The significance of lead entering the human food chain via livestock ingestion from the agricultural use of biosolids, with special reference to the UK

Long-term application of biosolids to agricultural soil results in the slow accumulation of potentially toxic elements (PTEs), which are regulated by maximum permitted limit values to protect human health and the environment. Two programmes of UK government-funded (MAFF/DoE) research were commissioned in the 1990s to investigate the safety of the controls on PTEs in relation to the potential transfer to the food chain via the animal ingestion route by sheep grazing biosolids-amended soil. Here, we re-examine this evidence in the light of other recent research and revised food quality standards, to determine the significance of lead (Pb) accumulation in soil from the agricultural use of biosolids. Direct ingestion of biosolids-amended soil is the main transfer pathway of Pb to grazing livestock. The concentrations of Pb in muscle tissue of animals grazing biosolids-amended soil observed in the MAFF/DoE trials, and reported in the scientific literature, were generally small and similar to background, control values. Lambs and ewes ingesting biosolids-amended soil with a total Pb concentration > 200 mg kg-1 dry soil at a rate of 10 % in the diet exceeded the current maximum permitted concentration of Pb in offal (0.5 mg kg-1 fresh weight). However, the decline in PTE concentrations found in biosolids, due to improved industrial practices and stricter controls on the emissions of contaminants to the environment in general and wastewater in particular, has mitigated the risk of Pb accumulation above the food quality standard for this element in offal. Given the significant improvements in biosolids quality, and particularly in the Pb content, regulatory soil and sludge limits for Pb are no longer likely to have a practical or significant impact on the amount of Pb entering the food chain through the animal ingestion route from biosolids-amended agricultural soil.

Transfer of polychlorinated, brominated and mixed-halogenated dioxins, furans and biphenyls, polychlorinated naphthalenes and alkanes, polycyclic aromatic hydrocarbons and chlorobenzenes to the milk of dairy cattle from controlled ingestion of industrial and municipal bioresources recycled to agricultural land

Recycled bioresources (biosolids, compost-like-output, meat and bonemeal ash, poultry litter ash, paper sludge ash) were added to the feed of dairy cattle to simulate incidental ingestion from agricultural utilisation, to investigate the transfer of organic contaminants from the ingested materials to milk. The bioresources were blended with a loamy sand soil at agronomic rates to simulate a single application to land, which was added to the diet at 5 % of the total intake on a dry matter (DM) basis. Biosolids, and control treatments consisting of unamended soil, were also added directly to the feed at 5 % DM. The cattle were fed the bioresource amended diets for a target period of three to four weeks, depending on material, and monitoring continued for four weeks after treatment withdrawal. Milk samples were taken weekly with chemical analysis of selected samples for a range of organic contaminants including: polychlorinated, polybrominated and mixed-halogenated dioxins, furans and biphenyls, polychlorinated naphthalenes and alkanes (often called chlorinated paraffins), polycyclic aromatic hydrocarbons and chlorobenzenes. No statistically significant additional transfer of organic contaminants to the milk was detected when bioresources were blended with soil due to the relatively low levels of contaminants present when the bioresources were blended with soil at agronomic rates. However, direct biosolids ingestion by cattle significantly increased the transfer of contaminants to milk in comparison to control animals. Although present in larger concentrations in biosolids than their chlorinated counterparts, the carry over rates and bioconcentration factors for brominated dioxins and furans were considerably smaller. Direct ingestion of biosolids resulted in most contaminants approaching, but not always completely reaching, steady state concentrations within the treatment feeding period, however, concentrations generally declined to control values within four-weeks after withdrawing the biosolids-amended diet.

Concentrations of organic contaminants in industrial and municipal bioresources recycled in agriculture in the UK

Many types of bioresource materials are beneficially recycled in agriculture for soil improvement and as alternative bedding materials for livestock, but they also potentially transfer contaminants into plant and animal foods. Representative types of industrial and municipal bioresources were selected to assess the extent of organic chemical contamination, including: (i) land applied materials: treated sewage sludge (biosolids), meat and bone meal ash (MBMA), poultry litter ash (PLA), paper sludge ash (PSA) and compost-like-output (CLO), and (ii) bedding materials: recycled waste wood (RWW), dried paper sludge (DPS), paper sludge ash (PSA) and shredded cardboard. The materials generally contained lower concentrations of polychlorinated dibenzo-p-dioxins/dibenzofurans (PCDD/Fs) and dioxin-like polychlorinated biphenyls (PCBs) relative to earlier reports, indicating the decline in environmental emissions of these established contaminants. However, concentrations of polycyclic aromatic hydrocarbons (PAHs) remain elevated in biosolids samples from urban catchments. Polybrominated dibenzo-p-dioxins/dibenzofurans (PBDD/Fs) were present in larger amounts in biosolids and CLO compared to their chlorinated counterparts and hence are of potentially greater significance in contemporary materials. The presence of non-ortho-polychlorinated biphenyls (PCBs) in DPS was probably due to non-legacy sources of PCBs in paper production. Flame retardent chemicals were one of the most significant and extensive groups of contaminants found in the bioresource materials. Decabromodiphenylether (deca-BDE) was the most abundant polybrominated diphenyl ether (PBDE) and may explain the formation and high concentrations of PBDD/Fs detected. Emerging flame retardant compounds, including: decabromodiphenylethane (DBDPE) and organophosphate flame retardants (OPFRs), were also detected in several of the materials. The profile of perfluoroalkyl substances (PFAS) depended on the type of waste category; perfluoroundecanoic acid (PFUnDA) was the most significant PFAS for DPS, whereas perfluorooctane sulfonate (PFOS) was dominant in biosolids and CLO. The concentrations of polychlorinated alkanes (PCAs) and di-2-ethylhexyl phthalate (DEHP) were generally much larger than the other contaminants measured, indicating that there are major anthropogenic sources of these potentially hazardous chemicals entering the environment. The study results suggest that continued vigilance is required to control emissions and sources of these contaminants to support the beneficial use of secondary bioresource materials.

The significance of cadmium entering the human food chain via livestock ingestion from the agricultural use of biosolids, with special reference to the UK

When biosolids are applied to agricultural soil, potentially toxic elements (PTEs) accumulate in the topsoil, although it takes many repeated applications to reach soil limit values. Two programmes of UK government-funded research were commissioned in the 1990s to investigate the transfer of PTEs to the food chain via ingestion by sheep grazing biosolids-amended soil. Here, we critically re-examine this evidence in the light of other published work and current food quality standards. This was particularly motivated by the need to determine the safety of biosolids controls on PTEs in relation to revised and stricter European food quality controls for PTEs in foodstuffs. The major pathway for transfer of PTEs to grazing livestock is via direct ingestion of biosolids or biosolids-amended soil from the soil surface. The main elements of concern for the human diet are cadmium (Cd) and lead (Pb), with Cd being the focus of the current paper. Animal ingestion of plant tissue is also a potential pathway for Cd exposure, which, unlike Pb, can transfer to crop tissues. The concentrations of Cd in the muscle tissue of sheep grazing biosolids-amended soil were generally small and similar to control values. Cadmium concentrations in sheep offal were below the maximum permitted concentration for human consumption. This was despite ingestion of soils exceeding the maximum permissible concentration for Cd in soil (3 mg kg^-1 dry soil) by up to three times, at an ingestion rate of 10% total dietary dry matter intake. Grazing trials under practical conditions on high Cd soils demonstrated that the Cd concentrations in sheep offal remained below the food limit value for this element in offal from the combined intakes from biosolids-amended soil and herbage. Futhermore, given the substantial fall in environmental emissions and concentrations in biosolids of this element and, consequently, it cannot accumulate in soil to the limit value, biosolids Cd does not represent an issue for the safety of animal meat products.

Verification of an alternative sludge treatment process for pathogen reduction at two wastewater treatment plants in Victoria, Australia

At South East Water wastewater treatment plants (WwTPs) in Victoria, Australia, biosolids are stockpiled for three years in compliance with the State guidelines to achieve the highest pathogen reduction grade (T1), suitable for unrestricted use in agriculture and landscaping. However, extended stockpiling is costly, may increase odour nuisance and greenhouse gas emissions, and reduces the fertiliser value of the biosolids. A verification programme of sampling and analysis for enteric pathogens was conducted at two WwTPs where sludge is treated by aerobic and anaerobic digestion, air drying (in drying pans or solar drying sheds) and stockpiling, to enumerate and, if present, monitor the decay of a range of enteric pathogens and parasites. The sludge treatment processes at both WwTPs achieved T1 grade biosolids with respect to prescribed pathogenic bacterial numbers (<1 Salmonella spp. 50 g^-1 dry solids (DS) and <100 Escherichia coli g^-1 DS) and >3 log₁₀ enteric virus reduction after a storage period of one year. No Ascaris eggs were detected in the influent to the WwTPs, confirming previous studies that the presence of helminth infections in Victoria is extremely low and that Ascaris is not applicable as a control criterion for the microbiological quality of biosolids in the region.

A critical review of nitrogen mineralization in biosolids-amended soil, the associated fertilizer value for crop production and potential for emissions to the environment

International controls for biosolids application to agricultural land ensure the protection of human health and the environment, that it is performed in accordance with good agricultural practice and that nitrogen (N) inputs do not exceed crop requirements. Data from the scientific literature on the total, mineral and mineralizable N contents of biosolids applied to agricultural land under a wide range of climatic and experimental conditions were collated. The mean concentrations of total N (TN) in the dry solids (DS) of different biosolids types ranged from 1.5% (air-dried lime-treated (LT) biosolids) to 7.5% (liquid mesophilic anaerobic digestion (LMAD) biosolids). The overall mean values of mineralizable N, as a proportion of the organic N content, were 47% for aerobic digestion (AeD) biosolids, 40% for thermally dried (TD) biosolids, 34% for LT biosolids, 30% for mesophilic anaerobic digestion (MAD) biosolids, and 7% for composted (Com) biosolids. Biosolids air-dried or stored for extended periods had smaller total and mineralizable N values compared to mechanically dewatered types. For example, for biosolids treated by MAD, the mean TN (% DS) and mineralizable N (% organic N) contents of air-dried materials were 3% and 20%, respectively, compared to 5% and 30% with mechanical dewatering. Thus, mineralizable N declined with the extent of biological stabilization during sewage sludge treatment; nevertheless, overall plant available N (PAN=readily available inorganic N plus mineralizable N) was broadly consistent across several major biosolids categories within climatic regions. However, mineralizable N often varied significantly between climatic regions for similar biosolids types, influencing the overall PAN. This may be partly attributed to the increased rate, and also the greater extent of soil microbial mineralization of more stable, residual organic N fractions in biosolids applied to soil in warmer climatic zones, which also raised the overall PAN, compared to cooler temperate areas. It is also probably influenced by differences in upstream wastewater treatment processes that affect the balance of primary and secondary, biological sludges in the final combined sludge output from wastewater treatment, as well as the relative effectiveness of sludge stabilization treatments at specific sites. Better characterization of biosolids used in N release and mineralization investigations is therefore necessary to improve comparison of system conditions. Furthermore, the review suggested that some international fertilizer recommendations may underestimate mineralizable N in biosolids, and the N fertilizer value. Consequently, greater inputs of supplementary mineral fertilizer N may be supplied than are required for crop production, potentially increasing the risk of fertilizer N emissions to the environment. Thus greater economic and environmental savings in mineral N fertilizer application are potentially possible than are currently realized from biosolids recycling programmes.

Nitrogen availability and indirect measurements of greenhouse gas emissions from aerobic and anaerobic biowaste digestates applied to agricultural soils

Recycling biowaste digestates on agricultural land diverts biodegradable waste from landfill disposal and represents a sustainable source of nutrients and organic matter (OM) to improve soil for crop production. However, the dynamics of nitrogen (N) release from these organic N sources must be determined to optimise their fertiliser value and management. This laboratory incubation experiment examined the effects of digestate type (aerobic and anaerobic), waste type (industrial, agricultural and municipal solid waste or sewage sludge) and soil type (sandy loam, sandy silt loam and silty clay) on N availability in digestate-amended soils and also quantified the extent and significance of the immobilisation of N within the soil microbial biomass, as a possible regulatory mechanism of N release. The digestate types examined included: dewatered, anaerobically digested biosolids (DMAD); dewatered, anaerobic mesophilic digestate from the organic fraction of municipal solid waste (DMADMSW); liquid, anaerobic co-digestate of food and animal slurry (LcoMAD) and liquid, thermophilic aerobic digestate of food waste (LTAD). Ammonium chloride (NH4Cl) was included as a reference treatment for mineral N. After 48 days, the final, maximum net recoveries of mineral N relative to the total N (TN) addition in the different digestates and unamended control treatments were in the decreasing order: LcoMAD, 68%; LTAD, 37%, DMAD, 20%; and DMADMSW, 11%. A transient increase in microbial biomass N (MBN) was observed with LTAD application, indicating greater microbial activity in amended soil and reflecting the lower stability of this OM source, compared to the other, anaerobic digestate types, which showed no consistent effects on MBN compared to the control. Thus, the overall net release of digestate N in different soil types was not regulated by N transfer into the soil microbial biomass, but was determined primarily by digestate properties and the capacity of the soil type to process and turnover digestate N. In contrast to the sandy soil types, where nitrate (NO3-) concentrations increased during incubation, there was an absence of NO3- accumulation in the silty clay soil amended with LTAD and DMADMSW. This provided indirect evidence for denitrification activity and the gaseous loss of N, and the associated increased risk of greenhouse gas emissions under certain conditions of labile C supply and/or digestate physical structure in fine-textured soil types. The significance and influence of the interaction between soil type and digestate stability and physical properties on denitrification processes in digestate-amended soils require urgent investigation to ensure management practices are appropriate to minimise greenhouse gas emissions from land applied biowastes.

The use of alum sludge to improve cereal production on a nutrient-deficient soil

Alum sludge from wastewater treatment was applied at five rates on a phosphorus-deficient sand, and the effects on cereal growth and nutrition were investigated over 2 years. An inorganic fertilizer treatment, reapplied in the second year, was also included. The grain yield for inorganic fertilizer was 44% higher than the control in year 1 and 58% higher in year 2. Alum sludge was an adequate source of nitrogen for crop growth, and supplied sufficient residual nitrogen to meet crop requirements in year 2. However, grain yield in the alum sludge treatment applied at an equivalent available nitrogen rate to the inorganic fertilizer was 62% (year 1) and 69% (year 2) of the yield achieved by the inorganic fertilizer, though greater than the control. No toxic forms of aluminium were detected in the soil at any rate of alum sludge application. Plant shoot tissue analysis indicated that wheat sown in alum sludge-amended soil and the control were phosphorus deficient, whereas phosphorus was adequate in the inorganic fertilizer treatment. There was no evidence of any other nutrient deficiency. Alum sludge amendment resulted in an increase in soil phosphorus; however, further soil analysis indicated that forms of phosphorus present in alum sludge-amended soil may not be available for crop uptake; this is consistent with phosphorus deficiency observed in plant tissue in alum sludge-treated soil. It is suggested that on this nutrient-poor sand, the ability of alum sludge to provide sufficient phosphorus for plant production was limited in the 2 years after application.

Land application of sewage sludge (biosolids) in Australia: risks to the environment and food crops

Australia is a large exporter of agricultural products, with producers responsible for a range of quality assurance programs to ensure that food crops are free from various contaminants of detriment to human health. Large volumes of treated sewage sludge (biosolids), although low by world standards, are increasingly being recycled to land, primarily to replace plant nutrients and to improve soil properties; they are used in agriculture, forestry, and composted. The Australian National Biosolids Research Program (NBRP) has linked researchers to a collective goal to investigate nutrients and benchmark safe concentrations of metals nationally using a common methodology, with various other research programs conducted in a number of states specific to regional problems and priorities. The use of biosolids in Australia is strictly regulated by state guidelines, some of which are under review following recent research outcomes. Communication and research between the water industry, regulators and researchers specific to the regulation of biosolids is further enhanced by the Australian and New Zealand Biosolids Partnership (ANZBP). This paper summarises the major issues and constraints related to biosolids use in Australia using specific case examples from Western Australia, a member of the Australian NBRP, and highlights several research projects conducted over the last decade to ensure that biosolids are used beneficially and safely in the environment. Attention is given to research relating to plant nutrient uptake, particularly nitrogen and phosphorus (including that of reduced phosphorus uptake in alum sludge-amended soil); the risk of heavy metal uptake by plants, specifically cadmium, copper and zinc; the risk of pathogen contamination in soil and grain products; change to soil pH (particularly following lime-amended biosolids); and the monitoring of faecal contamination by biosolids in waterbodies using DNA techniques. Examples of products that are currently produced in Western Australia from sewage sludge include mesophilic anaerobically digested and dewatered biosolids cake, lime-amended biosolids, alum sludge and compost.

Caring for stroke survivors: baseline and 1-year determinants of caregiver burden

BACKGROUND

Caregiver burden following stroke can have significant adverse health consequences for caregivers and threatens the recovery and successful rehabilitation of patients. Our objective was to identify patient factors that contribute to higher levels of caregiver burden.

METHODS

We prospectively studied patients admitted to our stroke unit over a 2-year period (2001-2002). Data were collected at baseline and at 1 year. Caregiver burden was measured at 1 year using the Relatives Stress Scale (completed by 155 caregivers) and the Bakas Caregiver Outcomes Scale (143 caregivers). Explanatory patient factors at baseline included sociodemographic status, stroke severity, stroke sub-type, functional disability (Barthel Index), functional handicap (Oxford Handicap Scale and Modified Rankin Scale), and cognitive status (orientation, clock drawing). At 1 year, mental health and health-related quality of life were assessed using the Fatigue Impact Scale, Geriatric Depression Scale, Global Deterioration Scale, and 36-item Short Form Health Survey.

RESULTS

The baseline patient factors predictive of caregiver burden by multiple regression analysis were older patient age (P<0.01), male gender (P<0.05), ischemic stroke (P<0.05), urinary incontinence (P<0.0001), and impaired clock drawing (P<0.05). At 1 year, significant correlates of caregiver burden were older patient age (P<0.05), male gender (P<0.01), poor mental health (P<0.05), functional handicap (P<0.05), and functional disability (P<0.001).

CONCLUSIONS

The functional status of patients can be used to identify caregivers at risk of caregiver burden. Patient demographic variables, cognitive function, and mental health status may further expose vulnerable caregivers. These factors should be considered in the development of strategies to offset caregiver burden.

A Systematic Review of Caregiver Burden following Stroke

Caregiver burden following stroke is increasingly recognised as a significant health care concern. A growing number of studies have evaluated the patient, caregiver, and social support factors that contribute to increased caregiver burden. We conducted a systematic review of this literature to guide future research. A search of the MEDLINE, PsyclNFO, CINAHL, and EMBASE databases (up to July 2008) and reference sections of published studies using a structured search strategy yielded 24 relevant articles. Studies were included if they evaluated predictors and/or correlates of caregiver burden in the setting of stroke. The prevalence of caregiver burden was 25–54% and remained elevated for an indefinite period following stroke. In studies that evaluated independent baseline predictors of subsequent caregiver burden, none of the factors reported were consistent across studies. In studies that assessed concurrent factors independently contributing to caregiver burden in the poststroke period, patient characteristics and social support factors were inconsistently reported. Several studies identified caregiver mental health and the amount of time and effort required of the caregiver as significant determinants of caregiver burden. Our findings highlight the need for more research to identify caregivers in need of support and guide the development and implementation of appropriate interventions to offset caregiver burden.

Giant bathing trunk naevus with lymphadenopathy and unusual pathology

Giant congenital melanocytic naevi remain a challenge to clinicians and histopathologists with respect to observation for malignant change and interpretation of histology findings, respectively. We report a 5-year-old boy with a giant bathing trunk naevus who, after multiple previous skin biopsies, developed lymphadenopathy. Biopsy from the lymph nodes demonstrated collections of naevomelanocytes within the lymph node. Interpretation of these findings and subsequent management is discussed.

Expression of VEGF(xxx)b, the inhibitory isoforms of VEGF, in malignant melanoma

Malignant melanoma is the most lethal of the skin cancers and the UK incidence is rising faster than that of any other cancer. Angiogenesis – the growth of new vessels from preexisting vasculature – is an absolute requirement for tumour survival and progression beyond a few hundred microns in diameter. We previously described a class of anti-angiogenic isoforms of VEGF, VEGF_xxxb, that inhibit tumour growth in animal models, and are downregulated in some cancers, but have not been investigated in melanoma. To determine whether VEGF_xxxb expression was altered in melanoma, PCR and immunohistochemistry of archived human tumour samples were used. In normal epidermis and in a proportion of melanoma samples, VEGF_xxxb staining was seen. Some melanomas had much weaker staining. Subsequent examination revealed that expression was significantly reduced in primary melanoma samples (both horizontal and vertical growth phases) from patients who subsequently developed tumour metastasis compared with those who did not (analysis of variance (ANOVA) P<0.001 metastatic vs nonmetastatic), irrespective of tumour thickness, while the surrounding epidermis showed no difference in expression. Staining for total VEGF expression showed staining in metastatic and nonmetastatic melanomas, and normal epidermis. An absence of VEGF_xxxb expression appears to predict metastatic spread in patients with primary melanoma. These results suggest that there is a switch in splicing as part of the metastatic process, from anti-angiogenic to pro-angiogenic VEGF isoforms. This may form part of a wider metastatic splicing phenotype.

Chemokine-mediated migration of melanoma cells towards lymphatics--a mechanism contributing to metastasis

The mechanisms that cause tumors such as melanomas to metastasize into peripheral lymphatic capillaries are poorly defined. Non-mutually-exclusive mechanisms are lymphatic endothelial cell (LEC) chemotaxis and proliferation in response to tumor cells (chemotaxis-lymphangiogenesis hypothesis) or LECs may secrete chemotactic agents that attract cancer cells (chemotactic metastasis hypothesis). Using migration assays, we found evidence supporting both hypotheses. Conditioned medium (CM) from metastatic malignant melanoma (MMM) cell lines attracted LEC migration, consistent with the lymphangiogenesis hypothesis. Conversely, CM from mixed endothelial cells or LECs, but not blood endothelial cells, attracted MMM cells but not non-metastatic melanoma cells, consistent with the chemotactic metastasis hypothesis. MMM cell lines expressed CCR7 receptors for the lymphatic chemokine CCL21 and CCL21 neutralizing antibodies prevented MMM chemotaxis in vitro. To test for chemotactic metastasis in vivo tumor cells were xenotransplanted into nude mice approximately 1 cm from an injected LEC depot. Two different MMM grew directionally towards the LECs, whereas non-metastatic melanomas did not. These observations support the hypothesis that MMM cells grow towards regions of high LEC density owing to chemotactic LEC secretions, including CCL21. This chemotactic metastasis may contribute to the close association between metastasizing tumor cells and peri-tumor lymphatic density and promote lymphatic invasion.

Lymphatic density and metastatic spread in human malignant melanoma

Malignant melanoma (MM), the most common cause of skin cancer deaths, metastasises to regional lymph nodes. In animal models of other cancers, lymphatic growth is associated with metastasis. To assess if lymphatic density (LD) was increased in human MM, and its association with metastasis, we measured LD inside and around archival MM samples (MM, n=21), and compared them with normal dermis (n=11), basal cell carcinoma (BCC, n=6) and Merkel cell carcinoma (MCC), a skin tumour thought to metastasise through a vascular route (MCC, n=6). Lymphatic capillary density (mm⁻²), as determined by immunohistochemical staining with the lymphatic specific marker LYVE-1, was significantly increased around MM (10.0±2.5 mm⁻²) compared with normal dermis (2.4±0.9 mm⁻²), BCC (3.0±0.9 mm⁻²) and MCC (2.4±1.4 mm⁻²) (P<0.0001). There was a small decrease in LD inside MM (1.1±0.7 mm⁻²) compared with normal dermis, but a highly significant decrease in BCC (0.14±0.13) and MCC (0.12±2.4) (P<0.01 Kruskal–Wallis). Astonishingly, LD discriminated between melanomas that subsequently metastasised (12.8±1.6 mm⁻²) and those that did not (5.4±1.1 mm⁻², P<0.01, Mann–Whitney). Lymphatic invasion by tumour cells was seen mainly in MM that metastasised (70% compared with 12% not metastasising, P<0.05 Fisher's Exact test). The results show that LD was increased around MMs, and that LD and tumour cell invasion of lymphatics may help to predict metastasis. To this end, a prognostic index was calculated using LD, lymphatic invasion and thickness that clearly discriminated metastatic from nonmetastatic tumours.

The detection of tyrosinase mRNA in peripheral blood samples is unlikely to aid in the management of patients with localised malignant melanoma

A number of authors have reported the detection of tyrosinase mRNA in the peripheral blood of patients with malignant melanoma using the reverse transcription polymerase chain reaction (RT-PCR). The precise value of this assay as a prognostic tool, however, remains in doubt. This is particularly so with relation to localised disease, where relatively little data has been accumulated. In this study we analysed the peripheral blood of 50 consecutive patients with primary malignant melanoma referred to a plastic surgical centre with the facility of a pigmented lesion clinic. Samples were analysed from an additional 35 patients with advanced melanoma disease and 35 patients with benign pigmented cutaneous lesions. We were able to identify tyrosinase transcripts in the peripheral blood of only two of 50 patients with localised disease. Of those with more advanced disease, a positive finding was found in three with regional disease and four patients with metastatic spread. Stage of disease was found to correlate significantly with PCR status. No correlation was identified with other prognostic markers or with outcome over a three-year period. This data would support the conclusion that the detection of tyrosinase mRNA in peripheral blood is likely to be of little value as an aid in the management of patients with early malignant melanoma.

Nodal metastatic melanoma in the neck of a 4-year-old girl after diagnosis of Spitz nevus of the cheek

A 4-year-old girl was referred to the plastic surgery unit with metastatic malignant melanoma diagnosed in a cervical lymph node. She had previously undergone excision of a Spitz nevus of the cheek at age 18 months. The management of this patient is discussed along with a review of the literature relating to Spitz nevi and malignant melanoma in childhood.

Detection of melanoma seeding during surgical procedures--an RT-PCR based model

AIM

It has long been suggested that malignant cells may be shed into the blood stream during any given surgical procedure for cancer. A number of studies have now reported the detection of occult melanoma cells in peripheral blood using a reverse transcriptase polymerase chain reaction (RT-PCR) based assay. The principal aim of these studies has been to determine a prognostic value for the test and not to evaluate the influence of intervention upon results.

METHODS

In this pilot study we aimed to determine whether the assay could be used as a model to detect cells that are seeded during surgery. Peripheral blood samples were obtained pre- and post-operatively on twenty patients undergoing surgery for malignant melanoma - ten with primary disease and ten undergoing regional lymphadenectomy. A further ten patients undergoing surgery for non-melanoma conditions provided controls.

RESULTS

Using RT-PCR, it was possible to identify tyrosinase transcripts in the peripheral blood of one of ten patients undergoing excision of local disease and four of ten undergoing surgery for regional metastatic disease.

CONCLUSION

It was concluded that this technique does enable detection of a greater percentage of RT-PCR findings post-operatively. This in turn may provide a means for optimizing or comparing surgical techniques and provides a potential guide in the use of adjuvant therapies.

Follow-up requirements for thick cutaneous melanoma

The primary aim of postoperative melanoma follow-up is the early detection and treatment of treatable recurrences which gives a survival advantage to these patients. The need for follow-up is universally accepted. However, there is ongoing controversy about the duration of follow-up and frequency of reviews. We present a retrospective review of 244 patients with localised thick (> or = 4.0 mm) cutaneous melanoma, who had completed a 10-year follow-up or had died form their melanoma within 10 years. For these criteria, this is the largest series of this type which has been reported to date. The incidence of treatable recurrences peaked in the first postoperative year at 40% and then rapidly decreased, levelling off after year 5 at 2.5% per annum. We believe that this high incidence of treatable recurrences reinforces the need for 10-year follow-up of these patients. We also recommend that the annual frequency of follow-up reviews in each year be based on that year's risk for getting a treatable recurrence. Following this principle, we provide an example of such a follow-up programme.

Perceptions of baby talk, frequency of receiving baby talk, and self-esteem among community and nursing home residents

Community-living seniors (n = 113) and nursing home residents (n = 43) provided their impressions of baby-talk and neutral-talk scenarios and completed measures of functional health, need for succorance, and self-esteem. Two orthogonal dimensions were found in perceptions of baby talk: Warmth and Superiority. The personality trait of need for succorance was consistently associated with perceptions of warmth in baby talk, whereas functional health, age, and institutionalization were associated with perceptions of superiority. Significant interactions were found between perceptions of baby talk and frequency of receiving baby talk in the prediction of self-esteem, providing suggestive evidence for previously expressed concerns about potentially harmful effects of receiving baby talk on self-esteem among seniors who have negative perceptions of baby talk. However, older persons with positive perceptions of baby talk reported higher self-esteem when they frequently received baby talk, in accordance with person-environment theory. The self-esteem interaction for men occurred on the Superiority dimension, whereas the interaction for women occurred on the Warmth dimension.

Perceptions of baby talk, frequency of receiving baby talk, and self-esteem among community and nursing home residents

Community-living seniors (n = 113) and nursing home residents (n = 43) provided their impressions of baby-talk and neutral-talk scenarios and completed measures of functional health, need for succorance, and self-esteem. Two orthogonal dimensions were found in perceptions of baby talk: Warmth and Superiority. The personality trait of need for succorance was consistently associated with perceptions of warmth in baby talk, whereas functional health, age, and institutionalization were associated with perceptions of superiority. Significant interactions were found between perceptions of baby talk and frequency of receiving baby talk in the prediction of self-esteem, providing suggestive evidence for previously expressed concerns about potentially harmful effects of receiving baby talk on self-esteem among seniors who have negative perceptions of baby talk. However, older persons with positive perceptions of baby talk reported higher self-esteem when they frequently received baby talk, in accordance with person-environment theory. The self-esteem interaction for men occurred on the Superiority dimension, whereas the interaction for women occurred on the Warmth dimension.

Allelotypes of primary cutaneous melanoma and benign melanocytic nevi

A multistep genetic model of tumorigenesis, based on genetic alterations in benign and primary malignant lesions, has been proposed for neoplasms such as colonic carcinoma. However, evidence for a similar genetic progression in melanoma has relied heavily on findings in cultured lesions or metastases. We have investigated every autosomal arm for loss of heterozygosity in 41 primary cutaneous melanomas and 32 benign melanocytic nevi, and have investigated several chromosome arms that show loss in melanoma in 27 Spitz nevi (a nevus with histological similarities to melanoma). Loss of heterozygosity in primary melanoma was identified most frequently on chromosomes 9p (46%) at loci near the p16INK4 gene, 10q (31%), 6q (31%), and 18q (22%); loss of these chromosome arms were related to the progression of the melanoma. Only two benign melanocytic nevi (both of which showed atypical features on histology) demonstrated genetic alterations, including p9 loss in one case. In addition, two Spitz nevi contained interstitial deletions on chromosome 9p. Our findings show that loss of heterozygosity of 9p is not confined to melanoma, but that other uncultured melanocytic lesions can also display loss of this chromosome arm, and that other genetic changes (e.g., loss of 10q, 6q, and 18q) may be important in conveying the malignant phenotype to melanoma.

Rectal endosonography accurately predicts depth of penetration in rectal cancer

Sixty-three patients with primary rectal adenocarcinomas have been examined prior to surgery with rectal endosonography (ES). Maximum depths of tumour penetration measured endosonographically have been compared with subsequent maximum depths measured on the fixed resected specimen (n = 30) and the histological slide (n = 61). In both cases there was a good degree of correlation between the ultrasonic estimations of depth and the histological ones (r = 0.36, p = 0.05, CI = 95% and r = 0.46, p less than 0.001, CI = 99% respectively). In 12 cases ultrasonic depths of tumour were also measured in the laboratory and then compared with depths from fixed (n = 12) and fresh specimens (n = 5) with a good correlation (r = 0.75, p = 0.005, CI = 99% and r = 0.79, p = 0.036, CI = 95% respectively). Rectal endosonographic estimation of rectal cancer depth of invasion is an accurate measure of tumour penetration and may help distinguish between fixation due to inflammatory tissue and tumour fixity.

The detection and evaluation of locally recurrent rectal cancer with rectal endosonography

Eighty-five patients treated surgically for rectal cancer have been followed up by conventional clinical examination, sigmoidoscopy, and endosonography. Local recurrence was diagnosed in 22 patients. Nineteen of these had either sigmoidoscopic or digital evidence of recurrence and three were diagnosed solely by endosonography. In all cases endosonography gave additional information on which to base management decisions. Routine use of endosonography should allow the detection of early recurrence in a larger number of patients.

Preoperative assessment of mesorectal lymph node involvement in rectal cancer

One hundred patients with rectal adenocarcinoma were examined preoperatively with rectal endosonography (ES) and 50 were also examined with computed tomography (CT). ES predicted mesorectal lymph node involvement with an accuracy of 83 per cent, sensitivity of 88 per cent, specificity of 79 per cent, positive predictive value of 78 per cent and negative predictive value of 89 per cent. CT in comparison had an accuracy of 57 per cent, sensitivity of 25 per cent, specificity of 91 per cent, positive predictive value of 75 per cent and negative predictive value of 53 per cent. No particular histological architectural feature could be identified as responsible for false positive diagnosis though nodal size was significantly larger in the true positive and false positive group when compared with the true negatives (P less than 0.001 and P less than 0.01 respectively).