Preceptors' experiences of supervising internationally educated nurses attending a bridging program: An interview study

BACKGROUND

Internationally educated nurses attending a bridging program must demonstrate clinical competence and meet requirements to apply for a nursing license in Sweden.

OBJECTIVES

To describe preceptors' experiences of supervising internationally educated nurses undergoing clinical practice education during a bridging program.

DESIGN

A qualitative descriptive study.

SETTINGS

Two universities offering the 1-year bridging program for nurses with a nursing degree from outside European Union/European Economic Area and Switzerland.

PARTICIPANTS

Fifteen preceptors, all registered nurses, who supervised internationally educated nurses were included.

METHODS

Semi-structured interviews were performed, and data were analyzed using qualitative content analysis.

RESULTS

Supervising internationally educated nurses was not the same as supervising nursing students and raised feelings of both joy and frustration. Preceptors had to adapt supervision to the student's nursing knowledge and skills. They had to help students communicate in Swedish and form good relationships with other students, patients, and other professionals. Most preceptors requested more information about the student's nurse education, country of education/cultural background, and previous work experiences. Mixed experiences of support from the university, first-line managers, and colleagues were reported.

CONCLUSIONS

Being a preceptor for internationally educated nurses is a challenge, and supervision training is important for managing preceptorship. To supervise students based on their level of knowledge and skills, more information must be shared with the preceptor. Encounters with others are of importance in the training, where teamwork and person-centered care must be in focus, both in prior theoretical education and in clinical practice education.

A Validation Study of cT-Categories in the Swedish National Urinary Bladder Cancer Register-Norrland University Hospital

BACKGROUND

In Sweden, all patients with urinary bladder cancer (UBC) are recorded in the Swedish National Register for Urinary Bladder Cancer (SNRUBC). The purpose of this study was to validate the registered clinical tumour categories (cT-categories) in the SNRUBC for Norrland University Hospital, Sweden, from 2009 to 2020, inclusive.

METHODS

The medical records of all 295 patients who underwent radical cystectomy for the treatment of UBC were reviewed retrospectively. Possible factors impacting the cT-categories were identified. To optimise cT-classification, computed tomography urography of all patients with suspected tumour-associated hydronephrosis (TAH) or suspected tumour in bladder diverticulum (TIBD) were retrospectively reviewed by a radiologist. Discrepancy was tested with a logistic regression model.

RESULTS

cT-categories differed in 87 cases (29.5%). Adjusted logistic regression analysis found TIBD and TAH as significant predictors for incorrect registration; OR = 7.71 (p < 0.001), and OR = 17.7, (p < 0.001), respectively. In total, 48 patients (68.6%) with TAH and 12 patients (52.2%) with TIBD showed discrepancy regarding the cT-category. Incorrect registration was mostly observed during the years 2009-2012.

CONCLUSION

The study revealed substantial incorrect registration of cT-categories in SNRUBC. A major part of the misclassifications was related to TAH and TIBD. Registration of these variables in the SNRUBC might be considered to improve correct cT-classification.

Performance of a System for Rapid Phenotypic Antimicrobial Susceptibility Testing of Gram-Negative Bacteria Directly from Positive Blood Culture Bottles

The rapid administration of optimal antimicrobial treatment is paramount for the treatment of bloodstream infections (BSIs), and rapid antimicrobial susceptibility testing (AST) results are essential. Q-linea has developed the ASTar system, a rapid phenotypic AST device. Here, we report the performance of the ASTar BC G- (Gram-negative) kit when assessed according to the ISO 20776-2:2007 standard for performance evaluation of in vitro diagnostic AST devices. The evaluated ASTar BC G- kit uses a broad panel of 23 antimicrobials for the treatment of BSIs caused by Gram-negative fastidious and nonfastidious bacteria across a range of 6 to 14 2-fold dilutions, including cefoxitin as a screening agent for AmpC-producing Enterobacterales. The ASTar system processes blood culture samples to generate data on MICs and susceptible, intermediate, or resistant (SIR) category. The automated protocol includes concentration determination and concentration adjustment to enable a controlled inoculum, followed by broth microdilution (BMD) and microscopy performed continuously to generate MIC values within approximately 6 h once the test is run on the ASTar system. The performance of the ASTar system was assessed against the ISO 20776-2:2007 standard BMD reference method. Testing was performed across three sites, with results from 412 contrived blood cultures and 74 fresh clinical blood cultures. The ASTar system was also tested for reproducibility, with triplicate testing of 11 strains. The accuracy study comprised 8,650 data points of bacterium-antimicrobial tests. The ASTar system demonstrated an overall essential agreement (EA) of 95.8% (8,283/8,650) and a categorical agreement (CA) of 97.6% (8,433/8,639) compared to the reference BMD method. The overall rate of major discrepancies (MDs) was 0.9% (62/6,845), and that of very major discrepancies (VMDs) was 2.4% (30/1,239). This study shows that the ASTar system delivers reproducible results with overall EA and CA of >95%.

Three paths to a Swedish nursing license: Two for internationally educated nurses and one for regular nursing students - A cross-sectional study of self-rated professional competence, self-efficacy, and thriving

BACKGROUND

Bridging programs are offered to support migrated nurses, but in some countries, nurses can also choose to validate their nursing competence. Thus far, little is known about how migrated nurses estimate their competence when they are about to enter working life in a new country and how this differs from regular nursing students.

OBJECTIVE

To compare two groups of internationally educated nurses' - those from bridging programs and those who chose validation - and one group of regular nursing students' self-rated professional competence when they are about to start working as registered nurses. The hypotheses were: 1) internationally educated nurses rate their competence higher than regular nursing students and 2) those from bridging programs rate their competence higher than those who chose validation. In addition, the aim was to compare the groups' self-efficacy and thriving.

DESIGN

A cross-sectional, comparative design.

SETTINGS

Five universities in Sweden.

PARTICIPANTS

Nurses educated in non-European countries from a bridging program (n = 128, response rate 79.0 %) or validation process (n = 61, response rate 59.2 %) and students graduating from the regular nursing program (n = 213, response rate 68.3 %).

METHODS

Data were collected with coded questionnaires (paper or online) between 2019 and 2021 and analyzed using non-parametric tests, e.g., Kruskal-Wallis.

RESULTS

Both groups of internationally educated nurses had higher median scores on total nursing competence (both groups p < 0.001), general self-efficacy (bridging programs p < 0.001, validation p = 0.020), and total thriving (bridging programs p < 0.001, validation p = 0.012) than regular nursing students did. However, comparing the groups of internationally educated nurses showed no significant differences.

CONCLUSION

Internationally educated nurses rated their competence high but with differences within the groups for different competence areas. More research is needed to investigate whether the different paths are important for nurses' competence later in working life, and some of the competence areas might need extra attention when nurses start working.

Control computerized tomography in neoadjuvant chemotherapy for muscle invasive urinary bladder cancer, has no value for treatment decisions and low correlation with nodal status

BACKGROUND

Control computerized tomography (cCT) is routinely used in many cystectomy centres before the final treatment cycle in patients with muscle-invasive urinary bladder cancer (MIBC) undergoing neoadjuvant chemotherapy (NAC). This is for evaluating response or nonresponse to NAC treatment. In a real-world retrospective cohort, we intended to evaluate the frequency of changed individual treatment strategies following cCT and to investigate any discrepancies between cCT-results on nodal staging and final pN-stages.

METHODS

We performed a retrospective data-based, multicenter study of 242 MIBC-patients, staged cT2N0M0-cT4aN0M0, having undergone NAC and radical cystectomy (RC) between 2008 and 2019 at four Swedish cystectomy centres. Statistical analysis was performed using IBM SPSS statistics 26.

RESULTS

Overall, 139/242 patients were examined with cCT. Six patients were staged as progressive at cCT and 5/139 (3.6%) underwent a change of previously planned treatment strategy. 2/6 patients with suspected progression (33%) did not change strategy and underwent all preplanned NAC-cycles plus RC. Only 1/6 patients assigned as progressive at the cCT, showed progression in the postoperative pathology specimen. In total 133/139 patients were considered being without progress on cCT, yet 28/133 (21%) presented with nodal progression at postoperative pathology examinations. Only 1/29 patients with histopathologically verified nodal dissemination were detected with cCT, thus 28/29 (96.6%) with pN + were undetected. The sensitivity for cCT to predict pTNM was 17% CI [0%-64%] and the specificity was 78% CI [71%-86%].

CONCLUSIONS

CCT prior to the final treatment cycle of NAC in MIBC, leads to a low percentage of treatment strategy changes and cCT cannot accurately predict pN-status.

S53P4 bioactive glass scaffolds induce BMP expression and integrative bone formation in a critical-sized diaphysis defect treated with a single-staged induced membrane technique

Critical-sized diaphysis defects are complicated by inherent sub-optimal healing conditions. The two-staged induced membrane technique has been used to treat these challenging defects since the 1980's. It involves temporary implantation of a membrane-inducing spacer and subsequent bone graft defect filling. A single-staged, graft-independent technique would reduce both socio-economic costs and patient morbidity. Our aim was to enable such single-staged approach through development of a strong bioactive glass scaffold that could replace both the spacer and the graft filling. We constructed amorphous porous scaffolds of the clinically used bioactive glass S53P4 and evaluated them in vivo using a critical-sized defect model in the weight-bearing femur diaphysis of New Zealand White rabbits. S53P4 scaffolds and standard polymethylmethacrylate spacers were implanted for 2, 4, and 8 weeks. Induced membranes were confirmed histologically, and their osteostimulative activity was evaluated through RT-qPCR of bone morphogenic protein 2, 4, and 7 (BMPs). Bone formation and osseointegration were examined using histology, scanning electron microscopy, energy-dispersive X-ray analysis, and micro-computed tomography imaging. Scaffold integration, defect union and osteosynthesis were assessed manually and with X-ray projections. We demonstrated that S53P4 scaffolds induce osteostimulative membranes and produce osseointegrative new bone formation throughout the scaffolds. We also demonstrated successful stable scaffold integration with early defect union at 8 weeks postoperative in critical-sized segmental diaphyseal defects with implanted sintered amorphous S53P4 scaffolds. This study presents important considerations for future research and the potential of the S53P4 bioactive glass as a bone substitute in large diaphyseal defects. STATEMENT OF SIGNIFICANCE: Surgical management of critical-sized diaphyseal defects involves multiple challenges, and up to 10% result in delayed or non-union. The two-staged induced membrane technique is successfully used to treat these defects, but it is limited by the need of several procedures and bone graft. Repeated procedures increase costs and morbidity, while grafts are subject to donor-site complications and scarce availability. To transform this two-staged technique into one graft-independent procedure, we developed amorphous porous scaffolds sintered from the clinically used bioactive glass S53P4. This work constitutes the first evaluation of such scaffolds in vivo in a critical-sized diaphyseal defect in the weight-bearing rabbit femur. We provide important knowledge and prospects for future development of sintered S53P4 scaffolds as a bone substitute.

Attending a bridging program to obtain a Swedish nursing license: An interview study with internationally educated nurses

BACKGROUND

Bridging programs have been created to facilitate internationally educated nurses' integration process. Thus far, studies on bridging programs have been few and have only been conducted in English-speaking countries. Due to language barriers, it may be a greater challenge to attend a bridging program in a non-English-speaking country.

OBJECTIVES

The aim was to examine internationally educated nurses' experience of attending a one-year bridging program to obtain a Swedish nursing license.

DESIGN

A qualitative study with a descriptive design was applied.

SETTINGS

The study setting was the five universities offering the one-year, full-time Swedish bridging program.

PARTICIPANTS

Purposive sampling was used. Eighteen nurses participated in the study at the end of the program.

METHODS

Semi-structured interviews were conducted and analyzed using qualitative content analysis.

RESULTS

Studying in a new environment and language was challenging and intensive, as were adapting to a new healthcare system and relearning some nursing practices. However, attending the bridging program was also rewarding and gave feelings of happiness and pride; the nurses developed their nursing skills as well as their language and academic skills. Moreover, they became familiar with Sweden's nursing practices, healthcare system, and culture. Good support was important, but not always enough.

CONCLUSIONS

By attending a bridging program, nurses can become familiar with the country's healthcare system and nursing practices. Moreover, develop their language skills and attain skills important to lifelong learning. Although the program may not eliminate all difficulties nurses often experience in a new country, it can offer the support nurses need to handle the challenges. However, for some nurses, due to different backgrounds and prerequisites, the support offered may need to be more individualized.

Sintered S53P4 bioactive glass scaffolds have anti-inflammatory properties and stimulate osteogenesis in vitro

Bioactive glasses (BAG) are used as bone-graft substitutes in orthopaedic surgery. A specific BAG scaffold was developed by sintering BAG-S53P4 granules. It is hypothesised that this scaffold can be used as a bone substitute to fill bone defects and induce a bioactive membrane (IM) around the defect site. Beyond providing the scaffold increased mechanical strength, that the initial inflammatory reaction and subsequent IM formation can be enhanced by coating the scaffolds with poly(DL-lactide-co-glycolide) (PLGA) is also hypothesised. To study the immunomodulatory effects, BAG-S53P4 (± PLGA) scaffolds were placed on monolayers of primary human macrophage cultures and the production of various pro- and anti-inflammatory cytokines was assessed using reverse transcriptase quantitative polymerase chain reaction (RT-qPCR) and ELISA. To study the osteogenic effects, BAG-S53P4 (± PLGA) scaffolds were cultured with rabbit mesenchymal stem cells and osteogenic differentiation was evaluated by RT-qPCR and matrix mineralisation assays. The scaffold ion release was quantified and the BAG surface reactivity visualised. Furthermore, the pH of culture media was measured. BAG-S53P4 scaffolds had both anti-inflammatory and osteogenic properties that were likely attributable to alkalinisation of the media and ion release from the scaffold. pH change, ion release, and immunomodulatory properties of the scaffold could be modulated by the PLGA coating. Contrary to the hypothesis, the coating functioned by attenuating the BAG surface reactions and subsequent anti-inflammatory properties, rather than inducing an elevated inflammatory response compared to BAG-S53P4 alone. These results further validated the use of BAG-S53P4 (± PLGA) scaffolds as bone substitutes and indicate that scaffold properties can be tailored to a specific clinical need.

Computerized tomography before the final treatment cycle of neoadjuvant chemotherapy or induction chemotherapy in muscle-invasive urinary bladder cancer, cannot predict pathoanatomical outcomes and does not reflect prognosis-results of a single centre retrospective prognostic study

Background

Evaluating the routine of using control computer tomography (cCT) for determining the response status of muscle-invasive bladder cancer (MIBC) prior to final cycle of neoadjuvant chemotherapy (NAC) or induction chemotherapy (IC), in terms of predicting histopathological pTNM-staging and pathoanatomical responses/non-responses. Secondly, predicting two and three-year overall survival (OS).

Methods

Seventy-seven patients with localized MIBC (cT2-4aN0M0) and 3 patients with minimal nodal dissemination (cN1-2), undergoing NAC or IC and radical cystectomy (RC), the years 2006–2014 at Norrland university hospital in Umeå, Sweden. Baseline pre-cystectomy CTs and cCTs prior to final chemotherapy-cycle, were reviewed and underwent attempted RECIST-criteria categorization, into five response/non-response related subgroups (n=71). The diagnostic accuracy of cCT in comparison with pTNM was assessed using sensitivity, specificity, positive- and negative likelihood ratios. OS for 2 and 3 years was calculated, both in relation to histopathological pTNM-stages in all patients (n=80) and for the patients with cCT-evaluated categories (n=71). Multivariable analysis for OS, was performed in correlation to pTNM-stages firstly, and to radiological staging secondly.

Results

The sensitivity of cCT to predict non-responders according to pTMN was 64% and specificity 36%. The positive likelihood ratio=1 and the negative likelihood ratio =1. CT-evaluations couldn’t accurately predict pTNM-stages in terms of response/non-response. No statistically significant results were found in correlating cCTs with two and three-year OS.

Conclusions

cCT prior to planned final preoperative chemotherapy-cycle in MIBC patients undergoing NAC or IC, has a poor correlation with pTNM and cannot predict pathoanatomical responses. Prediction of OS based on cCTs is unfeasible.

“Brave men” and “emotional women”: A literature review on gendered norms towards patients with pain

Background

More women than men report chronic pain but despite the large body of research on sex differences there is a lack of knowledge on the influence of social and cultural gender. As gender norms can lead to gender bias in health care it is important to raise awareness about them. The purpose of this study was to illustrate gendered norms about men and women with chronic pain in scientific journals, and to analyze how societal norms are reproduced in health care.

Methods

A literature search of the databases PsycINFO, CINAHL and PubMed was conducted, January 2000 to April 2015, with the search term chronic pain combined with femininity, masculinity, gender bias, gender stereotypes and gender roles. A total of 77 articles met the inclusion criteria and were analyzed qualitatively. The integrative approach enabled a review of articles from both social and medical sciences, and to include qualitative and quantitative research. The material was sorted into theoretical categories and further coded into substantive categories.

Results

The included articles showed a variety of gendered norms about men’s and women’s experience and expression of pain, their identity, lifestyle and coping style. Women were described as emotional and hysterical, constantly dealing with mistrust from health care. Men were pictured as brave, stoic and struggling with their sense of masculinity. Prevailing societal norms are consolidated in health care, positioning the masculine man as the ideal patient.

Conclusions

Gender stereotypes are reproduced in healthcare, which can lead to gender bias in the treatment of patients with pain. The findings were used to develop a tool, “the pain cube”, aimed to improve health care providers’ consciousness about gendered norms.

Key messages

Men and women with chronic pain are depicted in a stereotypical way in scientific articles. Increased awareness about gendered norms can support health care professionals in providing equitable care.

Geometric Flow Control Lateral Flow Immunoassay Devices (GFC-LFIDs): A New Dimension to Enhance Analytical Performance

The nitrocellulose (NC) membrane based lateral flow immunoassay device (LFID) is one of the most important and widely used biosensor platforms for point-of-care (PoC) diagnostics. However, the analytical performance of LFID has limitations and its optimization is restricted to the bioassay chemistry, the membrane porosity, and the choice of biolabel system. These bottom neck technical issues resulted from the fact that the conventional LFID design principle has not evolved for many years, which limited the LFID for advanced biosensor applications. Here we introduce a new dimension for LFID design and optimization based on geometric flow control (GFC) of NC membranes, leading to highly sensitive GFC-LFID. This novel approach enables comprehensive flow control via different membrane geometric features such as the width (w) and the length (l) of a constriction, as well as its input angle (θ₁) and output angle (θ₂). The GFC-LFID (w=0.5 mm, l=7 mm, θ₁= 60°, θ₂= 45°) attained a 10-fold increase in sensitivity for detection of interleukin-6 (IL-6), compared with conventional LFID, whereas reducing by 10-fold the antibody consumption. The GFC-LFID detects IL-6 over a linear range of 0.1–10 ng/mL with a limit of detection (LoD) of 29 pg/mL, which even outperforms some commercial IL-6 LFIDs. Such significant improvement is attained by pure geometric control of the NC membrane, without additives, that only relaying on a simple high throughput laser ablation procedure suitable for integration on regular large-scale manufacturing of GFC-LFIDs. Our new development on GFC-LFID with the combination of facile scalable fabrication process, tailored flow control, improved analytical performance, and reduced antibodies consumption is likely to have a significant impact on new design concept for the LFID industry.

Altered profile of immune regulatory cells in the peripheral blood of lymphoma patients

BACKGROUND

Regulatory immune cells may modulate the lymphoma microenvironment and are of great interest due to the increasing prevalence of treatment with immunotherapies in lymphoma patients. The aim was to explore the composition of different immune regulatory cell subsets in the peripheral blood of newly diagnosed lymphoma patients in relation to treatment outcome.

METHODS

Forty-three newly diagnosed patients with lymphoma were included in the study; 24 with high-grade B-cell lymphoma (HGBCL) and 19 with classical Hodgkin lymphoma (cHL). Peripheral blood was prospectively collected and immune regulatory cells were identified by multi-color flow cytometry and analyzed in relation to healthy blood donors and clinical characteristics and outcome.

RESULTS

The percentage of CD3-positive T-cells was lower (p = 0.03) in the peripheral blood of lymphoma patients at diagnosis compared to healthy blood donors regardless of lymphoma subtype, although statistically, neither the percentage of monocytes (p = 0.2) nor the T-cell/monocyte ratio (p = 0.055) differed significantly. A significant decrease in the percentage of a subset of regulatory NK cells (CD7⁺/CD3^-/CD56^bright/CD16^dim/-) was identified in the peripheral blood of lymphoma patients compared to healthy blood donors (p = 0.003). Lymphoma patients also had more granulocytic myeloid-derived suppressor cells (MDSCs) (p = 0.003) compared to healthy blood donors, whereas monocytic MDSCs did not differ significantly (p = 0.07). A superior disease-free survival was observed for cHL patients who had an increase in the percentage of granulocytic MDSCs (p = 0.04).

CONCLUSIONS

An altered profile of immune cells in the peripheral blood with a decrease in T-cells and regulatory NK-cells was observed in newly diagnosed lymphoma patients. CHL patients with higher percentages of regulatory NK cells and higher percentages of granulocytic MDSCs might have a better outcome, although the number of patients was low.

Efficacy of selective serotonin reuptake inhibitors in the absence of side effects: a mega-analysis of citalopram and paroxetine in adult depression

It has been suggested that the superiority of antidepressants over placebo in controlled trials is merely a consequence of side effects enhancing the expectation of improvement by making the patient realize that he/she is not on placebo. We explored this hypothesis in a patient-level post hoc-analysis including all industry-sponsored, Food and Drug Administration-registered placebo-controlled trials of citalopram or paroxetine in adult major depression that used the Hamilton Depression Rating Scale (HDRS) and included a week 6 symptom assessment (n=15). The primary analyses, which compared completers on active treatment without early adverse events to completers on placebo (with or without adverse events) with respect to reduction in the HDRS depressed mood item showed larger symptom reduction in patients given active treatment, the effect sizes being 0.48 for citalopram and 0.33 for paroxetine. In actively treated subjects reporting early adverse events, who also outperformed those given placebo, the severity of the adverse events did not predict response. Several sensitivity analyses, for example, including (i) those using change of the sum of all HDRS-17 items as effect parameter, (ii) those excluding all subjects with adverse events (that is, also those on placebo) and (iii) those based on the intention-to-treat population, were all in line with the primary analyses. The finding that both paroxetine and citalopram are clearly superior to placebo also when not producing adverse events, as well as the lack of association between adverse event severity and response, argue against the theory that antidepressants outperform placebo solely or largely because of their side effects.

The Effect of Va rious Anticoagulant/Anti platelet Mixtures on Determination of Plasminogen Activator Inhibitor, Platelet Proteins and Hemostasis Farameters

Blood collected in different anticoagulant/antiplatelet agents(ETP, EDTA, citrate, citratelcitric acid pH 4.5 and CTAD) was compared with respect to determination of PAI-1 activity and PAI-1 antigen. βTG and PF4 were analysed as markers of platelet release. Both the middle layer and the remaining layer of the plasma were studied. Moreover vWF:Ag, FVII:Ag, ECLI t-PA:Ag, t-PA activity, APTT VIII: C and VII: C were assayed in blood collected in citrate and CTAD

PAI-1 activity showed the same level in all citrate based anticoagulants and ETP and no increase was found in blood standing for 2 hours at room temperature. On the contrary quick handling was most important for determination of PAI-1 antigen. In tubes anticoagulated with citrate no significant increase was found if the sample was prepared within 1 hour. EDTA was not suitable as anticoagulant mixture. Tubes containing the antiplatelet mixture CTAD could be used for determination of PAI activity, PAI antigen, vWF:Ag, FVIIiAg, t-PA activity and APTT.

For measurement of PAI-1 antigen quick handling of blood anticoagulated with antiplatelet mixtures are preferable, and plasma treated in that manner could also be used to assay some hemostasis parameters.

Heparin and Fibrinolysis - Comparison of Subcutaneous Administration of Unfractionated and Low Molecular Weight Heparin

The effects on the fibrinolytic system after a single s.c. bolus injection (at 9 a.m.) of either 5000 IU conventional heparin or 5000 anti-Xa U of a fractionated low molecular weight heparin (Fragmin, KabiVitrum, Sweden) were investigated in 9 healthy volunteers. The effects were compared to those of an injection of normal saline in 6 volunteers. Samples for biochemical analyses were taken regularily during 6 hours after drug or placebo administration.

In the coagulation system the following parameters were measured: Activated partial thromboplastin time (APTT), anti- Xa activity, thrombin time and fibrinogen. The fibrinolytic system was monitored by analysing: plasminogen, ɑ2-antiplasmin, fibrinogen) degradation products (FDP), euglobulin clot lysis time (ECLT), tissue plasminogen activator (t-PA) activity, t-PA antigen and plasminogen activator inhibitor (PAI) activity. Injection of the 2 drugs was followed by elevations in APTT and anti-Xa activity, and were more pronounced for Fragmin than heparin. The fibrinolytic system exhibited a diurnal variation with decreasing PAI activity and increasing t-PA activity during the day. Volunteers receiving normal saline (placebo) showed a similar pattern. The results were unrelated to heparin.

It is concluded from this study that neither heparin nor Fragmin had any significant effect on the fibrinolytic parameters when measured after a single s.c. bolus injection since the observed variations were within the diurnal range.

Recycling of plastic waste: Screening for brominated flame retardants (BFRs)

Flame retardants are chemicals vital for reducing risks of fire and preventing human casualties and property losses. Due to the abundance, low cost and high performance of bromine, brominated flame retardants (BFRs) have had a significant share of the market for years. Physical stability on the other hand, has resulted in dispersion and accumulation of selected BFRs in the environment and receiving biota. A wide range of plastic products may contain BFRs. This affects the quality of waste plastics as secondary resource: material recycling may potentially reintroduce the BFRs into new plastic product cycles and lead to increased exposure levels, e.g. through use of plastic packaging materials. To provide quantitative and qualitative data on presence of BFRs in plastics, we analysed bromophenols (tetrabromobisphenol A (TBBPA), dibromophenols (2,4- and 2,6-DBP) and 2,4,6-tribromophenol (2,4,6-TBP)), hexabromocyclododecane stereoisomers (α-, β-, and γ-HBCD), as well as selected polybrominated diphenyl ethers (PBDEs) in samples of household waste plastics, virgin and recycled plastics. A considerable number of samples contained BFRs, with highest concentrations associated with acrylonitrile butadiene styrene (ABS, up to 26,000,000ngTBBPA/g) and polystyrene (PS, up to 330,000ng∑HBCD/g). Abundancy in low concentrations of some BFRs in plastic samples suggested either unintended addition in plastic products or degradation of higher molecular weight BFRs. The presence of currently restricted flame retardants (PBDEs and HBCD) identified in the plastic samples illustrates that circular material flows may be contaminated for extended periods. The screening clearly showed a need for improved documentation and monitoring of the presence of BFRs in plastic waste routed to recycling.

Incidence of early anxiety aggravation in trials of selective serotonin reuptake inhibitors in depression

OBJECTIVE

Selective serotonin reuptake inhibitors (SSRIs) may aggravate anxiety and agitation during the first days of treatment but the frequency of such reactions remains unknown.

METHOD

We analysed patient-level data from placebo-controlled trials of sertraline, paroxetine or citalopram in depressed adults. Somatic anxiety, psychic anxiety and psychomotor agitation as assessed using the Hamilton Depression Rating Scale (HDRS) were analysed in all trials (n = 8262); anxiety-related adverse events were analysed in trials investigating paroxetine and citalopram (n = 5712).

RESULTS

After one but not two weeks, patients on an SSRI were more likely than those on placebo to report enhanced somatic anxiety (adjusted risk 9.3% vs. 6.7%); likewise, mean rating of somatic anxiety was higher in the SSRI group. In contrast, patients receiving an SSRI were less likely to report aggravation of psychic anxiety (adjusted risk: 7.0% vs. 8.5%) with mean rating of psychic anxiety and agitation being lower in the SSRI group. The adverse event 'nervousness' was more common in patients given an SSRI (5.5% vs. 2.5%). Neither aggravation of HDRS-rated anxiety nor anxiety-related adverse events predicted poor antidepressant response.

CONCLUSION

Whereas an anxiety-reducing effect of SSRIs is notable already during the first week of treatment, these drugs may also elicit an early increase in anxiety in susceptible subjects that however does not predict a poor subsequent response to treatment.

Pigs, Unlike Mice, Have Two Distinct Colonic Stem Cell Populations Similar to Humans That Respond to High-Calorie Diet prior to Insulin Resistance

Basal colonic crypt stem cells are long lived and play a role in colon homeostasis. Previous evidence has shown that high-calorie diet (HCD) enhances colonic stem cell numbers and expansion of the proliferative zone, an important biomarker for colon cancer. However, it is not clear how HCD drives dysregulation of colon stem cell/colonocyte proliferative kinetics. We used a human-relevant pig model and developed an immunofluorescence technique to detect and quantify colonic stem cells. Pigs (n = 8/group) were provided either standard diet (SD; 5% fat) or HCD (23% fat) for 13 weeks. HCD- and SD-consuming pigs had similar total calorie intake, serum iron, insulin, and glucose levels. However, HCD elevated both colonic proliferative zone (KI-67) and stem cell zone (ASCL-2 and BMI-1). Proliferative zone correlated with elevated innate colonic inflammatory markers TLR-4, NF-κB, IL6, and lipocalin-2 (r ≥ 0.62, P = 0.02). Elevated gut bacterial phyla proteobacteria and firmicutes in HCD-consuming pigs correlated with proliferative and stem cell zone. Colonic proteome data revealed the upregulation of proteins involved in cell migration and proliferation and correlated with proliferative and stem cell zone expansion. Our study suggests that pig colon, unlike mice, has two distinct stem cells (ASCL-2 and BMI-1) similar to humans, and HCD increases expansion of colonic proliferative and stem cell zone. Thus, pig model can aid in the development of preventive strategies against gut bacterial dysbiosis and inflammation-promoted diseases, such as colon cancer. Cancer Prev Res; 10(8); 442-50. ©2017 AACR.

A food-based approach that targets interleukin-6, a key regulator of chronic intestinal inflammation and colon carcinogenesis

Studies have shown a causal link between high-calorie diet (HCD) and colon cancer. However, molecular mechanisms are not fully elucidated. To understand etiology of HCD-induced colon carcinogenesis, we screened 10 pathways linked to elevated colonic cell proliferation and chronic inflammation in an HCD-consuming human-relevant pig model. We observed elevated colonic mucosal interleukin-6 (IL-6) expression in HCD-consuming pigs compared to standard diet controls (SD, P=.04), and IL-6 strongly correlated with Ki-67 proliferative index and zone, early biomarkers of colon cancer risk (r=0.604 and 0.743 and P=.017 and .002, respectively). Liquid chromatography-tandem mass spectrometry-based proteomic analysis and Ingenuity Pathway Analysis showed that HCD consumption altered IL-6 signaling pathway proteins (PI3KR4, IL-1α, Mapk10, Akt3, PIK3CG, PIK3R5, Map2k2). Furthermore, these proteins also correlated with Ki-67 proliferative index/zone. Anti-IL-6 therapeutics are available for treating colon cancer; however, they are expensive and induce negative side effects. Thus, whole foods could be a better way to combat low-grade chronic colonic inflammation and colon cancer. Whole plant foods have been shown to decrease chronic diseases due to the potential of anti-inflammatory dietary compounds acting synergistically. We observed that supplementation of HCD with anthocyanin-containing purple-fleshed potatoes (10% w/w), even after baking, suppressed HCD-induced IL-6 expression (P=.03) and the IL-6-related proteins IL-1α and Map2k1 (P≤.1). Our results highlight the importance of IL-6 signaling in diet-linked induction/prevention of colonic inflammation/cancer and demonstrate the potential of a food-based approach to target IL-6 signaling.

The Global Engagement in Care Convening: Recommended Actions to Improve Health Outcomes for People Living With HIV

The National HIV AIDS Strategy (NHAS) calls for a more coordinated response to the HIV epidemic. The Global Engagement in Care Convening created a forum for domestic and international experts to identify best practices in HIV care. This manuscript summarizes the meeting discussions and recommendations from meeting notes and an audio recording of the meeting. Recommendations include: further standardization of performance goals and performance measures; additional research; a more robust system to support competing needs of clients receiving services; electronic information exchanges for HIV-related data; an expansion of the role of other health professionals to extend the capacity of physicians and other members of the care team; and revisions to current financing systems to increase reimbursement for and access to services that promote linkage to and retention in HIV care. The recommendations provide a unique example of "reverse technical assistance" and will inform U.S. program development, research, and policy.

Early assessment of neoadjuvant chemotherapy by FEC-courses of locally advanced breast cancer using 99mTc-MIBI

Purpose: Response assessment at neoadjuvant (preoperative) chemotherapy of locally advanced breast cancer using clinical examination and mammography is insensitive. Mammoscintigraphy with 99mTc-MIBI was studied for the prediction of response at such therapy before finishing the chemotherapy cycles.

Material and Methods: Chemotherapy was given as repeated courses of 5-fluorouracil, epirubicin and cyclophosphamide (FEC). In 1 patient group ( n = 23), the tumor uptake relative to surrounding breast tissue and lung tissue at SPECT examination after finishing neoadjuvant chemotherapy was compared with the examination made before chemotherapy. In another group ( n = 30), a similar comparison after the first therapy cycle (mean 19 days) with a baseline examination was made. Histologic examination of the resected tumors was made.

Results: After finishing chemotherapy, there was a strong reduction of the relative tumor activity, while there was no correlation with therapy effect as assessed by histology. After one therapy course, there was no significant reduction of the relative tumor uptake.

Conclusion: Scintigraphy with 99mTc-MIBI demonstrated the response after finished neoadjuvant chemotherapy of breast cancer using FEC-courses. It cannot be used to predict a therapy response after one therapy course.

Recycling of plastic waste: Presence of phthalates in plastics from households and industry

Plastics recycling has the potential to substitute virgin plastics partially as a source of raw materials in plastic product manufacturing. Plastic as a material may contain a variety of chemicals, some potentially hazardous. Phthalates, for instance, are a group of chemicals produced in large volumes and are commonly used as plasticisers in plastics manufacturing. Potential impacts on human health require restricted use in selected applications and a need for the closer monitoring of potential sources of human exposure. Although the presence of phthalates in a variety of plastics has been recognised, the influence of plastic recycling on phthalate content has been hypothesised but not well documented. In the present work we analysed selected phthalates (DMP, DEP, DPP, DiBP, DBP, BBzP, DEHP, DCHP and DnOP) in samples of waste plastics as well as recycled and virgin plastics. DBP, DiBP and DEHP had the highest frequency of detection in the samples analysed, with 360μg/g, 460μg/g and 2700μg/g as the maximum measured concentrations, respectively. Among other, statistical analysis of the analytical results suggested that phthalates were potentially added in the later stages of plastic product manufacturing (labelling, gluing, etc.) and were not removed following recycling of household waste plastics. Furthermore, DEHP was identified as a potential indicator for phthalate contamination of plastics. Close monitoring of plastics intended for phthalates-sensitive applications is recommended if recycled plastics are to be used as raw material in production.

A mega-analysis of fixed-dose trials reveals dose-dependency and a rapid onset of action for the antidepressant effect of three selective serotonin reuptake inhibitors

The possible dose-dependency for the antidepressant effect of selective serotonin reuptake inhibitors (SSRIs) remains controversial. We believe we have conducted the first comprehensive patient-level mega-analysis exploring this issue, one incentive being to address the possibility that inclusion of low-dose arms in previous meta-analyses may have caused an underestimation of the efficacy of these drugs. All company-sponsored, acute-phase, placebo-controlled, fixed-dose trials using the Hamilton Depression Rating Scale (HDRS) and conducted to evaluate the effect of citalopram, paroxetine or sertraline in adult major depression were included (11 trials, n=2859 patients). The single-item depressed mood, which has proven a more sensitive measure to detect an antidepressant signal than the sum score of all HDRS items, was designated the primary effect parameter. Doses below or at the lower end of the usually recommended dose range (citalopram: 10-20 mg, paroxetine: 10 mg; sertraline: 50 mg) were superior to placebo but inferior to higher doses, hence confirming a dose-dependency to be at hand. In contrast, among doses above these, there was no indication of a dose-response relationship. The effect size (ES) after exclusion of suboptimal doses was of a more respectable magnitude (0.5) than that usually attributed to the antidepressant effect of the SSRIs. In conclusion, the observation that low doses are less effective than higher ones challenges the oft-cited view that the effect of the SSRIs is not dose-dependent and hence not caused by a specific, pharmacological antidepressant action. Moreover, we suggest that inclusion of suboptimal doses in previous meta-analyses has led to an underestimation of the efficacy of these drugs.

Quantification of chemical contaminants in the paper and board fractions of municipal solid waste

Chemicals are used in materials as additives in order to improve the performance of the material or the production process itself. The presence of these chemicals in recyclable waste materials may potentially affect the recyclability of the materials. The addition of chemicals may vary depending on the production technology or the potential end-use of the material. Paper has been previously shown to potentially contain a large variety of chemicals. Quantitative data on the presence of chemicals in paper are necessary for appropriate waste paper management, including the recycling and re-processing of paper. However, a lack of quantitative data on the presence of chemicals in paper is evident in the literature. The aim of the present work is to quantify the presence of selected chemicals in waste paper derived from households. Samples of paper and board were collected from Danish households, including both residual and source-segregated materials, which were disposed of (e.g., through incineration) and recycled, respectively. The concentration of selected chemicals was quantified for all of the samples. The quantified chemicals included mineral oil hydrocarbons, phthalates, phenols, polychlorinated biphenyls, and selected toxic metals (Cd, Co, Cr, Cu, Ni, and Pb). The results suggest large variations in the concentration of chemicals depending on the waste paper fraction analysed. Research on the fate of chemicals in waste recycling and potential problem mitigation measures should be focused on in further studies.

Academic Status of Plastic Surgery in the United States and the Relevance of Independence

BACKGROUND

The basic administrative structures at most academic institutions were implemented more than 50 years ago and have remained largely unchanged. Since the surgical specialties were in nascent stages during that time, they were clubbed together within the department of surgery. There has been extensive growth in the breadth and depth of plastic surgery over the past few decades and current administrative structures might not truly reflect the current standing of plastic surgery.

OBJECTIVES

The goal of this article was to review the academic status of Plastic Surgery in the United States and assess the relevance of independence from the department of surgery.

RESULTS

A national survey of 94 hospitals with plastic surgery residency training programs in the United States was conducted to investigate the academic status of plastic surgery. 25 out of those 94 programs had department status with their respective hospitals while another 9 programs were actively planning on transitioning to department status. Out of the 25 plastic surgery hospital departments, 17 programs were also University departments. The number of plastic surgery departments has more than doubled over the past 10 years and continues to rise as more plastic surgery divisions seek department status.

CONCLUSIONS

There are multiple advantages to seeking department status such as financial and administrative autonomy, ability to participate in medical school curricula, easier access to interdepartmental institutes and faculties, parity with other specialties, and increased control of resident education. There has been concerted advocacy for separating from surgery departments and seeking independent departmental status for plastic surgery. However, the transition from a division to department is a slow and demanding process and requires a well-planned strategy.

Consistent superiority of selective serotonin reuptake inhibitors over placebo in reducing depressed mood in patients with major depression

The recent questioning of the antidepressant effect of selective serotonin reuptake inhibitors (SSRIs) is partly based on the observation that approximately half of company-sponsored trials have failed to reveal a significant difference between active drug and placebo. Most of these have applied the Hamilton depression rating scale to assess symptom severity, the sum score for its 17 items (HDRS-17-sum) serving as effect parameter. In this study, we examined whether the negative outcomes of many SSRI trials may be partly caused by the use of this frequently questioned measure of response. We undertook patient-level post-hoc analyses of 18 industry-sponsored placebo-controlled trials regarding paroxetine, citalopram, sertraline or fluoxetine, and including in total 6669 adults with major depression, the aim being to assess what the outcome would have been if the single item depressed mood (rated 0-4) had been used as a measure of efficacy. In total, 32 drug-placebo comparisons were reassessed. While 18 out of 32 comparisons (56%) failed to separate active drug from placebo at week 6 with respect to reduction in HDRS-17-sum, only 3 out of 32 comparisons (9%) were negative when depressed mood was used as an effect parameter (P<0.001). The observation that 29 out of 32 comparisons detected an antidepressant signal from the tested SSRI suggests the effect of these drugs to be more consistent across trials than previously assumed. Further, the frequent use of the HDRS-17-sum as an effect parameter may have distorted the current view on the usefulness of SSRIs and hampered the development of novel antidepressants.

Bisphenol A and its structural analogues in household waste paper

Bisphenol A (BPA) is an industrial chemical produced in large volumes. Its main use is associated with polycarbonate plastic, epoxy resins and thermal paper. In contrast to other applications, thermal paper contains BPA in its un-reacted form as an additive, which is subjected to migration. Receiving a significant amount of attention from the scientific community and beyond, due to its controversial endocrine-disrupting effects, the industry is attempting to substitute BPA in variety of applications. Alternative phenolic compounds have been proposed for use in thermal paper; however, information to what extent BPA alternatives have been used in paper is sparse. The aim of the present work was to quantify BPA and its alternatives (bisphenol S (BPS), bisphenol E (BPE), bisphenol B (BPB), 4-cumylphenol (HPP) and bisphenol F (BPF)) in waste paper and board from Danish households, thermal paper receipts, non-carbon copy paper and conventional printer paper. BPA was found in all waste paper samples analysed, while BPS was identified in 73% of them. Only BPB was not identified in any of the samples. BPA and BPS were found in the majority of the receipts, which contained no measurable concentrations of the remaining alternatives. Although receipts showed the highest concentrations of BPA and BPS, office paper, flyers and corrugated boxes, together with receipts, represented the major flux of the two compounds in waste paper streams.

[Progress in face transplantation]

Vascularised composite allotransplantation (VCA) is utilised for restoration of complex defects. In this context, restoration describes the replacement of destroyed tissue by identical anatomic structures. Up to date, over 150 VCAs including 31 face transplantations have been performed worldwide. Face transplantation is a life giving, rather than life saving procedure that is intended to significantly improve the patient's quality of life. Safe revascularisation as well as aesthetic and functional reintegration are the ultimate goals of face transplantation. The necessary lifelong immunosuppression with potentially life-threatening side effects imposes the need for a very strict risk-benefit ratio assessment and currently limits the indications of face transplantation. Different transplant centres use different protocols for induction and maintenance immunosuppression. Skin is the most immunogenic part of the vascularised composite allograft and has been the focus of intensive research efforts in order to replicate the success of immunosuppressive regimens for solid organ transplantation. Organ preservation during transfer from donor to recipient is another important field of research within VCA. The general public's originally rejecting attitude towards non-lifesaving VCA procedures has changed towards a general acceptance following the publication of promising results after the first cases of face transplantation. Further improvements of surgical techniques and immunosuppressive strategies will be important to drive these young and exciting procedures forward in the future.

Effect of anaerobic digestion at 35, 55 and 60 °C on pharmaceuticals and organic contaminants

The application of treated sewage sludge on farmland is a suggested method for recycling nutrients and reducing demand for commercial fertilizer. However, sludge needs to be safe from possible contaminants which can cause acute and long-term health and environmental problems. Residual pharmaceuticals and organic contaminants are mentioned as emerging threats since wastewater treatment plants are not designed to degrade these substances. The aim of this study was to screen and evaluate the presence, and reduction, of pharmaceuticals and polycyclic aromatic hydrocarbons (PAHs) during anaerobic digestion of mixed primary and waste-activated sludge at 35, 55 and 60 °C and during pasteurization at 70 °C. The study showed the difficulty of analysing pharmaceutical compounds in low concentrations in the sludge matrix. No general reduction of these compounds was seen during treatment, but for individual substances some reduction occurred. The PAHs were generally not reduced during digestion or pasteurization, but for three substances (indeno[1,2,3-cd]pyrene and dibenzo[a,h]anthracene (analysed together) and benzo[g,h,i]perylene) reduction (up to 60%) during digestion was seen. Digestion at 35 and 55 °C resulted in about the same order of reduction of the three individual PAHs, which was higher than for digestion at 60 °C.

A study of the possible association between adenosine A2A receptor gene polymorphisms and attention-deficit hyperactivity disorder traits

The adenosine A2A receptor (ADORA2A) is linked to the dopamine neurotransmitter system and is also implicated in the regulation of alertness, suggesting a potential association with attention-deficit hyperactivity disorder (ADHD) traits. Furthermore, animal studies suggest that the ADORA2A may influence ADHD-like behavior. For that reason, the ADORA2A gene emerges as a promising candidate for studying the etiology of ADHD traits. The aim of this study was to examine the relationship between ADORA2A gene polymorphisms and ADHD traits in a large population-based sample. This study was based on the Child and Adolescent Twin Study in Sweden (CATSS), and included 1747 twins. Attention-deficit hyperactivity disorder traits were assessed through parental reports, and samples of DNA were collected. Associations between six single nucleotide polymorphisms (SNPs) and ADHD traits were examined, and results suggested a nominal association between ADHD traits and three of these SNPs: rs3761422, rs5751876 and rs35320474. For one of the SNPs, rs35320474, results remained significant after correction for multiple comparisons. These results indicate the possibility that the ADORA2A gene may be involved in ADHD traits. However, more studies replicating the present results are warranted before this association can be confirmed.

Comparison of pollutant emission control strategies for cadmium and mercury in urban water systems using substance flow analysis

The European Union (EU) Water Framework Directive (WFD) requires Member States to protect inland surface and groundwater bodies but does not directly stipulate how the associated environmental quality standards should be achieved. This paper develops and assesses the performance of a series of urban emission control strategies (ECS) with an emphasis on the scientific and technological benefits which can be achieved. Data from the literature, in combination with expert judgement, have been used to develop two different semi-hypothetical case cities (SHCC), which represent virtual platforms for the evaluation of ECS using substance flow analysis (SFA). The results indicate that the full implementation of existing EU legislation is capable of reducing the total emissions of cadmium (Cd) and mercury (Hg) by between 11% and 20%. The ability to apply voluntary reduction practices is shown to be particularly effective for Cd with the potential to further lower the overall emissions by between 16% and 27%. The most efficient protection of the receiving surface water environment is strongly influenced by the city characteristics with the introduction of stormwater treatment practices being particularly effective for one city (59% reduction of Hg; 39% reduction of Cd) and the other city being most influenced by the presence of efficient advanced wastewater treatment processes (63% reduction of Hg; 43% reduction of Cd). These reductions in receiving water loads are necessarily accompanied by either increases in stormwater sediment loadings (2.6-14.9 kg/year or 0.6-2.4 kg/year for Hg) or wastewater sludge loadings (45.8-57.2 kg/year or 42.0-57.4 kg/year for Cd).

Quantification of uncertainty in modelled partitioning and removal of heavy metals (Cu, Zn) in a stormwater retention pond and a biofilter

Strategies for reduction of micropollutant (MP) discharges from stormwater drainage systems require accurate estimation of the potential MP removal in stormwater treatment systems. However, the high uncertainty commonly affecting stormwater runoff quality modelling also influences stormwater treatment models. This study identified the major sources of uncertainty when estimating the removal of copper and zinc in a retention pond and a biofilter by using a conceptual dynamic model which estimates MP partitioning between the dissolved and particulate phases as well as environmental fate based on substance-inherent properties. The two systems differ in their main removal processes (settling and filtration/sorption, respectively) and in the time resolution of the available measurements (composite samples and pollutographs). The most sensitive model factors, identified by using Global Sensitivity Analysis (GSA), were related to the physical characteristics of the simulated systems (flow and water losses) and to the fate processes related to Total Suspended Solids (TSS). The model prediction bounds were estimated by using the Generalized Likelihood Uncertainty Estimation (GLUE) technique. Composite samples and pollutographs produced similar prediction bounds for the pond and the biofilter, suggesting a limited influence of the temporal resolution of samples on the model prediction bounds. GLUE highlighted model structural uncertainty when modelling the biofilter, due to disregard of plant-driven evapotranspiration, underestimation of sorption and neglect of oversaturation with respect to minerals/salts. The results of this study however illustrate the potential for the application of conceptual dynamic fate models base on substance-inherent properties, in combination with available datasets and statistical methods, to estimate the MP removal in different stormwater treatment systems and compare with environmental quality standards targeting the dissolved MP fraction.

Replication and meta-analysis of TMEM132D gene variants in panic disorder

A recent genome-wide association study in patients with panic disorder (PD) identified a risk haplotype consisting of two single-nucleotide polymorphisms (SNPs) (rs7309727 and rs11060369) located in intron 3 of TMEM132D to be associated with PD in three independent samples. Now we report a subsequent confirmation study using five additional PD case-control samples (n = 1670 cases and n = 2266 controls) assembled as part of the Panic Disorder International Consortium (PanIC) study for a total of 2678 cases and 3262 controls in the analysis. In the new independent samples of European ancestry (EA), the association of rs7309727 and the risk haplotype rs7309727-rs11060369 was, indeed, replicated, with the strongest signal coming from patients with primary PD, that is, patients without major psychiatric comorbidities (n = 1038 cases and n = 2411 controls). This finding was paralleled by the results of the meta-analysis across all samples, in which the risk haplotype and rs7309727 reached P-levels of P = 1.4e-8 and P = 1.1e-8, respectively, when restricting the samples to individuals of EA with primary PD. In the Japanese sample no associations with PD could be found. The present results support the initial finding that TMEM132D gene contributes to genetic susceptibility for PD in individuals of EA. Our results also indicate that patient ascertainment and genetic background could be important sources of heterogeneity modifying this association signal in different populations.

Sentinel node detection in renal cell carcinoma. A feasibility study for detection of tumour-draining lymph nodes

OBJECTIVE

To evaluate the feasibility of performing sentinel node detection in patients with renal cell carcinoma (RCC).

MATERIALS AND METHODS

An open series of 13 arbitrarily selected patients with T1b-T3b RCC scheduled for radical nephrectomy at a single Tertiary Academic Centre were examined with different modalities of sentinel node detection. Preoperative ultrasonography-guided injection of radioactive isotope, lymphoscintigram and single photon emission computed tomography/computed tomography, followed by intraoperative gamma-probe detection and Patent Blue detection, as well as postoperative scintigram of the main specimen were the planned interventions. These investigations were performed in conjunction with intended open radical nephrectomy.

RESULTS

In 10 of the 13 patients sentinel node detection was achieved with 32 sentinel nodes displayed. Radio-guided surgery using an intraoperative gamma-probe resulted in the highest realtive detection rate with detection of sentinel nodes in nine patients. In total, nine metastatic sentinel nodes were detected in three patients. One patient, preoperatively staged as N+, was restaged after sentinel node detection and histopathology as pN0.

CONCLUSIONS

Sentinel node detection in renal tumours is feasible although evaluation of different modes of detection needs further refinement and standardization. All nodes preoperatively detected by routine computed tomography as suspicious metastatic lesions were confirmed as sentinel nodes, including two nodes considered as metastatic by preoperative routine imaging but ultimately staged as non-metastatic sentinel nodes.

Restoration of facial form and function after severe disfigurement from burn injury by a composite facial allograft

Composite facial allotransplantation is emerging as a treatment option for severe facial disfigurements. The technical feasibility of facial transplantation has been demonstrated, and the initial clinical outcomes have been encouraging. We report an excellent functional and anatomical restoration 1 year after face transplantation. A 59-year-old male with severe disfigurement from electrical burn injury was treated with a facial allograft composed of bone and soft tissues to restore midfacial form and function. An initial potent antirejection treatment was tapered to minimal dose of immunosuppression. There were no surgical complications. The patient demonstrated facial redness during the initial postoperative months. One acute rejection episode was reversed with a brief methylprednisolone bolus treatment. Pathological analysis and the donor's medical history suggested that rosacea transferred from the donor caused the erythema, successfully treated with topical metronidazol. Significant restoration of nasal breathing, speech, feeding, sensation and animation was achieved. The patient was highly satisfied with the esthetic result, and regained much of his capacity for normal social life. Composite facial allotransplantation, along with minimal and well-tolerated immunosuppression, was successfully utilized to restore facial form and function in a patient with severe disfigurement of the midface.

Water management in cities of the future using emission control strategies for priority hazardous substances

Cities of the future face challenges with respect to the quantity and quality of water resources, and multiple managerial options need to be considered in order to safeguard urban surface water quality. In a recently completed project on 'Source control options for reducing emissions of Priority Pollutants' (ScorePP), seven emission control strategies (ECSs) were developed and tested within a semi-hypothetical case city (SHCC) to evaluate their potential to reduce the emission of selected European priority hazardous substances (PHSs) to surface waters. The ECSs included (1) business-as-usual, (2) full implementation of relevant European (EU) directives, (3) ECS2 in combination with voluntary options for household, municipalities and industry, (4) ECS2 combined with industrial treatment and best available technologies (BAT), (5) ECS2 in combination with stormwater and combined sewer overflow treatment, (6) ECS2 in combination with advanced wastewater treatment, and (7) combinations of ECS3-6. The SHCC approach was chosen to facilitate transparency, to allow compensating for data gaps and to decrease the level of uncertainty in the results. The selected PHSs: cadmium (Cd), hexachlorobenzene (HCB), nonylphenol (NP) and pentabromodiphenyl ether (PBDE) differ in their uses and environmental fate and therefore accumulate in surface waters to differing extents in response to the application of alternative ECS. To achieve the required reduction in PHS levels in urban waters the full implementation of existing EU regulation is prioritised and feasible combinations of managerial and technological options (source control and treatment) can be highly relevant for mitigating releases.

Presence and fate of priority substances in domestic greywater treatment and reuse systems

A wide range of household sources may potentially contribute to contaminant loads in domestic greywater. The ability of greywater treatment systems to act as emission control barriers for household micropollutants, thereby providing environmental benefits in addition to potable water savings, have not been fully explored. This paper investigates the sources, presence and potential fate of a selection of xenobiotic micropollutants in on-site greywater treatment systems. All of the investigated compounds are listed under the European Water Framework Directive as either "Priority Substances" (PS) or "Priority Hazardous Substances" (PHS). Significant knowledge gaps are identified. A wide range of potential treatment trains are available for greywater treatment and reuse but treatment efficiency data for priority substances and other micropollutants is very limited. Geochemical modelling indicates that PS/PHS removal during treatment is likely to be predominantly due to sludge/solid phase adsorption, with only minor contributions to the water phase. Many PS/PHS are resistant to biodegradation and as the majority of automated greywater treatment plants periodically discharge sludge to the municipal sewerage system, greywater treatment is unlikely to act as a comprehensive PS/PHS emission barrier. Hence, it is important to ensure that other source control options (e.g. eco-labeling, substance substitution, and regulatory controls) for household items continue to be pursued, in order that PS/PHS emissions from these sources are effectively reduced and/or phased out as required under the demands of the European Water Framework Directive.