–1.29; p<0.001) and non-significant in those with prior MI (HR 0.86, 95% CI 0.56–1.33; p=0.51). The risk of MI in the 4thquartile of platelet count was higher regardless of the history of previous MI (p for interaction=0.11). The risk of stroke in the 4thquartile of platelet count was higher regardless of the history of previous stroke (p for interaction=0.15).

Conclusions

In this population-based, prospective, cohort study there was no difference in the incidence of adverse events across various strata of baseline platelet morphology. However, patients with highest platelet count at baseline showed a significantly higher risk of all-cause death, MI and stroke. Whether or not these individuals should be targeted by more aggressive primary prophylactic measures including antiplatelet treatment, remains to be proven.

P4441Serum activity against specific G-protein coupled receptors is associated with the severity of orthostatic symptoms in patients with POTS

Background

Postural orthostatic tachycardia syndrome (POTS) is characterised by an excessive heart rate increase upon standing and orthostatic intolerance. Previous studies indicate autoimmune involvement mediated via G-protein coupled receptors (GPCRs) as a possible aetiology.

Purpose

To test if serum from POTS patients and controls activates selected GPCRs and if the activation associates with the severity of symptoms.

Methods

A total of 34 POTS patients (age 28.9 [9.9] years; 29 women) and a population-based control group of 25 healthy subjects (age 30.7 [8.6] years; 21 women) were included. The subjects performed an active standing test and completed the orthostatic hypotension questionnaire (OHQ) including ten items related to orthostatic intolerance. The OHQ composite score was calculated (range 0–10).

Sera were analysed by a FRET-based reporter system (Tango GeneBLAzer, Thermo Fischer) based on a beta-arrestin-linked transcription factor driving transgenic betalactamase transcription. HEK293M-cells over-expressing one of the GPCRs, adrenergic alpha-1 (ADRA1), adrenergic beta-2 (ADRB2), muscarinic type-2 (CHRM2) and opioid-receptor-like 1 (OPRL1) receptor were plated in 96-well optical plates and allowed to re-attach during 48 hrs. The cells were treated with 10% sera diluted in RPMI for 5 hours, followed by addition of the FRET-substrate, incubation for 60 min and quantification analysis in a CLARIOStar multi-purpose plate reader.

Quantification of the activation of the GPCRs was log-transformed and related to the OHQ composite and individual scores in age-adjusted linear regression models. OHQ scores were compared according to the median of sera activation, using independent samples t-test.

Results

Serum ADRA1 activation associated with the OHQ composite score (beta 0.77 OHQ points per SD of activity; p=0.009), whereas there were no significant associations among controls (p=0.953). The association between ADRA1 and total OHQ was significant also after adjusting for heart rate and systolic blood pressure at 3 min (p=0.024). The OHQ composite score was higher in with above median serum ADRA1 activation (Figure 1).

ADRA1 activation associated with a higher score for vision problems (p<0.001) and symptoms during prolonged standing (p=0.037) and walking for short (p=0.042) or long periods (p=0.001).

The activity of ARB2, CHRM2 and OPRL1 did not associate with OHQ composite score in neither POTS patients nor controls.

Figure 1. OHQ according to ADRA1 activation

Conclusions

Activating serum proteins for the adrenergic alpha-1 receptor are associated with the severity of orthostatic symptoms in POTS patients, partly independent of the orthostatic hemodynamic response. Serum activity against alpha1 receptors is related particularly to symptoms of disturbed vision and symptoms during walking or prolonged standing. Serum activity against the adrenergic alpha 1 receptor may be a one factor underlying the orthostatic symptoms in POTS.

Acknowledgement/Funding

The Swedish Heart-Lung Foundation, The Swedish Heart and Lung Association, Solidex, ALF funds, Crafoord Foundation, Ernhold Lundströms Foundation.

Psychological screening of adults and young people following the Manchester Arena incident

BACKGROUND

Terrorist attacks have increased globally since the late 1990s with clear evidence of psychological distress across both adults and children and young people (CYP). After the Manchester Arena terrorist attack, the Resilience Hub was established to identify people in need of psychological and psychosocial support.

AIMS

To examine the severity of symptoms and impact of the programme.

METHOD

The hub offers outreach, screening, clinical telephone triage and facilitation to access evidenced treatments. People were screened for trauma, depression, generalised anxiety and functioning who registered at 3, 6 and 9 months post-incident. Baseline scores were compared between screening groups (first screen at 3, 6 or 9 months) in each cohort (adult, CYP), and within groups to compare scores at 9 months.

RESULTS

There were significant differences in adults' baseline scores across screening groups on trauma, depression, anxiety and functioning. There were significant differences in the baseline scores of CYP across screening groups on trauma, depression, generalised anxiety and separation anxiety. Paired samples t-tests demonstrated significant differences between baseline and follow-up scores on all measures for adults in the 3-month screening group, and only depression and functioning measures for adults in the 6-month screening group. Data about CYP in the 3-month screening group, demonstrated significant differences between baseline and follow-up scores on trauma, generalised anxiety and separation anxiety.

CONCLUSIONS

These findings suggest people who register earlier are less symptomatic and demonstrate greater improvement across a range of psychological measures. Further longitudinal research is necessary to understand changes over time.

DECLARATION OF INTEREST

None.

Differentiation of Autoimmune Pancreatitis from Pancreatic Cancer Remains Challenging

BACKGROUND

Autoimmune pancreatitis (AIP) is an uncommon form of chronic pancreatitis. Whilst being corticosteroid responsive, AIP often masquerades radiologically as pancreatic neoplasia. Our aim is to appraise demographic, radiological and histological features in our cohort in order to differentiate AIP from pancreatic malignancy.

METHODS

Clinical, biochemical, histological and radiological details of all AIP patients 1997-2016 were analysed. The initial imaging was re-reviewed according to international guidelines by three blinded independent radiologists to evaluate features associated with autoimmune pancreatitis and pancreatic cancer.

RESULTS

There were a total of 45 patients: 25 in type 1 (55.5%), 14 type 2 (31.1%) and 6 AIP otherwise not specified (13.3%). The median (IQR) age was 57 (51-70) years. Thirty patients (66.6%) were male. Twenty-six patients (57.8%) had resection for suspected malignancy and one for symptomatic chronic pancreatitis. Three had histologically proven malignancy with concurrent AIP. Two patients died from recurrent pancreatic cancer following resection. Multidisciplinary team review based on radiology and clinical history dictated management. Resected patients (vs. non-resected group) were older (64 vs. 53, p = 0.003) and more frequently had co-existing autoimmune pathologies (22.2 vs. 55.6%, p = 0.022). Resected patients also presented with less classical radiological features of AIP, which are halo sign (0/25 vs. 3/17, p = 0.029) and loss of pancreatic clefts (18/25 vs. 17/17, p = 0.017). There were no differences in demographic features other than age.

CONCLUSION

Despite international guidelines for diagnosing AIP, differentiation from pancreatic cancer remains challenging. Resection remains an important treatment option in suspected cancer or where conservative treatment fails.

Monitoring of cerebral oximetry during head-up tilt test in adults with history of syncope and orthostatic intolerance

Aims

We applied near-infrared-spectroscopy (NIRS) to measure absolute frontal cerebral tissue oxygen saturation (SctO2) during head-up tilt test (HUT) in patients investigated for unexplained syncope.

Methods and results

Synchronized non-invasive beat-to-beat haemodynamic monitoring, ECG, SctO2 (NIRS; normal range: 60-80%), and peripheral oxygen saturation (left hand, SpO2) were applied during HUT in a random sample of patients with unexplained syncope. Tracings of 54 patients (mean-age: 55 ± 19 years, 39% male) with negative HUT, vasovagal syncope (VVS), or orthostatic hypotension (OH) were analysed. In 44 patients HUT was diagnostic, in 10 HUT was negative. Thirty-one experienced VVS. Of these, 6 had spontaneous and 25 nitroglycerin-induced syncope. Thirteen patients had orthostatic hypotension (OH). Although there was no significant change in mean-arterial pressure from baseline to 1 min before syncope or end of passive HUT phase (-1.4 ± 13.9 mmHg; P = 0.45), there was a significant fall in SctO2 during the same period (-3.2 ± 3.2%; P ≤ 0.001). Among patients who experienced syncope, a decrease in SctO2 from 71 ± 5% at baseline to 53 ± 9% (P < 0.001) at syncope was observed. During HUT, there was a significant difference in delta SctO2 between spontaneous VVS (-4.5 ± 3.0%) and negative HUT (-1.3 ± 1.9%; P  = 0.021), but not between spontaneous VVS and OH (-5.4 ± 4.2%; P = 0.65). In spontaneous VVS, progressive decrease of SctO2 was independent of mean arterial pressure decrease (P  = 0.22).

Conclusions

Progressive decrease in cerebral tissue oxygenation independent of mean-arterial pressure may precede spontaneous vasovagal reflex during tilt. Patients experience syncope when SctO2 falls below 60%. These data confirm clinical utility of absolute cerebral oximetry monitoring for syncope investigation. We applied NIRS to measure frontal cerebral tissue oxygen saturation (SctO2) during head-up tilt test (HUT) in patients with unexplained syncope. In 44 of 54 patients, HUT was diagnostic. In patients with syncope, a significant SctO2-decrease was observed. Different patterns of SctO2 can be detected.

Characterization of brominated, chlorinated, and phosphate flame retardants in San Francisco Bay, an urban estuary

Flame retardant chemical additives are incorporated into consumer goods to meet flammability standards, and many have been detected in environmental matrices. A uniquely wide-ranging characterization of flame retardants was conducted, including polybrominated diphenyl ethers (PBDEs) and 52 additional brominated, chlorinated, or phosphate analytes, in water, sediment, bivalves, and harbor seal blubber of San Francisco Bay, a highly urbanized estuary once considered a hot spot for PBDE contamination. Among brominated flame retardants, PBDEs remained the dominant contaminants in all matrices, though declines have been observed over the last decade following their phase-out. Hexabromocyclododecane (HBCD) and other hydrophobic, brominated flame retardants were commonly detected at lower levels than PBDEs in sediment and tissue matrices. Dechlorane Plus (DP) and related chlorinated compounds were also detected at lower levels or not at all across all matrices. In contrast, phosphate flame retardants were widely detected in Bay water samples, with highest median concentrations in the order TCPP > TPhP > TBEP > TDCPP > TCEP. Concentrations in Bay water were often higher than in other estuarine and marine environments. Phosphate flame retardants were also widely detected in sediment, in the order TEHP > TCrP > TPhP > TDCPP > TBEP. Several were present in bivalves, with levels of TDCPP comparable to PBDEs. Only four phosphate flame retardants were detected in harbor seal blubber: TCPP, TDCPP, TCEP, and TPhP. Periodic, multi-matrix screening is recommended to track contaminant trends impacted by changes to flammability standards and manufacturing practices, with a particular focus on contaminants like TDCPP and TPhP that were found at levels comparable to thresholds for aquatic toxicity.

A novel digital method to assess air space loss associated with acute lung injury in experimental acute pancreatitis

BACKGROUND/OBJECTIVES

Respiratory dysfunction and/or failure from acute lung injury (ALI) are common in acute pancreatitis (AP), but assessment of ALI in experimental AP has lacked standardisation.

METHODS

A range of experimental AP models induced in C57BL/6 mice with corresponding controls (n = 6/group). Full double lung or right lung specimens were taken for histopathological assessment and slides analysed by a pre-set pipeline using Aperio Scanner (Leica), ImageJ software and CellProfiler software. Findings were compared to other routinely assessed parameters.

RESULTS

Overall histopathological changes were similar between both lungs. Mean lung field occupancy was significantly different between moderate and severe CER-AP (21.9% v 27.5%, p < 0.05) and corresponded with lung MPO and local injury severity parameters and was mirrored for all models tested.

CONCLUSION

We have developed a novel, simple method for assessment of ALI to improve measurement of systemic organ injury in experimental AP and contribute to preclinical drug development.

Anaesthetic management of pregnant patients with cardiac implantable electronic devices: case reports and review

Heart disease is a leading cause of maternal mortality and morbidity. Pregnant women with structural, conduction or degenerative cardiac disease who require rhythm control or who are at high risk of sudden cardiac death may carry a cardiac implantable electronic device or may occasionally require the insertion of one during their pregnancy. These women are now encountered more frequently in clinical practice, and it is essential that a multidisciplinary approach, beginning from the early antenatal phase, be adopted in their counselling and management. Contemporary cardiac rhythm control devices are a constantly evolving technology with increasingly sophisticated features; anaesthetists should therefore have an adequate understanding of the principles of their operation and the special considerations for their use, in order to enable their safe management in the peripartum period. Of particular importance is the potential adverse effect of electromagnetic interference, which may cause device malfunction or damage, and the precautions required to reduce this risk. The ultimate goal in the management of this patient subgroup is to minimise the disruption to cardiovascular physiology that may occur near the time of labour and delivery and to control the factors that impact on device integrity and function. We present the ante- and peripartum management of two pregnant women with an implantable cardioverter-defibrillator, followed by a review and update of the anaesthetic management of parturients with cardiac implantable electronic devices.

Accuracy of circulating histones in predicting persistent organ failure and mortality in patients with acute pancreatitis

BACKGROUND

Early prediction of acute pancreatitis severity remains a challenge. Circulating levels of histones are raised early in mouse models and correlate with disease severity. It was hypothesized that circulating histones predict persistent organ failure in patients with acute pancreatitis.

METHODS

Consecutive patients with acute pancreatitis fulfilling inclusion criteria admitted to Royal Liverpool University Hospital were enrolled prospectively between June 2010 and March 2014. Blood samples were obtained within 48 h of abdominal pain onset and relevant clinical data during the hospital stay were collected. Healthy volunteers were enrolled as controls. The primary endpoint was occurrence of persistent organ failure. The predictive values of circulating histones, clinical scores and other biomarkers were determined.

RESULTS

Among 236 patients with acute pancreatitis, there were 156 (66·1 per cent), 57 (24·2 per cent) and 23 (9·7 per cent) with mild, moderate and severe disease respectively, according to the revised Atlanta classification. Forty-seven healthy volunteers were included. The area under the receiver operating characteristic (ROC) curve (AUC) for circulating histones in predicting persistent organ failure and mortality was 0·92 (95 per cent c.i. 0·85 to 0·99) and 0·96 (0·92 to 1·00) respectively; histones were at least as accurate as clinical scores or biochemical markers. For infected pancreatic necrosis and/or sepsis, the AUC was 0·78 (0·62 to 0·94). Histones did not predict or correlate with local pancreatic complications, but correlated negatively with leucocyte cell viability (r = -0·511, P = 0·001).

CONCLUSION

Quantitative assessment of circulating histones in plasma within 48 h of abdominal pain onset can predict persistent organ failure and mortality in patients with acute pancreatitis. Early death of immune cells may contribute to raised circulating histone levels in acute pancreatitis.

The MLL recombinome of acute leukemias in 2017

Chromosomal rearrangements of the human MLL/KMT2A gene are associated with infant, pediatric, adult and therapy-induced acute leukemias. Here we present the data obtained from 2345 acute leukemia patients. Genomic breakpoints within the MLL gene and the involved translocation partner genes (TPGs) were determined and 11 novel TPGs were identified. Thus, a total of 135 different MLL rearrangements have been identified so far, of which 94 TPGs are now characterized at the molecular level. In all, 35 out of these 94 TPGs occur recurrently, but only 9 specific gene fusions account for more than 90% of all illegitimate recombinations of the MLL gene. We observed an age-dependent breakpoint shift with breakpoints localizing within MLL intron 11 associated with acute lymphoblastic leukemia and younger patients, while breakpoints in MLL intron 9 predominate in AML or older patients. The molecular characterization of MLL breakpoints suggests different etiologies in the different age groups and allows the correlation of functional domains of the MLL gene with clinical outcome. This study provides a comprehensive analysis of the MLL recombinome in acute leukemia and demonstrates that the establishment of patient-specific chromosomal fusion sites allows the design of specific PCR primers for minimal residual disease analyses for all patients.