Distance-dependent accuracy in Le Fort I maxillary repositioning procedures

It has been hypothesised that, in maxillary repositioning procedures, longer distances correlate with less accurate transfers and particularly the repositioning forces of facial skin and muscles that increase exponentially. However, this has not to our knowledge been confirmed. The purpose of this study was to search for differences in the accuracy of transfer from maxillary repositioning procedures parallel to the three orthogonal planes and with respect to three different anatomical landmarks of the first molar left and right (M1L and M1R) and the first incisor (I). Cone-beam computed tomography (CT) datasets taken before and after operation for 92 patients who had Le Fort I maxillary repositioning procedures were aligned to measure the changes in the maxillary position in the axial, sagittal, and transverse directions. Differences between planned distances and those achieved were calculated and analysed with Pearsons correlation coefficient. The strongest significant correlations between the extent of planned repositioning distances and achieved differences (error) were detected in the sagittal plane for the anatomical landmarks of the right (M1R) and left first molar (M1L). Correlations became weaker if a limited planned distance ranging from 0-4mm was compared with a complete observed range that reached up to 12mm. Our results show for the first time to our knowledge that the accuracy of transfer of wafer-based maxillary positioning procedures depends on the distance being moved. Longer distances correlate with less accuracy, particularly in the sagittal plane and in the first molar region.

Striated Nephrogram as an Incidental Finding in MRI Examination of Children

PURPOSE

A highly striated contrast pattern of the kidneys occasionally appears in abdominal MRI examinations of children following the administration of gadolinium. As this phenomenon is well known but has not yet been explicitly described in literature, we investigated how frequently and in which clinical context this occurred.

MATERIAL AND METHODS

855 abdominal MRI examinations with contrast media of 362 children between 2006 and 2014 were analysed retrospectively.

RESULTS

A striated renal parenchyma was found in a total of nine children and eleven examinations (1.3 % of examinations) and did only occur at a field strength of 3 Tesla. Of these children, seven had previously had tumors and chemotherapy. In two children there was no evidence of a previously serious condition with medications or a kidney disease. All of them had a normal renal function.

CONCLUSION

A noticeably striated nephrogram in the later phase of an MRI examination following administration of gadolinium may appear as an incidental finding in examinations at 3 Tesla without pathological relevance.

KEY POINTS

• striated nephrograms may appear at a field strength of 3 Tesla. • incidental finding without pathological relevance.

Significance of MR angiography in the diagnosis of aberrant renal arteries as the cause of ureteropelvic junction obstruction in children

PURPOSE

To determine the importance of MRI with contrast-enhanced MRA for the detection or exclusion of aberrant or obstructing renal arteries in ureteropelvic junction obstruction in children.

MATERIALS AND METHODS

Key word-based search in RIS database (ureteropelvic junction obstruction/ MRI) and retrospective comparison of arterial findings from preoperative contrast -enhanced MRA and intra-operative inspection. From 2007 to 2013, 19 children with ureteropelvic junction obstruction underwent contrast-enhanced MRA. Based on the results of the MRI scan and MAG3 scintigraphy, the children were referred to surgery (Anderson-Hynes-pyeloplasty).

RESULTS

An aberrant renal artery was diagnosed with MRI in 14 of 19 children, and intra-operative inspection confirmed 13 of those 14. In the remaining 5 children, no aberrant vessel could be observed in MRI and this was confirmed intra-operatively in 3 of the 5 cases, while in the remaining 2, an aberrant vessel was found. Of the 14 children with aberrant vessels, 12 underwent surgery due to assumed ureteral obstruction, which was confirmed by surgery in 11 cases. In one case, an aberrant artery was found intra-operatively, but obstruction could not be confirmed. In one of the 14 children, the vessel was found in MRI, but its obstructing character was negated via MRA, which was confirmed intra-operatively. In the diagnosis of aberrant and obstructing renal arteries, contrast-enhanced MRA presents 85% sensitivity and 80% specificity, with a positive predictive value of 0.8.

CONCLUSION

MRI with contrast-enhanced MRA is suitable to detect aberrant and obstructing renal arteries. An obstructive effect of the aberrant vessel is to be assumed if the vessel has a close relationship to the ureteropelvic junction and if it is linearly stretched.

KEY POINTS

• MRI with contrast-enhanced MRA is a sure method for the detection of aberrant renal arteries in children with ureteropelvic junction obstruction. • The obstructive effect of the aberrant vessel can be derived from the close proximity of the vessel to the ureteropelvic junction and from the streched course of the vessel.

Accuracy of peri-implant bone evaluation using cone beam CT, digital intra-oral radiographs and histology

OBJECTIVES

The present study assesses the accuracy of three-dimensional (3D) cone beam CT (CBCT) and intra-oral radiography (CR) in visualizing peri-implant bone compared with histology.

METHODS

26 titanium dental implants were placed in dog jaws with chronic type vestibular defects. After a healing period of 2 and 8 weeks (n = 12 dogs) the animals were sacrificed. CBCT scans and CR of the specimen were recorded. Dissected blocks were prepared, and histomorphometric analysis was performed. Both modalities were measured twice by two observers and compared with histomorphometry regarding bone levels and thickness around implants as well as length and diameter of implants.

RESULTS

Measurements of CBCT correlated well with histomorphometry of the vestibular bone level, oral bone thickness and implant length (all p-values <0.05). Compared with histomorphometry, the mean differences between CBCT and histomorphometry were between 0.06 and 2.61 mm. Mesial bone level (MBL) and distal bone level (DBL) were underestimated by both CR and CBCT. CR and histology measurements were only significantly correlated for implant length measurements. All intraclass correlations were highly significant.

CONCLUSIONS

3D CBCT provides usable information about bone in all dimensions around implants with varying accuracy. CR and CBCT perform similar in assessing MBL and DBL, but, within its limits, the CBCT can assess oral and buccal bone. Metallic artefacts limit the visualization quality of bone around implants and further research could elucidate the value of post-processing algorithms. When information about osseous perforation of implants is needed, CBCT may still provide clinically valuable information.

Diagnostic accuracy of CBCT for periodontal lesions

OBJECTIVES

The present study compares the diagnostic value of periodontal bone defect images using conventional two-dimensional single-tooth radiographs and three-dimensional cone beam computed tomography (CBCT) images.

MATERIALS AND METHODS

Classified periodontal bone defects were prepared on pig mandibles and presented radiographically. Fifteen dentists were instructed to make a diagnosis based on these x-rays, regarding the type and the extent of the bone defects. Subsequently, the results were evaluated and compared to the morphology of the surgically prepared defects as the gold standard.

RESULTS

On average, the diagnosis of infrabony defects were 21 %, dehiscence 25 %, and fenestration 33 % more accurate using the three-dimensional projection than with the single-tooth radiograph. Furthermore, the CBCT allows grade II furcation to be captured more accurately.

CONCLUSIONS

The results of this study indicate that a considerably more precise analysis of periodontal defects is possible due to the third dimension. Particularly, in the oro-vestibular orientation, defects could be detected significantly more accurate.

CLINICAL RELEVANCE

CBCT images offer an advantageous alternative to the conventional single-tooth radiograph while taking the higher exposure of radiation into account.

Registration accuracy of three-dimensional surface and cone beam computed tomography data for virtual implant planning

OBJECTIVE

Virtual wax-ups based on three-dimensional (3D) surface models can be matched (i.e. registered) to cone beam computed tomography (CBCT) data of the same patient for dental implant planning. Thereby, implant planning software can visualize anatomical and prosthetic information simultaneously. The aim of this study is to assess the accuracy of a newly developed registration process.

MATERIAL AND METHODS

Data pairs of CBCT and 3D surface data of 16 patients for dental implant planning were registered and the discrepancy between the visualized 3D surface data and the corresponding CBCT data were measured on 64 teeth at seven points by two investigators in two iterations with a total of 1792 measurements.

RESULTS

All data pairs were matched successfully and mean distances between CBCT and 3D surface data were between 0.03(±0.33) and 0.14(±0.18) mm. At two of seven measuring points, statistically significant correlations were determined between the measured error and the presence and type of restorations. Registration errors in maxilla and mandible were not statistically significantly different.

CONCLUSION

According to the results of this study, registration of 3D surface data and CBCT data works reliably and is sufficiently accurate for dental implant planning. Thereby, barium-sulfate scanning templates can be avoided and dental implant planning can be accomplished fully virtual.

CAD/CAM-produced surgical guides: Optimizing the treatment workflow

The increased availability of devices for 3D radiological diagnosis allows the more frequent use of CAD/CAM-produced surgical guides for implant placement. The conventional workflow requires a complex logistic chain which is time-consuming and costly. In a pilot study, the workflow of directly milled surgical guides was evaluated. These surgical guides were designed based on the fusion of an optical impression and the radiological data. The clinical use showed that the surgical guides could be accurately placed on the residual dentition without tipping movements. The conventional surgical guides were used as a control for the manual check of the deviation of the implant axis. The direct transfer of the digital planning data allows the fabrication of surgical guides in an external center without the need of physical transport, which reduces the logistic effort and expense of the central fabrication of surgical guides.

Digital 3-D implant planning: Cerec meets Galileos

Prosthetically based implant planning is necessary so that implants are set expediently and correctly during surgery. A clinical case is presented to describe how this can be performed today purely digitally. Prosthetic planning was undertaken with the Cerec CAD/CAM system. The data record created was transferred and superimposed on a CBCT 3-D radiograph. The position of the implant was planned taking the prosthetic planning into account.

Metals in the Human Environment Strategic Network (MITHE-SN): the interface of risk assessment, public policy, and advocacy

A 5-year strategic research network with a diverse base of industry, government, and academic partners was approved for support by National Sciences and Engineering Research Council of Canada (NSERC) on January 3, 2005. This Metals in the Human Environment Strategic Network (MITHE-SN) builds on, and further extends, science knowledge developed by the NSERC-sponsored Metals in the Environment Research Network (MITE-RN, 1999-2004). In addition to the initial award, the MITHE-SN received an additional 2-year grant specifically targeted to (1) enhance training opportunities for internships with international organizations, (2) increase international networking and linkages, and (3) optimize knowledge dissemination and technology transfer. The research program is comprised of three themes and represents a cascade of effects along food webs, from the lowest trophic levels to the highest consumers. Each of the themes addresses issues related to distinguishing the magnitudes and roles of natural background and anthropogenic metal inputs in biotic exposure to metals; estimating the bioavailable fraction of metals in the exposure media, thus better quantifying the true exposure concentration; and determining the factors that influence bioavailability of metals in media, so that predictive models can be developed for use in the development of site-specific metals criteria.

Predicting plasma concentrations of bisphenol A in children younger than 2 years of age after typical feeding schedules, using a physiologically based toxicokinetic model

BACKGROUND

Concerns have recently been raised regarding the safety of potential human exposure to bisphenol A (BPA), an industrial chemical found in some polycarbonate plastics and epoxy resins. Of particular interest is the exposure of young children to BPA via food stored in BPA-containing packaging.

OBJECTIVES

In this study we assessed the age dependence of the toxicokinetics of BPA and its glucuronidated metabolite, BPA-Glu, using a coupled BPA-BPA-Glu physiologically based toxicokinetic (PBTK) model.

METHODS

Using information gathered from toxicokinetic studies in adults, we built a PBTK model. We then scaled the model to children < 2 years of age based on the age dependence of physiologic parameters relevant for absorption, distribution, metabolism, and excretion.

RESULTS

We estimated the average steady-state BPA plasma concentration in newborns to be 11 times greater than that in adults when given the same weight-normalized dose. Because of the rapid development of the glucuronidation process, this ratio dropped to 2 by 3 months of age. Simulation of typical feeding exposures, as estimated by regulatory authorities, showed a 5-fold greater steady-state BPA plasma concentration in 3- and 6-month-olds compared with adults, reflecting both a reduced capacity for BPA metabolism and a greater weight-normalized BPA exposure. Because of uncertainty in defining the hepatic BPA intrinsic clearance in adults, these values represent preliminary estimates.

CONCLUSIONS

Simulations of the differential BPA dosimetry between adults and young children point to the need for more sensitive analytical methods for BPA to define, with greater certainty, the adult hepatic BPA intrinsic clearance, as well as a need for external exposure data in young children.

Intraoperative navigation in the maxillofacial area based on 3D imaging obtained by a cone-beam device

The aim of this study was to evaluate intraoperative navigation in the maxillofacial area based on three-dimensional imaging obtained by a cone-beam device. Digital volume tomograms (DVT) were obtained by the prototype of GALILEOS (Sirona Dental Systems Inc., Bensheim, Germany), a newly developed, compact size, cone-beam machine with a scan volume of 15 cm x 15 cm x 15 cm. Intraoperative navigation was performed in 12 patients in three selected indications. Target detection error expressing the accuracy of DVT navigation and registration performance of specially developed methods for image-to-patient registration was estimated. Target detection error was maximally 2 mm and depended on the registration method chosen. The automatic detection rate of the fiducial markers ranged between 0.64 and 0.32. The preoperatively defined treatment plan was fully accomplished in 11 out of 12 cases. A favourable surgical outcome was achievable in all cases. Intraoperative complications were not observed. Intraoperative navigation based on DVT imaging can be considered as a valuable alternative to CT-based procedures. Special characteristics of the cone-beam technique, in terms of contrast resolution and the limited field-of-view size of the devices, restrict the indication spectrum and create a demand for modifications of the usual registration methods.

Addressing the linkage between exposure to pesticides and human health effects--research trends and priorities for research

In recent years, there has been escalating concern over the possible association between exposure to pesticides and adverse human health effects by a number of non-governmental organizations, professional and public interest groups. Recognizing the need to document the scientific basis of these concerns as a foundation for initiating a research theme devoted to linkages between exposures to pesticides and human health effects, the Canadian Institutes of Health Research (CIHR) requested a summary of recent research trends that address these linkages. Experts across Canada in the field of pesticide regulation and research were invited to participate in the review. The review summarizes the limitations of past and current studies related to pesticides and human health effects research and makes suggestions for future research priorities and proposed study designs that will improve the assessment of pesticide exposure, the associated health risks, and improved methodology for regulatory decision making.

Indirect sources of herbicide exposure for families on Ontario farms

Although direct contact during mixing/loading, application or repair and clean-up is the major pathway by which individuals living on farms are exposed to herbicides, indirect sources such as contact with contaminated surfaces may also contribute. As part of a biomonitoring study to measure the nature and extent of exposure of farm families to herbicides, we attempted to identify potential indirect sources of exposure in a subset of 32 Ontario farms. Herbicide residues in drinking water samples as well as surface swipes of common surfaces within the home were measured and compared with urinary concentrations of the applicator, spouse and child. Residues of 2,4-dichlorophenoxyacetic acid (2,4-D) were measured on all surfaces that were tested, with the highest levels found on the washing machine knob and wash-up faucet within the home. Drinking water was not a significant source of exposure to 2,4-D for farm families. Urine samples of family members were weakly correlated with residues of 2,4-D measured on the exterior door knob. The applicators in our study, the most highly exposed subpopulation in our study group, had exposures that were less than one-third of the exposure on a daily, lifetime basis deemed to be safe by regulatory agencies in Canada and the United States. As 2,4-D residues were detected on surfaces in farm homes where 2,4-D was not reportedly used at that time, this suggests that 2,4-D applied during a previous season (or on a neighbouring farm) may be tracked into the home and persist on hard surfaces and be a chronic, albeit low level, source of exposure for family members. Pesticide applicators and their families should be counselled on hygienic practices (e.g. removing footware and washing soiled hands prior to entering the home) to reduce indirect sources of exposure. Journal of Exposure Science and Environmental Epidemiology (2006) 16, 98-104. doi:10.1038/sj.jea.7500441; published online 13 July 2005.

Phenoxyacetic acid herbicide exposure for women on Ontario farms

Women living and working on farms would be expected to have higher exposure to pesticides than the general nonoccupationally exposed population. Urinary concentrations of the herbicides 2,4-dichlorophenoxyacetic acid (2,4-D) and (4-chloro-2-methyl) phenoxyacetic acid (MCPA) were measured in 125 women living on farms in Ontario where these herbicides had recently been used for the first time that growing season. The women collected a spot urine void prior to the start of herbicide handling by spouses, followed by 2 consecutive 24-h urine samples. The pesticide applicator provided questionnaire data on pesticides that were used on the farm. Approximately 80% of the women had no detectable level of either herbicide in their urine. Geometric mean urinary concentrations of 2,4-D and MCPA in the d-2 samples were 0.7 microg/L. The responses to the questions on herbicide use on the farm were compared with urinary levels of the herbicide and the sensitivity for MCPA was determined to be 95-100%; however, the false positive rate for exposure was 70%. For 2,4-D, the sensitivity and specificity were approximately 70%, with a false positive rate of 30%. A simple question on whether the herbicide was used recently can accurately identify people who are likely not exposed; however, further research is required to be able to more validly predict those individuals who are exposed. Based on our study, it was concluded that exposure estimates based on questionnaire data alone may be fraught with uncertainties, which may differ depending on the particular pesticide of interest.

Biomonitoring of herbicides in Ontario farm applicators

OBJECTIVES

Biomonitoring of pesticide residues in urine offers the advantages of integrating exposure due to all routes of entry and accounting for individual differences in several factors such as pharmacokinetics. The study was designed to measure the body burden of 2,4-dichlorophenoxyacetic acid (2,4-D) and 4-chloro-2-methylphenoxyacetic acid (MCPA) in farm applicators and to measure compliance with label recommendations regarding the use of personal protective gear and the impact of such use on exposure.

METHODS

Farmers (N=126) from Ontario, Canada, collected a preexposure spot sample of urine and then two consecutive 24-hour urine samples immediately following the farmers' first use of these herbicides during 1996. Details on the pesticides used and handling practices were collected by questionnaire.

RESULTS

For the farmers who reported using 2,4-D, the mean urinary concentration was 27.6 microg/l in the day-1 sample and 40.8 microg/l in the day-2 sample. The comparable figures for MCPA were 44.4 microg/l and 58.0 microg/l, respectively. Adherence to all of the recommended personal protective gear was rare (3%). Wearing goggles or a face shield during mixing and loading was associated with the lowest exposures.

CONCLUSIONS

The urinary concentrations of 2,4-D and MCPA of these farm applicators were of the same order of magnitude as those published in the past decade, but lower than earlier studies, indicating that improvements in education, equipment, and labeling have likely had an impact on the degree of exposure in occupational settings.

A high-wavenumber boundary-element method for an acoustic scattering problem

In this paper we show stability and convergence for a novel Galerkin boundary-element-method approach to the impedance boundary-value problem for the Helmholtz equation in a half-plane with piecewise constant boundary data. This problem models, for example, outdoor sound propagation over inhomogeneous flat terrain. To achieve a good approximation with a relatively low number of degrees of freedom we employ a graded mesh with smaller elements adjacent to discontinuities in impedance, and a special set of basis functions for the Galerkin method so that, on each element, the approximation space consists of polynomials (of degree nu) multiplied by traces of plane waves on the boundary. In the case where the impedance is constant outside an interval [a,b], which only requires the discretization of [a,b], we show theoretically and experimentally that the L(2) error in computing the acoustic field on [a,b] is O(log(nu+3/2)|k(b-a)|M(-(nu+1)), where M is the number of degrees of freedom and k is the wavenumber. This indicates that the proposed method is especially commendable for large intervals or a high wavenumber. In a final section we sketch how the same methodology extends to more general scattering problems.

Farm Childrenʼs Exposure to Herbicides

BACKGROUND

Pesticide exposure has been associated with various childhood cancers. However, most studies rely on questionnaires, with few using biologic measures of dose. This study was designed to measure herbicide exposure directly in children of farm applicators, and to compare these results with exposure imputed from questionnaire information.

METHODS

Two consecutive 24-hour urine samples were collected from 92 children of Ontario farm applicators who used the herbicides 2,4-D (2,4-dichlorophenoxyacetic acid) or MCPA (4-chloro-2-methylphenoxyacetic acid) for the first time during 1996. The farm applicator completed questionnaires describing his pesticide-handling practices as well as the child's location during the various stages of handling these pesticides.

RESULTS

Approximately 30% of the children on farms using these herbicides had detectable concentrations in their urine, with maximum values of 100 microg/L for 2,4-D and 45 microg/L for MCPA. Children with higher levels were more likely to be boys and to have parents who also had higher mean urinary concentrations. The sensitivity and specificity of a simple indicator of use were 47% and 72%, respectively, for 2,4-D, and 91% and 30%, respectively, for MCPA, using the biomonitoring data as the gold standard.

CONCLUSIONS

Information on living on a farm, or on living on a farm where a specific pesticide is used, is not enough to classify children's exposures. Given this potential for misclassification, we urge incorporation of biomonitoring studies in subsets of children at least to estimate the extent of misclassification.

Interactive 3D segmentation and inspection of volumetric medial datasets

We propose an interactive method providing 3D real-time visualization of segmentation results while tuning some of the algorithmic parameters. Visual inspection in volume reduces the time spent in tuning cumbersome parameters and may increase accuracy in medical applications. To allow fast interaction, volume rendering is achieved by using 3D texture mapping. The output of the segmentation stage is then dynamically updated in the graphic pipeline through a color lookup table related to the tuned parameters. This technique enables our approach with immediate rendering of the user interaction during the segmentation. Isosurface methods and connectivity filters have been implemented with this technique. CT and MR modalities have been tested for anatomical structures extraction. For application in craniofacial surgical planning, measurements present improvement in accuracy and efficiency for 7 pathological cases. However, manual refinement is still necessary in order to realize clinical applicable 3D models.

Genomic instability in human lymphoid cells exposed to 1 GeV/amu Fe ions

The goal of this study was to assess whether charged particle radiations of importance to spaceflight elicit genomic instability in human TK6 lymphoblasts. The incidence of genomic instability in TK6 cells was assessed ~21 days after exposure to 2, 4, or 6 Fe ions (1 GeV/amu, LET= 146 keV/micrometers). Three indices of instability were used: intraclonal karyotypic heterogeneity, mutation rate analysis at the thymidine kinase (TK1) locus, and re-cloning efficiency. Fifteen of sixty clones demonstrated karyotypic heterogeneity. Five clones had multiple indicators of karyotypic change. One clone was markedly hypomutable and polyploid. Six clones were hypomutable, while 21 clones were mutators. Of these, seven were karyotypically unstable. Six clones had low re-cloning efficiencies, one of which was a mutator. All had normal karyotypes. In summary, many clones that survived exposure to a low fluence of Fe ions manifested one or more forms of genomic instability that may hasten the development of neoplasia through deletion or by recombination.

Sources, pathways, and relative risks of contaminants in surface water and groundwater: a perspective prepared for the Walkerton inquiry

On a global scale, pathogenic contamination of drinking water poses the most significant health risk to humans, and there have been countless numbers of disease outbreaks and poisonings throughout history resulting from exposure to untreated or poorly treated drinking water. However, significant risks to human health may also result from exposure to nonpathogenic, toxic contaminants that are often globally ubiquitous in waters from which drinking water is derived. With this latter point in mind, the objective of this commission paper is to discuss the primary sources of toxic contaminants in surface waters and groundwater, the pathways through which they move in aquatic environments, factors that affect their concentration and structure along the many transport flow paths, and the relative risks that these contaminants pose to human and environmental health. In assessing the relative risk of toxic contaminants in drinking water to humans, we have organized our discussion to follow the classical risk assessment paradigm, with emphasis placed on risk characterization. In doing so, we have focused predominantly on toxic contaminants that have had a demonstrated or potential effect on human health via exposure through drinking water. In the risk assessment process, understanding the sources and pathways for contaminants in the environment is a crucial step in addressing (and reducing) uncertainty associated with estimating the likelihood of exposure to contaminants in drinking water. More importantly, understanding the sources and pathways of contaminants strengthens our ability to quantify effects through accurate measurement and testing, or to predict the likelihood of effects based on empirical models. Understanding the sources, fate, and concentrations of chemicals in water, in conjunction with assessment of effects, not only forms the basis of risk characterization, but also provides critical information required to render decisions regarding regulatory initiatives, remediation, monitoring, and management. Our discussion is divided into two primary themes. First we discuss the major sources of contaminants from anthropogenic activities to aquatic surface and groundwater and the pathways along which these contaminants move to become incorporated into drinking water supplies. Second, we assess the health significance of the contaminants reported and identify uncertainties associated with exposures and potential effects. Loading of contaminants to surface waters, groundwater, sediments, and drinking water occurs via two primary routes: (1) point-source pollution and (2) non-point-source pollution. Point-source pollution originates from discrete sources whose inputs into aquatic systems can often be defined in a spatially explicit manner. Examples of point-source pollution include industrial effluents (pulp and paper mills, steel plants, food processing plants), municipal sewage treatment plants and combined sewage-storm-water overflows, resource extraction (mining), and land disposal sites (landfill sites, industrial impoundments). Non-point-source pollution, in contrast, originates from poorly defined, diffuse sources that typically occur over broad geographical scales. Examples of non-point-source pollution include agricultural runoff (pesticides, pathogens, and fertilizers), storm-water and urban runoff, and atmospheric deposition (wet and dry deposition of persistent organic pollutants such as polychlorinated biphenyls [PCBs] and mercury). Within each source, we identify the most important contaminants that have either been demonstrated to pose significant risks to human health and/or aquatic ecosystem integrity, or which are suspected of posing such risks. Examples include nutrients, metals, pesticides, persistent organic pollutants (POPs), chlorination by-products, and pharmaceuticals. Due to the significant number of toxic contaminants in the environment, we have necessarily restricted our discussion to those chemicals that pose risks to human health via exposure through drinking water. A comprehensive and judicious consideration of the full range of contaminants that occur in surface waters, sediments, and drinking water would be a large undertaking and clearly beyond the scope of this article. However, where available, we have provided references to relevant literature to assist the reader in undertaking a detailed investigation of their own. The information collected on specific chemicals within major contaminant classes was used to determine their relative risk using the hazard quotient (HQ) approach. Hazard quotients are the most widely used method of assessing risk in which the exposure concentration of a stressor, either measured or estimated, is compared to an effect concentration (e.g., no-observed-effect concentration or NOEC). A key goal of this assessment was to develop a perspective on the relative risks associated with toxic contaminants that occur in drinking water. Data used in this assessment were collected from literature sources and from the Drinking Water Surveillance Program (DWSP) of Ontario. For many common contaminants, there was insufficient environmental exposure (concentration) information in Ontario drinking water and groundwater. Hence, our assessment was limited to specific compounds within major contaminant classes including metals, disinfection by-products, pesticides, and nitrates. For each contaminant, the HQ was estimated by expressing the maximum concentration recorded in drinking water as a function of the water quality guideline for that compound. There are limitations to using the hazard quotient approach of risk characterization. For example, HQs frequently make use of worst-case data and are thus designed to be protective of almost all possible situations that may occur. However, reduction of the probability of a type II error (false negative) through the use of very conservative application factors and assumptions can lead to the implementation of expensive measures of mitigation for stressors that may pose little threat to humans or the environment. It is important to realize that our goal was not to conduct a comprehensive, in-depth assessment of risk for each chemical; more comprehensive assessments of managing risks associated with drinking water are addressed in a separate issue paper by Krewski et al. (2001a). Rather, our goal was to provide the reader with an indication of the relative risk of major contaminant classes as a basis for understanding the risks associated with the myriad forms of toxic pollutants in aquatic systems and drinking water. For most compounds, the estimated HQs were < 1. This indicates that there is little risk associated with exposure from drinking water to the compounds tested. There were some exceptions. For example, nitrates were found to commonly yield HQ values well above 1 in- many rural areas. Further, lead, total trihalomethanes, and trichloroacetic acid yielded HQs > 1 in some treated distribution waters (water distributed to households). These latter compounds were further assessed using a probabilistic approach; these assessments indicated that the maximum allowable concentrations (MAC) or interim MACs for the respective compounds were exceeded <5% of the time. In other words, the probability of finding these compounds in drinking water at levels that pose risk to humans through ingestion of drinking water is low. Our review has been carried out in accordance with the conventional principles of risk assessment. Application of the risk assessment paradigm requires rigorous data on both exposure and toxicity in order to adequately characterize potential risks of contaminants to human health and ecological integrity. Weakness rendered by poor data, or lack of data, in either the exposure or effects stages of the risk assessment process significantly reduces the confidence that can be placed in the overall risk assessment. (ABSTRACT TRUNCATED)

[Possibilities in the preservation and restoration of anal continence]

The preservation of anal continence and the improvement of the patients' quality of life in general are primary objectives of colorectal surgery. Earlier the loss of the entire rectum, colon required a definitive stoma. This review describes surgical procedures designed to preserve anal continence. This paper also describes operative techniques designed to improve impaired sphincter function. Total extirpation of the mesorectum reduces local recurrence of rectal tumours. At the same time, this operation requires formation of the anastomosis low, at the level of the levator muscle. Low colorectal or coloanal anastomoses are associated with higher incidence of suture leakage and poor functional outcome. The distance between anastomosis and anal verge was less than 7 cm in 249 sphincter-sparing rectal resections performed during the examined 6-year period in our institute. Different techniques to perform anastomoses were applied, the prevalence of suture leakage and the functional results are analysed. Restorative proctocolectomy has dramatically improved the treatment of familial polyposis and ulcerative colitis with rectal involvement. Although proctocolectomy is necessary to cure the disease, acceptable faecal continence can be achieved by creating ileoanal anastomosis with ileal reservoir. We discuss our results after 43 operations. Weakness of the sphincter apparatus is the most common cause of continence problems. Occasionally, the sphincter is no longer suitable for reconstruction because of extensive damage or denervation. In such cases, the levator muscles or--if neither these are of acceptable quality--the gluteus maximus muscle can be used to repair the external sphincter. Anterior levator plasty involves tightening the levator plate by suturing its arches together between the rectum and the vagina. This procedure enhances the resistance of the sphincter barrier primarily by increasing functional sphincter length. The functional outcome of this procedure was acceptable in two-thirds of the 52 operations. Post anal repair was performed only in 3 patients. This method comprises reinforcing the levator plate through an access between the external and the internal sphincters. When the levator plate is unsuitable, bilateral gluteus plasty can be performed to increase the strength of sphincter muscles. As the gluteus is a striated muscle it can improve only the of the external sphincter function. Therefore this procedure can restore acceptable continence to hard stool only. This is demonstrated by our clinical experience obtained in 10 patients.

[Treatment of anal fistulas]

The authors describe the traditional operative technique for correction of anal fistulae and analyse the outcome of surgical treatment. During a 5-years period between 1994 and 1998, 286 patients underwent surgery for anal fistula in the department--more than one--third of this population presented with recurrent disease. During the operation, the extrasphincteric segment of the anal fistula is excised and the margin of the sinus is marsupialized. Introducing a rubber band through the sinus tract eliminates lesions that penetrate the sphincter. As the tied band shears through the encircled sphincter muscle, the rate of transsection is controlled individually, by adjusting the tightness of the rubber band as necessary. The inner opening of the fistula is often difficult to identify and consequently, excision may be incomplete. This is a serious pitfall that commonly leads to recurrence. According to the authors' experience, flushing the fistula tract with hydrogen peroxide is the most effective methods for pinpointing the inner meatus. Using this technique, postoperative recurrence was detected in 30 patients (10%). Moderate impairment of anal continence had been observed in 57 patients (20%); however, this never progressed to permanent incontinence.

[Unusually large stromal tumor of the rectum causing obstruction]

A male, 74 years old patient with perineal, sacral pain and with defecation disorders attended the outpatient clinic of HIETE. The origine of the complains was a retrorectal, fist like, rectum narrowing tumor. The tumor was covered by normal mucosa from rectal side. Preoperative examinations--endoscopy, CT, MRI transrectal US--detected a tumor with size 7 x 6 x 5 cm, growing from the muscular wall of the rectum, with no connection with the surrounding tissues. Deep biopsy revealed malignant mesenchymal tumor. After preoperative irradiation abdominoperineal rectum amputation was performed. The recovery was uneventful. The definitive hystological examination proved a gastrointestinal stromal tumor (GIST). This type of tumor rarely occurs in the large intestine or in the rectum, that why the publishing can be interesting.

The impact of 4-chloro-m-cresol in heparin formulas on malignant hyperthermia: in vitro and in vivo

BACKGROUND

The preservative 4-chloro-m-cresol (4CmC) is a specific activator of sarcoplasmic Ca2- release and induces contractures in skeletal muscles of malignant hyperthermia susceptible (MHS) patients in vitro. Clinical formulas of heparin contain 4CmC. We studied whether (a) these heparin formulas induce contractures in isolated MHS and normal (MHN) human skeletal muscles and whether (b) significant serum levels of 4CmC are reached after heparinization in cardiopulmonary bypass patients.

METHODS

(a) In vitro, muscle bundles of 16 MHS and 22 MHN patients were exposed to the heparin formula Liquemin (containing 4CmC 0.08 mg/500 IU), to chlorocresol and to preservative-free heparin in the in vitro contracture test. (b) In vivo, serum 4CmC levels of 12 patients receiving Liquemin 500 IU/ kg before cardiopulmonary bypass were determined at 1, 5 and 60 min by high-pressure liquid chromatography.

RESULTS

(a) For Liquemin and 4CmC, significant contractures were measured with MHS muscles compared to MHN muscles at 61.4 microM 4CmC. (b) In control sera, the detection threshold for 4CmC was 4 microM. Concentrations of 4CmC in all patients' serum samples were below this threshold.

CONCLUSION

Heparin formulas, containing 4CmC, induce dose-dependent contractures in vitro in MHS human skeletal muscle at about 60 microM 4CmC. However, in vivo, 4CmC serum concentrations with therapeutic heparinization are less than 1/15 of the in vitro concentration. The lipophilicity of 4CmC with a high volume of distribution may account for these findings. MHS patients seem not to be at risk from clinical heparin formulas containing chlorocresol.

Modulation by GABA(B) and delta opioid receptors of neurally induced responses in isolated guinea-pig taenia coli and human colonic circular muscle

The GABA-ergic and opioid modulation of neurally induced muscle responses was studied in isolated guinea-pig taenia coli and human colonic circular muscle, using identical field stimulation parameters (rectangular pulses of 0.5 ms duration, 9 V x cm(-1) intensity, trains of 3 pulses at 0.5 Hz, repeated every 1/3/5 min). The stimulation-induced contractions were inhibited in both preparations by GABA and baclofen; the IC50 values in human colonic circular muscle were approximately 100 and 31.0 microM, respectively. In guinea-pig taenia coli, the inhibition by 10(-4) M GABA was dose-dependently reversed by 10(-4)-10(-3) M of GABA(B) receptor antagonist CGP 35348; antagonism by phaclofen was less effective in the same concentration range. In human colonic circular muscle, inhibition by 3 x 10(-5) M baclofen was fully reversed by 10(-3) M CGP 35348. With the exception of caecum, the delta 2 opioid receptor agonist deltorphin II was a potent inhibitor in human colonic circular muscle. 10(-8) M Deltorphin caused a 74.4 +/- 9.6% (n = 4) inhibition which was reversed by 10(-6) M of delta receptor selective peptide antagonist BOC-Tyr-Pro-Gly-Phe-Leu-Thr(OtBu). Deltorphin II was ineffective in guinea-pig taenia coli even at 10(-6) M; the same concentration caused an 84.3 +/- 7.9 (n = 4) inhibition in human preparations. It is concluded that: 1) GABA-ergic modulatory mechanisms are present both in human colonic circular muscle and guinea-pig taenia coli; 2) the GABA receptors involved are of type B; and 3) delta opioid receptor-mediated modulation functions only in human colonic circular muscle in regions other than the caecum.

Pesticide residues on fruits and vegetables from Ontario, Canada, 1991-1995

For the 5-year period 1991 to 1995, 1536 vegetable and 802 fruit samples were analyzed. The purpose of this study was to determine if pesticides were present on Ontario-produced fruits and vegetables, and if so, to determine if residues violated maximum residue limits (MRLs). Overall, 31.5% of the samples had no detectable pesticide residues, whereas 68.5% contained one or more residues. Most of the residues were present at very low concentrations; 48% of the detections were < 0.1 parts per million (ppm), and 86% were < 1 ppm. However, violations of MRL were observed in only 3.2% of the vegetables samples and 3.1% of the fruit samples. In addition, 4.8% of the samples contained a "technical" violation, that is, there was no specified MRL for the pesticide-commodity combination and the residues exceeded 0.1 ppm. Of the detectable residues, 63% were < 10% of the MRL, whereas 89% were < 50% of the MRL. More fruit samples (91.4%) had a detectable residue, compared with vegetable samples (56.6%). Fruit is often treated close to harvest or post harvest to ensure that wholesome produce reaches the consumer. Forty-six percent of the samples contained 2 or more residues, and 2% of all samples had more than 5 different pesticides detected; fruit samples tended to have more multiple residues. The most frequently found pesticides were captan, the dithiocarbamate fungicides, endosulfan, azinphos-methyl, phosmet, parathion, and iprodione. These pesticides were also used in the greatest quantity for crop production. Overall, the data agree fairly closely with those reported for the U.S. Department of Agriculture Pesticide Data Program because the 2 programs have similar analytical goals and objectives.

Tropisetron for treating established postoperative nausea and vomiting: a randomized, double-blind, placebo-controlled study

Tropisetron can prevent postoperative nausea and vomiting (PONV) at doses smaller than those used to control chemotherapy-induced nausea and vomiting. In this placebo-controlled study, the efficacy and tolerability of three different doses of tropisetron were compared for the treatment of established PONV after surgical procedures in general anesthesia. Of 1513 patients who satisfied inclusion criteria, 314 experiencing PONV during the first 2 h after recovery from anesthesia were treated with one of three different doses of tropisetron (0.5, 2, or 5 mg) or placebo, administered i.v. as a single dose. Patients were then observed during 24 h for efficacy and tolerability. All three doses of tropisetron were significantly better than placebo in controlling emetic episodes and in reducing the need for rescue treatment. There were no significant differences among the three doses. However, in the subgroup of patients who had previous PONV, and in those randomized for nausea alone, the 2-mg and 5-mg doses controlled emetic episodes better than the 0.5-mg dose. All studied doses of tropisetron were well tolerated and did not affect vital signs. We conclude that a single i.v. administration of tropiestron significantly reduces the recurrence of emetic episodes in patients with established PONV after elective surgery with general anesthesia. Its optimal dose seems to be 2 mg.

IMPLICATIONS

Three hundred-fourteen patients suffering from postoperative nausea and vomiting received different i.v. doses of a new antiemetic drug, tropisetron, to determine the lowest effective dose. We found that a single i.v. administration of tropisetron significantly reduced postoperative nausea and vomiting after elective surgery with general anesthesia.

Report of a panel on the relationship between public exposure to pesticides and cancer. Ad Hoc Panel on Pesticides and Cancer. National Cancer Institute of Canada

BACKGROUND

Pesticides, which by their nature are biologically active compounds, continue to raise public concern regarding their possible role as important etiologic agents in the development of human cancer.

METHODS

To examine this potential role, the National Cancer Institute of Canada convened an Ad Hoc Panel on Pesticides and Cancer to examine the possible contribution of pesticide exposure, particularly in the general population, to the development of human cancer.

RESULTS

The Panel focused primarily on exposure in the general population and reviewed a range of studies that addressed issues related to dietary exposure as well as incidental home and garden uses. In addition, the Panel examined the regulatory framework that exists to safeguard the public from potentially carcinogenic pesticides and also reviewed some potential benefits of pesticide use, including the availability of an abundant and low cost supply of fresh fruits and vegetables as an important strategy in the overall mitigation of cancer risk.

CONCLUSIONS

The Panel concluded that it was not aware of any definitive evidence to suggest that synthetic pesticides contribute significantly to overall cancer mortality. The Panel also concluded that it did not believe that any increased intake of pesticide residues associated with increased intake of fruits and vegetables poses any increased risk of cancer. The Panel further concluded, among other things, that tobacco use continues to be the most important preventable cause of cancer and premature mortality and thus is an appropriate focus for cancer control strategy.

Ecosystem health: challenges for ecotoxicology and environmental health

Restoring and safeguarding ecosystem health is a major challenge for the 21st century. Man-made substances, particularly persistent bioaccumulative substances have been among the forces that have contributed to weakening the health of ecosystems. However there are other stresses that interact synergistically with chemical stress. These forces, such physical restructuring (habitat change) tend to enhance the impacts of chemical stresses. A dose-response framework that encompasses an array of stresses with synergistic and occasional antagonistic effects is proposed for the assessment of ecosystem health. The flow of ecosystem services is curtailed in damaged systems. These services, such as provision of biodiversity, potable water, foodstuffs, sequestering of contaminants, will determine the suitability of ecosystems for humans. Linking ecotoxicology to ecosystem health provides an avenue for relating a variety of pressures on ecosystems to the conditions essential to sustain life that includes human communities.

Phase III randomized study to compare interferon alfa-2a in combination with fluorouracil versus fluorouracil alone in patients with advanced colorectal cancer

PURPOSE

To compare the efficacy and toxicity profiles of a combination of fluorouracil (5-FU) and recombinant human interferon alfa-2a ([IFN alpha 2a] Roferon-A; Hoffmann-LaRoche, Basel, Switzerland) versus 5-FU alone in the treatment of advanced colorectal cancer (ACC).

PATIENTS AND METHODS

A total of 245 previously untreated ACC patients were randomized to receive either IFN alpha 2a (9 million IU) subcutaneously (SC) three times weekly with 5-FU (750 mg/m2/d) by continuous intravenous (CIV) infusion on days 1 to 5 and then, after a 1-week hiatus, as a weekly IV bolus at the same dose (IFN/ 5-FU), or 5-FU alone at the same dose schedule (5-FU).

RESULTS

There were no significant differences between IFN/5-FU and 5-FU alone in the overall response rate (24% v 17%, P = .2), duration of response (median, 6.4 v 8.1 months), time to response (plateau at 3 months), time to progressive disease ([PD] median, 4.8 v 4.9 months), or survival duration (median, 13.9 v 13.2 months). Toxicity profiles were not statistically different except for constitutional symptoms, which were more frequent and more severe with IFN/5-FU. More patients interrupted treatment for adverse events (AEs) with IFN/ 5-FU (34%) than with 5-FU alone (21%) (P = .03). The number of deaths (mostly unrelated to drug treatment) during the study (8%) was similar with both regimens.

CONCLUSION

The combination IFN/5-FU produced a response rate, response duration, and survival duration similar to that of 5-FU alone. The addition of IFN to 5-FU in the doses and schedules used in this study did not provide any further benefit over 5-FU alone and cannot be recommended for patients with metastatic ACC. This study confirms the value of large prospective randomized clinical trials to determine the clinical value of regimens that emerge from smaller single-center phase II studies.