Urinary phthalate/DINCH metabolites associations with kisspeptin and reproductive hormones in teenagers: A cross-sectional study from the HBM4EU aligned studies

BACKGROUND

Exposure to phthalate/DINCH metabolites can induce human reproductive toxicity, however, their endocrine-disrupting mechanisms are not fully elucidated.

OBJECTIVE

To investigate the association between concentrations of phthalate/DINCH metabolites, serum kisspeptin, and reproductive hormones among European teenagers from three of the HBM4EU Aligned Studies.

METHODS

In 733 Belgian (FLEHS IV study), Slovak (PCB cohort follow-up), and Spanish (BEA study) teenagers, ten phthalate and two DINCH metabolites were measured in urine by high-performance liquid chromatography-tandem mass spectrometry. Serum kisspeptin (kiss54) protein, follicle-stimulating hormone (FSH), total testosterone (TT), estradiol (E2), and sex hormone-binding globulin (SHBG) levels were measured by immunosorbent assays. Free Androgen Index (FAI) was calculated as a proxy of free testosterone. Adjusted sex-stratified linear regression models for individual studies, mixed effect models (LME) accounting for random effects for pooled studies, and g-computation and Bayesian kernel machine regression (BKMR) models for the phthalate/DINCH mixture were performed.

RESULTS

The LME suggested that each IQR increase in ln-transformed levels of several phthalates was associated with lower kisspeptin [MnBP: %change (95%CI): -2.8 (-4.2;-0.4); MEHP: -1.4 (-3.4,0.2)] and higher FSH [∑DINP: 11.8 (-0.6;25.1)] levels in females from pooled studies. G-computation showed that the phthalates/DINCH mixture was associated with lower kisspeptin [-4.28 (-8.07;-0.34)] and higher FSH [22.13 (0.5;48.4)] also in females; BKMR showed similar although non-significant pattern. In males, higher phthalates metabolites [MEHP: -12.22 (-21.09;-1.18); oxo-MEHP: -12.73 (-22.34;-1.93)] were associated with lower TT and FAI, although higher DINCH [OH-MINCH: 16.31 (6.23;27.35), cx-MINCH: 16.80 (7.03;27.46), ∑DINCH: 17.37 (7.26;29.74)] were associated with higher TT levels. No mixture associations were found in males.

CONCLUSION

We observed sex-specific associations between urinary concentrations of phthalate/DINCH metabolites and the panel of selected effect biomarkers (kisspeptin and reproductive hormones). This suggests that exposure to phthalates would be associated with changes in kisspeptin levels, which would affect the HPG axis and thus influence reproductive health. However, further research is needed, particularly for phthalate replacements such as DINCH.

Consensus update on the therapeutic approach to patients with neurogenic detrusor overactivity

INTRODUCTION AND OBJECTIVES

A Consensus document on the management of patients with neurogenic detrusor overactivity (NDO) was published in 2018. The present document aims to update its recommendations regarding treatment considering the new evidence available, and to contribute to the standardization of the management of this disorder.

METHODS

The methodology used was based on a systematic review and the Nominal Group Technique. The clinical coordinator (CC) and the Consensus update group (CUG) defined the questions to be updated and carried out a systematic review to identify the new available evidence. After being evaluated by the expert panel, the relevant recommendations were updated and agreed in a consensus meeting.

RESULTS

A total of 3210 publications were identified and 26 publications that met the inclusion criteria were included. The CUG updated 18 recommendations on the therapeutic approach to NDO. Unanimous consensus was reached on all of them.

CONCLUSIONS

Previous recommendations need to be revised due to the availability of new drugs, the increasing evidence on the use of botulinum toxin or neuromodulation procedures, and new surgical options.

Prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players

Background

Identification of athletes with cardiac inflammation following COVID-19 can prevent exercise fatalities. The efficacy of pre and post COVID-19 infection electrocardiograms (ECGs) for detecting athletes with myopericarditis has never been reported. We aimed to assess the prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players.

Methods

We conducted a multicentre study over a 2-year period involving 5 centres and 34 clubs and compared pre COVID and post COVID ECG changes in 455 consecutive athletes. ECGs were reported in accordance with the International recommendations for ECG interpretation in athletes. The following patterns were considered abnormal if they were not detected on the pre COVID-19 infection ECG: (a) biphasic T-waves; (b) reduction in T-wave amplitude by 50% in contiguous leads; (c) ST-segment depression; (d) J-point and ST-segment elevation >0.2 mV in the precordial leads and >0.1 mV in the limb leads; (e) tall T-waves ≥1.0 mV (f) low QRS-amplitude in >3 limb leads and (g) complete right bundle branch block. Athletes exhibiting novel ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all 28 (6%) athletes, despite the absence of cardiac symptoms or ECG changes.

Results

Athletes were aged 22±5 years (89% male and 57% white). 65 (14%) athletes reported cardiac symptoms. The mean duration of illness was 3±4 days. The post COVID ECG was performed 14±16 days following a positive PCR. 440 (97%) athletes had an unchanged post COVID-19 ECG. Of these, 3 (0.6%) had cardiac symptoms and CMRs resulted in a diagnosis of pericarditis. 15 (3%) athletes demonstrated novel ECG changes following COVID-19 infection. Among athletes who demonstrated novel ECG changes, 10 (67%) reported cardiac symptoms. 13 (87%) athletes with novel ECG changes were diagnosed with inflammatory cardiac sequelae; pericarditis (n=6), healed myocarditis (n=3), definitive myocarditis (n=2), and possible/probable myocarditis (n=2). The overall prevalence of inflammatory cardiac sequelae based on novel ECG changes was 2.8%. None of the 28 (6%) athletes, who underwent a CMR, in the absence of cardiac symptoms or novel ECG changes revealed any abnormalities. Athletes revealing novel ECG changes, had a higher prevalence of cardiac symptoms (67% v 12% p<0.0001) and longer symptom duration (8±8 days v 2±4 days; p<0.0001) compared with athletes without novel ECG changes. Among athletes without cardiac symptoms, the additional yield of novel ECG changes to detect cardiac inflammation was 20% (n=3).

Conclusions

3% of elite soccer players demonstrated novel ECG changes post COVID-19 infection, of which almost 90% were diagnosed with cardiac inflammation during subsequent investigation. Most athletes with novel ECG changes exhibited cardiac symptoms. Novel ECGs changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms.

Funding Acknowledgement

Type of funding sources: None.

Synthetic cathinone (α-pyrrolidinohexanophenone): an emerging threat

Introduction

Alpha-pyrrolidinohexanophenone (α-PHP) is a synthetic cathinone with uneven distribution throughout the world. Its use is not uniformly regulated and its distribution is legal in some European countries. Easily accessible and available through different websites. Synthetic cathinones inhibit monoamine transporters which include dopamine, norepinephrine, and serotonin, resulting in increased neurotransmitter synaptic concentration. Ways of administration show wide range regarding latency period. Onset and appearance of symptoms as well as their duration and intensity may fluctuate. A decreasing order of latency (oral, inhaled, sublingual and intravenous) has been reported. α-PHP can result in the appearance of psychiatric symptoms, include among others, intoxication with sensory perception disturbances and α-PHP -induced psychotic episodes.

Objectives

The aim of our study was to assess the epidemiology, clinical and legal features regarding Alpha-pyrrolidinohexanophenone (α-PHP).

Methods

Review the current bibliography to upgrade the existing knowledge. -Present assorted cases with diverse clinical features. All cases include variability through psychopathological interview, symptoms assessment and treatment response according to rating scales (PANSS, YMRS). -Evaluate different treatment administration ways during acute phase and after hospital discharge.

Results

Differences were observed after hospitalization in the response using diverse rating scales. We used antipsychotics to treat intoxication with sensory perception disturbances and α-PHP -induced psychotic episodes. α-PHP had a negative impact on the quality of life of the patients.

Conclusions

α-PHP is a synthetic cathinone with potential risk to mental health and life of users. It is mandatory to implement common legislation all through the European Union to prevent its use and possible implications on population’s mental health.

Disclosure

No significant relationships.

How back pain intensity relates to clinical and psychosocial factors in patients with idiopathic scoliosis

OBJECTIVE

A pain intensity of 3 can reliably distinguish idiopathic scoliosis (IS) patients with acceptable pain or not. This research aims to analyze psychosocial, family and quality of life differences in patients according to their pain status.

MATERIAL AND METHODS

Patients with IS, without previous surgery, Cobb ≥ 30° and age (12-40) were included in the study. They completed the questionnaires Numerical Rate Scale (NRS), Tampa Scale for Kinesiophobia (TSK)-11, SRS22r, Hospital Anxiety-Depression Scale (HADS), COMI item 7 (work/school absenteeism) and family APGAR. Comorbidities and family health history were collected. Analysis of covariance was performed to compare means between the PAIN (NRS > 3), (NRS <  = 3) groups controlling for the effect of age and the magnitude of the curve.

RESULTS

In total, 272 patients were included. 37.1% belonged to the PAIN group (PG). The PG showed a significantly higher Cobb grade and age than the NO-PAIN group. After controlling for these variables, the PG had worse pain, mental health and SRS22-subtotal values. However, they did not differ in function or self-image. PG showed higher levels of kinesiophobia, anxiety, depression, absenteeism from work/school and impact on social/family environment. PG patients reported a higher prevalence of comorbidities and family history of nonspecific spinal pain.

CONCLUSIONS

Patients with IS and unacceptable pain constitute a group with a different incidence of psychological, social, family and comorbidities factors than those with acceptable pain. In contrast, the severity of IS was not substantially different between the groups. This profile is similar to that observed in patients with nonspecific spinal pain.

The 16th Hilbert problem for discontinuous piecewise isochronous centers of degree one or two separated by a straight line

In this paper, we deal with discontinuous piecewise differential systems formed by two differential systems separated by a straight line when these two differential systems are linear centers (which always are isochronous) or quadratic isochronous centers. It is known that there is a unique family of linear isochronous centers and four families of quadratic isochronous centers. Combining these five types of isochronous centers, we obtain 15 classes of discontinuous piecewise differential systems. We provide upper bounds for the maximum number of limit cycles that these fifteen classes of discontinuous piecewise differential systems can exhibit, so we have solved the 16th Hilbert problem for such differential systems. Moreover, in seven of the classes of these discontinuous piecewise differential systems, the obtained upper bound on the maximum number of limit cycles is reached.

Telemedicine and smart working: Spanish adaptation of the European Association of Urology recommendations

Introduction

Telemedicine provides remote clinical support through technology tools. It can facilitate medical care delivery while reducing unnecessary office visits. The COVID-19 outbreak has caused an abrupt change in our daily urological practice, where teleconsultations play a crucial role.

Objective

To provide practical recommendations for the effective use of technological tools in telemedicine.

Materials and methods

A literature search was conducted on Medline until April 2020. We selected the most relevant articles related to “telemedicine” and “smart working” that could provide valuable information.

Results

Telemedicine refers to the use of electronic information and telecommunication tools to provide remote clinical health care support. Smart working is a working approach that uses new or existing technologies to improve performance. Telemedicine is becoming a useful and fundamental tool during the COVID-19 pandemic and will be even more in the future. It is time for us to officially give telemedicine the place it deserves in clinical practice, and it is our responsibility to adapt and familiarize with all the tools and possible strategies for its optimal implementation. We must guarantee that the quality of care received by patients and perceived by them and their families is of the highest standard.

Conclusions

Telemedicine facilitates remote specialized urological clinical support and solves problems caused by limited patient mobility or transfer, reduces unnecessary visits to clinics and is useful to reduce the risk of COVID-19 viral transmission.

Telemedicine and smart working: Spanish adaptation of the European Association of Urology recommendations

Introducción

La telemedicina ofrece un soporte clínico remoto utilizando herramientas tecnológicas. Puede facilitar la atención médica al tiempo que reduce las visitas innecesarias a la consulta. La pandemia COVID-19 ha provocado un cambio brusco en nuestra práctica urológica diaria convirtiéndose en algo muy necesario el acto de la teleconsulta.

Objetivo

Proporcionar recomendaciones prácticas para el uso efectivo de herramientas tecnológicas en telemedicina.

Materiales y métodos

Se realizó una búsqueda en la literatura en la plataforma Medline hasta abril de 2020; seleccionamos los artículos más relevantes relacionados con «telemedicina» y «trabajo inteligente» que podrían proporcionar información útil.

Resultados

La telemedicina se refiere al uso de la información electrónica y a las herramientas de telecomunicaciones para proporcionar apoyo clínico remoto a la atención médica. El trabajo inteligente es un modelo de trabajo que utiliza tecnologías nuevas o existentes para mejorar el rendimiento. La telemedicina se está convirtiendo en una herramienta útil y necesaria durante la pandemia COVID-19 e incluso más allá de la misma. Es hora de que formalicemos y demos el lugar que se merece a la telemedicina en nuestra práctica clínica y es nuestra responsabilidad adaptar y conocer todas las herramientas y posibles estrategias para su implementación de una manera óptima, garantizar una atención de calidad a los pacientes y que dicha atención sea percibida por pacientes y familiares como de alto nivel.

Conclusiones

La telemedicina facilita la atención clínica urológica especializada a distancia y resuelve problemas como las limitaciones en la movilidad o el traslado de los pacientes, reduce las visitas innecesarias a las clínicas y es útil para reducir el riesgo de transmisión viral de la COVID-19.

Recombinant HIV-1 vaccine candidates based on replication-defective flavivirus vector

Multiple approaches utilizing viral and DNA vectors have shown promise in the development of an effective vaccine against HIV. In this study, an alternative replication-defective flavivirus vector, RepliVax (RV), was evaluated for the delivery of HIV-1 immunogens. Recombinant RV-HIV viruses were engineered to stably express clade C virus Gag and Env (gp120TM) proteins and propagated in Vero helper cells. RV-based vectors enabled efficient expression and correct maturation of Gag and gp120TM proteins, were apathogenic in a sensitive suckling mouse neurovirulence test, and were similar in immunogenicity to recombinant poxvirus NYVAC-HIV vectors in homologous or heterologous prime-boost combinations in mice. In a pilot NHP study, immunogenicity of RV-HIV viruses used as a prime or boost for DNA or NYVAC candidates was compared to a DNA prime/NYVAC boost benchmark scheme when administered together with adjuvanted gp120 protein. Similar neutralizing antibody titers, binding IgG titers measured against a broad panel of Env and Gag antigens, and ADCC responses were observed in the groups throughout the course of the study, and T cell responses were elicited. The entire data demonstrate that RV vectors have the potential as novel HIV-1 vaccine components for use in combination with other promising candidates to develop new effective vaccination strategies.

A direct transition to chaos in hysteretic systems with focus dynamics

A specific transition to chaos is detected in the study of periodic orbits of hysteretic systems with symmetry and dynamics of focus type. The corresponding bifurcation is rigorously justified by resorting to the analysis of transition maps, whose mathematical expressions are adequately derived. It is shown that, depending on a parameter related to the location of equilibria, such transition maps can pass from being a smooth function to a discontinuous, piecewise-smooth function. We deal with the intermediate situation for which the transition map is continuous but nonsmooth. Using a second parameter, and previous known results on chaotic maps, we show in a rigorous way the existence of a chaos boundary crisis bifurcation, where the transition from a configuration without periodic orbits to another with bounded chaotic solutions occurs.

Mercury levels in blood, urine and hair in a nation-wide sample of Spanish adults

Mercury (Hg) is among the top 10 environmental chemicals of major public health concern (WHO). The Minamata Convention on Mercury (United Nations Environment Program, 2017), commits signing countries to control anthropogenic mercury emissions and reduce human exposure. Human biomonitoring (HBM) programs, are the most straight-forward approaches to get information on the actual exposure levels in the population and assess over time. We report here the results of a HBM study in a nationwide cross-section of Spanish adults (18-65y) as baseline values obtained before the Minamata Convention entered into force. Subsequent follow-ups will show if the Convention has been successful. The study includes 1880 blood samples, 1704 urine samples and 577 hair samples from all Spanish regions collected and analysed under a strictly quality controlled and quality assured protocol. The EU-DEMOCOPHES project demonstrated that fish and seafood are the major sources of mercury exposure and that the Spanish as well as the Portuguese populations have higher levels than other European countries. The data from the present study confirms this pattern at national level and that inhabitants in coastal regions have higher values than from inland regions. The geometric mean (GM) for blood is 6.35 μg Hg/l, in urine is 1.11 μg Hg/l and for hair is 1.91 μg Hg/g. In an international comparison these values are not exceptional. Spanish concentrations fall into the group of Easter Mediterranean populations. Although information on gender, age, occupational sector, geographical area, sampling period and frequency of fish consumption is reported in the tables, the purpose of this paper has not been to analyse the determinants of exposure in detail but to provide baseline data for future assessments and for regional authorities.

Associations of multiple exposures to persistent toxic substances with the risk of hyperuricemia and subclinical uric acid levels in BIOAMBIENT.ES study

Hyperuricemia is becoming a serious public health issue, which is highly influenced by environmental factors, although there is still controversial information on the potential influence of the exposure to Persistent Toxic Substances (PTSs) in the general population. In this study we aimed to assess the association. PTS exposure with uric acid homeostasis in a sample of the Spanish population. Participants were recruited during 2009-2010 in all the main geographical areas of Spain. Exposure to 34 PTSs was estimated by chemical analyses of serum levels of 6 Polychlorinated Biphenyls (PCBs, n = 950), 13 Organochlorine Pesticides (OCPs, n = 453), 6 Perfluoroalkyl Substances (PFAs, n = 755), 7 Polybrominated Diphenyl Ethers (PBDEs, n = 365), urinary Cadmium (n = 926), and Lead in whole blood (n = 882). The two study outcomes were defined as the prevalence of hyperuricemia in the study population and uric acid levels, the latter only in individuals with no previous diagnosis of hyperuricemia. Statistical analyses were performed by means of binomial logistic regression and linear regression, and mixture effects were screened using Weighted Quantile Sum Regression (WQS). Serum concentrations of γ-HCH, o,p´-DDE, PCB-138, PCB-153, PFOA, and urinary Cadmium were associated with an increased risk of hyperuricemia, while PBDE-153 showed an inverse association with the effect. Furthermore, exposure to Cadmium, PCB-138, and to PCB-153 was positively associated with uric acid levels. Results were consistent after lipid adjustment or standardization. WQS analyses revealed a major contribution of PCB-153 within the PCB mixture on both the risk of hyperuricemia and uric acid levels. Sensitivity analyses were performed by adjusting for dietary habits, fasting glucose and estimated glomerular filtration rate. Overall, we found novel associations between human exposure to mixtures of PTSs and disturbances in uric acid homeostasis. However, we cannot completely rule out potential residual confounding effect or reversed-causality related to the cross-sectional design.

Differential contribution of animal and vegetable food items on persistent organic pollutant serum concentrations in Spanish adults. Data from BIOAMBIENT.ES project

Diet is considered the main source of Persistent Organic Pollutant (POP) exposure in the general population, although there are still several gaps of knowledge regarding the differential contribution of main food groups. The aim of this study was to identify dietary patterns that contribute to human exposure to organochlorine pesticides (OCPs), polychlorinated biphenyls (PCBs), and Perfluoroalkyl Substances (PFASs). Study population (n=1880, 18-65years old) was recruited during 2009-2010 in all the main geographical areas of Spain. For this work, exposure was estimated by chemical analyses of serum levels of 6 PCBs (n=1880), 13 OCPs (n=934), and 6 (PFASs) in a subsample of 755 (n=755). Dietary habits and covariates were gathered via self-administered questionnaires. Data analyses were performed by means of multivariable linear regression and weighted quantile sum regression. Both the consumption of animal-based and plant-based food were positively associated with the individual concentrations of p,p´-DDE, hexachlorobenzene, and PCB-congeners -138, -153, and-180. The contribution of animal-based products was 2.1-4.0× stronger except in p,p´-DDE, to which both patterns had similar contributions. In PFASs only animal food was positively associated with the exposure levels. The main animal-based contributors to PCB exposure were fish (49-64%) and eggs (19-36%), while OCP concentrations were mainly influenced by dairy products (32-48%) and fish (47-48%). PFOA and PFHxS were mainly explained by cold-meat (34-37%), fish (25-26%), and eggs (19-21%), while PFOS and PFDA were primarily influenced by fish consumption (44-77%). In the case of plant-based items, fruits (25-82%) and vegetables (18-63%) accounted for the majority of the variability of PCB and OCP concentrations. Our results highlight the relevance of dietary POP exposure as well as the need for the consideration of nutritional interventions in public health programs aiming to reduce POP exposure in the general population.

Environmental health surveillance in a future European health information system

BACKGROUND

To date Health information (HI) in the European Union does not comprise indicators or other information related to impacts of hazardous chemicals in consumer products, food, drinking water or air on the health status of the population. Therefore, we inventorised and evaluated the potential of environmental health surveillance and research data sources in the European population to provide HBM-based indicators of internal human exposure and health impact of relevant chemicals.

METHODS

We established an up-dated inventory of European cross-sectional Human Biomonitoring (HBM) surveys and of birth cohorts, and compared chemicals and chemical groups addressed by HBM with indicators and health end points collected via European Core Health Indicators (ECHI), in birth registries, as well as in environmental and food data bases and health registries to see on how data collection could be aligned. Finally, we investigated study designs of HBM survey and health examination surveys for potential synergies.

RESULTS

The inventory covers a total of 11 European cross-sectional national programmes and a large number of birth cohorts and includes information on study population, age groups, covered substances, sampled matrices, and frequency. The comparison of data collections shows that there are many overlaps between environmental chemicals with environmental and health reporting. HBM data could be linked with ECHI indicators for work-related risks, body mass index (BMI), and low birth weight, with perinatal disease, neurologic disorders, and some chronic diseases, or with data bases for e.g. indoor air, food, or consumer products. Existing initiatives to link data collections at European Environment Agency (EEA) and Joint Research Center (JRC) or at World Health Organization (WHO) are good options to further develop linkage of HBM with exposures sources and health end points.

CONCLUSIONS

There is potential to use HBM based information in a number of public health policies, and this would help to align reporting to international commitments. Environmental health surveillance based on HBM and HBM-based indicators, is an excellent tool to inform public health policies about risks from environmental chemicals, and the EU health information system would benefit from additional HBM-based indicators for monitoring exposure burden from environmental chemicals. Considerable efforts are needed to align and establish routine data collections and to develop a surveillance system and indicators which may inform public health policies.

Perfluorinated alkyl substances in Spanish adults: Geographical distribution and determinants of exposure

Per- and polyfluoroalkyl substances (PFAS) are widely found in humans and the environment. Their persistence, bioaccumulation and toxicity make them a source of increasing public health concern. In this study, we analyzed the concentrations and geographical distribution of six PFAS in the serum of 755 Spanish adults aged 18-65. The geometric mean concentrations (and P95 values) for PFOS (perfluoroctane sulfonate), PFOA (perfluorooctanoic acid), PFHxS (perfluorohexane sulfonate), PFNA (perfluorononanoic acid) and PFDA (perfluorodecanoic acid) were 7.67 (19.3), 1.99 (5.48), 0.91 (2.84), 0.96 (2.44) and 0.42 (0.99) μg/L, respectively. N-Methylperfluorooctane sulfonamide (N-MeFOSAA) was detected in only 3.3% of samples. Residents in northeast (Catalonia) and northwest of Spain (Galicia) were found to have the highest serum values, whereas residents in the Canary Islands had the lowest values for almost all PFAS. Men presented higher levels than women, and we confirm that lactation (breastfeeding) contributes to a reduced body burden for all PFAS in women. Our data provide new information on exposure to PFAS in a national cross section sample of Spanish adults, thus providing a proxy for reference values for the Spanish population and forming the base for following temporal trends in the future.

Urinary Phthalate Concentrations in Mothers and Their Children in Ireland: Results of the DEMOCOPHES Human Biomonitoring Study

Background: Phthalates are chemicals which are widespread in the environment. Although the impacts on health of such exposure are unclear, there is evidence of a possible impact on the incidence of a diverse range of diseases. Monitoring of human exposure to phthalates is therefore important. This study aimed to determine the extent of phthalate exposure among mothers and their children in both rural and urban areas in Ireland, and to identify factors associated with elevated concentrations. It formed part of the ‘Demonstration of a study to Co-ordinate and Perform Human Biomonitoring on a European Scale’ (DEMOCOPHES) pilot biomonitoring study. Methods: the concentration of phthalate metabolites were determined from a convenience sample of 120 mother/child pairs. The median age of the children was 8 years. A questionnaire was used to collect information regarding lifestyle and environmental conditions of the children and mothers. Rigorous quality assurance within DEMOCOPHES guaranteed the accuracy and international comparability of results. Results: Phthalate metabolites were detected in all of the samples from both children and mothers. Concentrations were significantly higher in respondents from families with lower educational attainment and in those exposed to such items as polyvinyl chloride (PVC), fast food and personal care products (PCP). Conclusions: The study demonstrates that human biomonitoring for assessing exposure to phthalates can be undertaken in Ireland and that the exposure of the population is widespread. Further work will be necessary before the consequences of this exposure are understood.

Abstract P4-20-01: Implications of financial modeling in breast cancer clinical research from 1990 to 2010

SUMMARY: Over the past two decades significant progress has been made in breast cancer treatment resulting in a substantial improvement in patients' outcome. But we have to think about who promotes all this research and the consequences of the type of fundingThis project aims to evaluate the implication of finance in clinical research and the variance according to the type of funding.

OBJETIVES: To evaluate the financial evolvement of breast cancer clinical trials in the past two decades, regarding the phase of development design of the studies, the collaboration between Academy (Acad) and Industry (Ind), the sample size, the study results and the statistical analyses conducted.

METHODS: A systematic review was performed using MEDLINE to identify breast cancer randomized clinical trials published between January1990 and December2010. Studies that involved chemotherapy, endocrine and/or targeted therapies, wherethe primary endpoint was considered adequate to support a drug approval in oncology according to the FDA and EMA (U.S. Food and Drug Administration and European Medicines Agency, respectively), were included.

RESULTS:Data were evaluated 2,211 and 472 met selection criteria comprised in the methodology During the first decade the Acad was the main breast cancer research promoter being replaced by the Inv. throughout the second decade (p &lt;0.0001). Thirty nine percent of the studies evaluated were phase III (39% Acad, 61% Ind), 15% were phase II (30% Acad, 70% Ind) and the remaining 47% were not classified by authors (65% Acad 35% Ind). As for the primary endpoint, 25% of the phase III trials evaluated progression free survival, 15% overall response rate, 1% time to progression and only 5% examined overall survival. Sixty five percent of the trials were national (60% Acad 40% Ind) and 35% international (25% Acad 75% Ind). Single-center studies accounted for 11% of the trial (65% Acad 35% Ind). Most of the national trials were developed by the US. Fifty four percent of the studies were conducted by research groups (67% supported by Ind. and 33% Acad.). The Ind sponsored 26% of the studies in the first decade and 50% during the second. The median number of patients enrolled by research groups was 892 in contrast with 409 included by other organizations. The primary endpoint was achieved in 19% of the Acad trials and 21% of the Ind trials. Only 53% of the studies declared intention to treat based analysis in their statistical workout.

RESULTS  ACADEMY(%)INDUSTRY (%)PPROMOTION OF THE STUDY1990-2000121(26)68(14)0,0001 2001-2010105(22)178(38)0,0001STUDY DESIGNUNICENTRIC TRIALS34(7)18(4)0,007 MULTICENTRIC TRIALS191(40)228(48)  NATIONAL TRIALS183(39)122(26)0,0001 INTERNATIONAL TRIALS42(9)124(26)  COOPERATIVE GROUP95(20)160(34)  NOT COOPERATIVE GROUP130(28)86(18) STATISTICAL ANALYSISINTENT OF TREAT86(18)163(35)  NOT DECLARATED140(30)83(18) 

CONCLUSIONS:There is a significant tendency towards the promotion of research by the pharmaceutical industries during the last two decades, leading a change in the clinical trials design and the endpoints.

Citation Format: Jerez Y, Lopez-Tarruella S, Marquez-Rodas I, Perez S, Ocaña A, Echavarria I, Lobo M, Gallego I, Torres G, Ortega L, Garcia G, Palomero I, Gonzalez Del Val R, Massarrah T, Esteban M, Del Monte-Millan M, Martin M. Implications of financial modeling in breast cancer clinical research from 1990 to 2010 [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-20-01.

Association between waist circumference and magnesium and uric acid in indigenous Argentinean children living at high altitude

BACKGROUND

Studies in adults show that central obesity increases the likelihood of Type 2 diabetes (T2DM).

OBJECTIVE

To determine the association between waist circumference (WC) and non-traditional risk factors such as magnesium (Mg), phosphorus, and uric acid in indigenous children living at high altitudes.

METHODS

A total of 354 (166 M) indigenous school children, aged 9.6 + 2.3 years, were enrolled in a cross-sectional study in November 2011. Central obesity was defined as WC > 90th percentile according to age and sex. Low Mg and phosphorus levels were defined as serum Mg <1.8 mg/dL and phosphorus <2.4 mg/dL . Hyperuricemia was defined as serum uric acid > 7 mg/dL.

RESULTS

The prevalence of central obesity was 6.8% (24/354). None of the children had hyperuricemia or low P levels. HypoMg was identified in 21.7% (57/263). There was a significant association between WC (z-score) and Mg (r-015), uric acid (r0.28), phosphorus (r-0.30), HOMA-IR (r0.49), Triglycerides (r0.24), and HDL-C (r0.24). However, calcium, sodium, and potassium were not significantly associated with WC. As z-WC quartiles increased Mg and phosphorus levels significantly decreased, whereas uric acid levels increased. Multiple linear regression analysis showed that z-WC was associated significantly and directly with uric acid (B0.31), triglycerides (B0.004), and HOMA-IR (B0.35); and inversely with Mg (B-0.83) and phosphorus (B-0.25), adjusted for confounding variables (R2 0.34).

CONCLUSION

Our results indicate that central obesity was significantly and inversely associated with Mg and phosphorus and directly with uric acid in indigenous school children. Supplementation with Mg and/or phosphorus could prevent future cardiovascular disease. Prospective and randomized studies should be performed to confirm these findings.

Cadmium levels in a representative sample of the Spanish adult population: The BIOAMBIENT.ES project

Urinary cadmium levels (U-Cd) were measured in 1770 adults (aged 18-65 years) as a representative sample of the Spanish workforce. The geometric mean (GM) was 0.28 μg/l with 95% CI: 0.27-0.32 μg/l (GM: 0.20 μg/g 95% CI: 0.18-022 μg/g creatinine). The 95% percentile was 1.03 μg/l. U-Cd increased with age, with women showing higher U-Cd than men (p<0.001; 0.24 μg/g vs 0.17 μg/g). A multivariate analysis confirmed that sex, age and smoking habit significantly influence U-Cd. Smoking habit increases U-Cd by ∼90% per 10 years of age, almost twice the increase observed for non-smoking. Female smokers had 85% higher U-Cd than non-smokers, whereas the corresponding value for male smokers and non-smokers was 45%. No regional differences were observed with respect to the national reference level. The Spanish population studied here exhibits similar urinary cadmium levels to its European counterparts in Germany and slightly lower levels than in France, the Czech Republic, Italy and the United Kingdom. This paper provides the first baseline information concerning cadmium exposure in the Spanish adult population on a national scale. As such, these findings will help us to establish reference levels, follow temporal trends and identify high-exposure groups, thereby enabling comparisons with other countries and contributing to the improvement of public health and environmental quality.

NYVAC vector modified by C7L viral gene insertion improves T cell immune responses and effectiveness against leishmaniasis

The NYVAC poxvirus vector is used as vaccine candidate for HIV and other diseases, although there is only limited experimental information on its immunogenicity and effectiveness for use against human pathogens. Here we defined the selective advantage of NYVAC vectors in a mouse model by comparing the immune responses and protection induced by vectors that express the LACK (Leishmania-activated C-kinase antigen), alone or with insertion of the viral host range gene C7L that allows the virus to replicate in human cells. Using DNA prime/virus boost protocols, we show that replication-competent NYVAC-LACK that expresses C7L (NYVAC-LACK-C7L) induced higher-magnitude polyfunctional CD8(+) and CD4(+) primary adaptive and effector memory T cell responses (IFNγ, TNFα, IL-2, CD107a) to LACK antigen than non-replicating NYVAC-LACK. Compared to NYVAC-LACK, the NYVAC-LACK-C7L-induced CD8(+) T cell population also showed higher proliferation when stimulated with LACK antigen. After a challenge by subcutaneous Leishmania major metacyclic promastigotes, NYVAC-LACK-C7L-vaccinated mouse groups showed greater protection than the NYVAC-LACK-vaccinated group. Our results indicate that the type and potency of immune responses induced by LACK-expressing NYVAC vectors is improved by insertion of the C7L gene, and that a replication-competent vector as a vaccine renders greater protection against a human pathogen than a non-replicating vector.

Pilot study testing a European human biomonitoring framework for biomarkers of chemical exposure in children and their mothers: experiences in the UK

Exposure to a number of environmental chemicals in UK mothers and children has been assessed as part of the European biomonitoring pilot study, Demonstration of a Study to Coordinate and Perform Human Biomonitoring on a European Scale (DEMOCOPHES). For the European-funded project, 17 countries tested the biomonitoring guidelines and protocols developed by COPHES. The results from the pilot study in the UK are presented; 21 school children aged 6-11 years old and their mothers provided hair samples to measure mercury and urine samples, to measure cadmium, cotinine and several phthalate metabolites: mono(2-ethyl-5-hydroxyhexyl)phthalate (5OH-MEHP), mono(2-ethyl-5-oxo-hexyl)phthalate (5oxo-MEHP) and mono(2-ethylhexyl)phthalate (MEHP), mono-ethyl phthalate (MEP), mono-iso-butyl phthalate (MiBP), mono-benzyl phthalate (MBzP) and mono-n-butyl phthalate (MnBP). Questionnaire data was collected on environment, health and lifestyle. Mercury in hair was higher in children who reported frequent consumption of fish (geometric mean 0.35 μg/g) compared to those that ate fish less frequently (0.13 μg/g, p = 0.002). Cadmium accumulates with age as demonstrated by higher levels of urinary cadmium in the mothers (geometric mean 0.24 μg/L) than in the children(0.14 μg/L). None of the mothers reported being regular smokers, and this was evident with extremely low levels of cotinine measured (maximum value 3.6 μg/L in mothers, 2.4 μg/L in children). Very low levels of the phthalate metabolites were also measured in both mothers and children (geometric means in mothers: 5OH-MEHP 8.6 μg/L, 5oxo-MEHP 5.1 μg/L, MEHP 1.2 μg/L, MEP 26.8 μg/L, MiBP 17.0 μg/L, MBzP 1.6 μg/L and MnBP 13.5 μg/L; and in children: 5OH-MEHP 18.4 μg/L, 5oxo-MEHP 11.4 μg/L, MEHP 1.4 μg/L, MEP 14.3 μg/L, MiBP 25.8 μg/L, MBzP 3.5 μg/L and MnBP 22.6 μg/L). All measured biomarker levels were similar to or below population-based reference values published by the US National Health and Nutrition Examination Survey (NHANES) and Germany's GerES surveys. No results were above available health guidance values and were of no concern with regards to health. The framework and techniques learnt here will assist with future work on biomonitoring in the UK.

Recommendations for the Diagnosis and Management of Bladder Pain Syndrome. Spanish Urological Association Consensus Document

INTRODUCTION

Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC) and other bladder pathologies share common manifestations, such as the presence of mictional symptoms and a negative impact on the patient's quality of life. To be properly diagnosed and clinically managed, it is important to distinguish between its clinical modalities and diagnostic criteria for adequate exclusion.

OBJECTIVE

The purpose of this study was to standardize criteria for making decisions in BPS management, for its diagnosis, initial treatment and follow-up.

MATERIAL AND METHOD

A nominal group methodology was employed, using scientific evidence on BPS taken from a systematic (non-exhaustive) literature review for developing recommendations along with specialist expert opinions.

RESULTS

The diagnosis of BPS should be made based on the patient's clinical history, with emphasis on pain and mictional symptoms as well as excluding other pathologies with similar symptomatology. BPS treatment should be directed towards restoring normal bladder function, preventing symptom relapse and improving patients' quality of life. It is therefore advisable to start with conservative treatment and to adopt less conservative treatments as the level of clinical severity increases. It is also recommended to abandon ineffective treatments and reconsider other therapeutic options.

CONCLUSIONS

Quickly identifying the pathology is important when trying to positively influence morbidity and care quality for these patients.

Urinary polycyclic aromatic hydrocarbon metabolites levels in a representative sample of the Spanish adult population: The BIOAMBIENT.ES project

In 2009, the Spanish Ministry of Agriculture, Food and Environment promoted the BIOAMBIENT.ES project, a Human Biomonitoring program on the national scale to estimate reference levels of environmental pollutants on a representative sample of the Spanish adults. The present study focuses on polycyclic aromatic hydrocarbons (PAHs). The urinary metabolites 1-hydroxypyrene, 1-,2-,3-,4- and 9-hydroxyphenanthrene and 3-hydroxybenzo[a]pyrene were selected as indicators of PAH exposure. Urine samples from 957 subjects (16-65 years old) were collected during year 2009-2010. Geometric mean and 95th percentile for 1-hydroxypyrene in μg g(-1) creatinine were 0.117 (non-smoker: 0.079, smokers: 0.184) and 0.67 μg g(-1) creatinine (non-smokers: 0.31, smokers: 0.69) respectively. GM and 95th percentile for sum of hydroxyphenanthrenes in μg g(-1) creatinine were 0.130 (non-smokers: 0.089, smokers: 0.317) and 1.29 (non-smokers: 0.71, smokers: 1.51) respectively. 3-Hydroxybenzo[a]pyrene was below the limit of quantitation (0.05 μg L(-1)) in all cases. Significant differences (p<0.05) regarding smokers and non-smokers, coal and wood heating, body mass index and second hand smoke were found, while other variables like gender, age, or diet showed no significant association. The geographical distribution of the metabolites showed higher levels in people who lived in the north and northwest of Spain. The PAH metabolites levels found were in the same range or lower than those reported from other European countries and they were higher than those found in the U.S. This study represents the first nationwide survey of exposure to PAHs in Spain and provides a background reference range for exposure to PAHs in the Spanish adult occupied population.

Lessons learnt on recruitment and fieldwork from a pilot European human biomonitoring survey

Within the European Environment and Health Action Plan an initiative to establish a coherent human biomonitoring approach in Europe was started. The project COPHES (COnsortium to Perform Human biomonitoring on a European Scale ) developed recommendations for a harmonized conduct of a human biomonitoring (HBM) survey which came into action as the pilot study DEMOCOPHES (DEMOnstration of a study to COordinate and Perform Human biomonitoring on a European Scale). Seventeen European countries conducted a survey with harmonized instruments for, inter alia, recruitment, fieldwork and sampling, in autumn/winter 2011/2012. Based on the countries' experiences of conducting the pilot study, following lessons learnt were compiled: the harmonized fieldwork instruments (basic questionnaire, urine and hair sampling) turned out to be very valuable for future HBM surveys on the European scale. A school approach was favoured by most of the countries to recruit school-aged children according to the established guidelines and country specific experiences. To avoid a low participation rate, intensive communication with the involved institutions and possible participants proved to be necessary. The communication material should also include information on exclusion criteria and offered incentives. Telephone contact to the participants the day before fieldwork during the survey can prevent the forgetting of appointments and first morning urine samples. To achieve comparable results on the European scale, training of interviewers in all issues of recruitment, fieldwork and sampling through information material and training sessions is crucial. A survey involving many European countries needs time for preparation and conduct. Materials for quality control prepared for all steps of recruitment, fieldwork and sampling proved to be important to warrant reliable results.

Communication in a Human biomonitoring study: Focus group work, public engagement and lessons learnt in 17 European countries

A communication strategy was developed by The Consortium to Perform Human Biomonitoring on a European Scale (COPHES), as part of its objectives to develop a framework and protocols to enable the collection of comparable human biomonitoring data throughout Europe. The framework and protocols were tested in the pilot study DEMOCOPHES (Demonstration of a study to Coordinate and Perform Human biomonitoring on a European Scale). The aims of the communication strategy were to raise awareness of human biomonitoring, encourage participation in the study and to communicate the study results and their public health significance. It identified the audiences and key messages, documented the procedure for dissemination of results and was updated as the project progressed. A communication plan listed the tools and materials such as press releases, flyers, recruitment letters and information leaflets required for each audience with a time frame for releasing them. Public insight research was used to evaluate the recruitment material, and the feedback was used to improve the documents. Dissemination of results was coordinated in a step by step approach by the participating countries within DEMOCOPHES, taking into account specific national messages according to the needs of each country. Participants received individual results, unless they refused to be informed, along with guidance on what the results meant. The aggregate results and policy recommendations were then communicated to the general public and stakeholders, followed by dissemination at European level. Several lessons were learnt that may assist other future human biomonitoring studies. Recruitment took longer than anticipated and so social scientists, to help with community engagement, should be part of the research team from the start. As a European study, involving multiple countries, additional considerations were needed for the numerous organisations, different languages, cultures, policies and priorities. Therefore, communication documents should be seen as templates with essential information clearly indicated and the option for each country to tailor the material to reflect these differences. Future studies should consider setting up multidisciplinary networks of medical professionals and communication experts, and holding training workshops to discuss the interpretation of results and risk communication. Publicity and wide dissemination of the results helped to raise awareness of human biomonitoring to the general public, policy makers and other key stakeholders. Effective and timely communication, at all stages of a study, is essential if the potential of human biomonitoring research to improve public health is to be realised.

Urinary BPA measurements in children and mothers from six European member states: Overall results and determinants of exposure

For the first time in Europe, both European-wide and country-specific levels of urinary Bisphenol A (BPA) were obtained through a harmonized protocol for participant recruitment, sampling and quality controlled biomarker analysis in the frame of the twin projects COPHES and DEMOCOPHES. 674 child-mother pairs were recruited through schools or population registers from six European member states (Belgium, Denmark, Luxembourg, Slovenia, Spain and Sweden). Children (5-12 y) and mothers donated a urine sample. Information on socio-demographic characteristics, life style, dietary habits, and educational level of the parents was provided by mothers. After exclusion of urine samples with creatinine values below 300 mg/L or above 3000 mg/L, 653 children and 639 mothers remained for which BPA was measured. The geometric mean (with 95% confidence intervals) and 90th percentile were calculated for BPA separately in children and in mothers and were named "European reference values". After adjustment for confounders (age and creatinine), average exposure values in each country were compared with the mean of the "European reference values" by means of a weighted analysis of variance. Overall geometric means of all countries (95% CI) adjusted for urinary creatinine, age and gender were 2.04 (1.87-2.24) µg/L and 1.88 (1.71-2.07) µg/L for children (n=653) and mothers (n=639), respectively. Multiple regression analysis was used to identify significant environmental, geographical, personal or life style related determinants. Consumption of canned food and social class (represented by the highest educational level of the family) were the most important predictors for the urinary levels of BPA in mothers and children. The individual BPA levels in children were significantly correlated with the levels in their mothers (r=0.265, p<0.001), which may suggest a possible common environmental/dietary factor that influences the biomarker level in each pair. Exposure of the general European population was well below the current health-based guidance values and no participant had BPA values higher than the health-based guidance values.

The Danish contribution to the European DEMOCOPHES project: A description of cadmium, cotinine and mercury levels in Danish mother-child pairs and the perspectives of supplementary sampling and measurements

Human biomonitoring (HBM) is an important tool, increasingly used for measuring true levels of the body burdens of environmental chemicals in the general population. In Europe, a harmonized HBM program was needed to open the possibility to compare levels across borders. To explore the prospect of a harmonized European HBM project, DEMOCOPHES (DEMOnstration of a study to COordinate and Perform Human biomonitoring on a European Scale) was completed in 17 European countries. The basic measurements performed in all implemented countries of DEMOCOPHES included cadmium, cotinine and phthalate metabolites in urine and mercury in hair. In the Danish participants, significant correlations between mothers and children for mercury in hair and cotinine in urine were found. Mercury in hair was further significantly associated with intake of fish and area of residence. Cadmium was positively associated with BMI in mothers and an association between cadmium and cotinine was also found. As expected high cotinine levels were found in smoking mothers. For both mercury and cadmium significantly higher concentrations were found in the mothers compared to their children. In Denmark, the DEMOCOPHES project was co-financed by the Danish ministries of health, environment and food safety. The co-financing ministries agreed to finance a number of supplementary measurements of substances of current toxicological, public and regulatory interest. This also included blood sampling from the participants. The collected urine and blood samples were analyzed for a range of other persistent and non-persistent environmental chemicals as well as two biomarkers of effect. The variety of supplementary measurements gives the researchers further information on the exposure status of the participants and creates a basis for valuable knowledge on the pattern of exposure to various chemicals.

Policy recommendations and cost implications for a more sustainable framework for European human biomonitoring surveys

The potential of Human Biomonitoring (HBM) in exposure characterisation and risk assessment is well established in the scientific HBM community and regulatory arena by many publications. The European Environment and Health Strategy as well as the Environment and Health Action Plan 2004-2010 of the European Commission recognised the value of HBM and the relevance and importance of coordination of HBM programmes in Europe. Based on existing and planned HBM projects and programmes of work and capabilities in Europe the Seventh Framework Programme (FP 7) funded COPHES (COnsortium to Perform Human Biomonitoring on a European Scale) to advance and improve comparability of HBM data across Europe. The pilot study protocol was tested in 17 European countries in the DEMOCOPHES feasibility study (DEMOnstration of a study to COordinate and Perform Human biomonitoring on a European Scale) cofunded (50%) under the LIFE+ programme of the European Commission. The potential of HBM in supporting and evaluating policy making (including e.g. REACH) and in awareness raising on environmental health, should significantly advance the process towards a fully operational, continuous, sustainable and scientifically based EU HBM programme. From a number of stakeholder activities during the past 10 years and the national engagement, a framework for sustainable HBM structure in Europe is recommended involving national institutions within environment, health and food as well as European institutions such as ECHA, EEA, and EFSA. An economic frame with shared cost implications for national and European institutions is suggested benefitting from the capacity building set up by COPHES/DEMOCOPHES.

Fish consumption patterns and hair mercury levels in children and their mothers in 17 EU countries

The toxicity of methylmercury (MeHg) in humans is well established and the main source of exposure is via the consumption of large marine fish and mammals. Of particular concern are the potential neurodevelopmental effects of early life exposure to low-levels of MeHg. Therefore, it is important that pregnant women, children and women of childbearing age are, as far as possible, protected from MeHg exposure. Within the European project DEMOCOPHES, we have analyzed mercury (Hg) in hair in 1799 mother-child pairs from 17 European countries using a strictly harmonized protocol for mercury analysis. Parallel, harmonized questionnaires on dietary habits provided information on consumption patterns of fish and marine products. After hierarchical cluster analysis of consumption habits of the mother-child pairs, the DEMOCOPHES cohort can be classified into two branches of approximately similar size: one with high fish consumption (H) and another with low consumption (L). All countries have representatives in both branches, but Belgium, Denmark, Spain, Portugal and Sweden have twice as many or more mother-child pairs in H than in L. For Switzerland, Czech Republic, Hungary, Poland, Romania, Slovenia and Slovakia the situation is the opposite, with more representatives in L than H. There is a strong correlation (r=0.72) in hair mercury concentration between the mother and child in the same family, which indicates that they have a similar exposure situation. The clustering of mother-child pairs on basis of their fish consumption revealed some interesting patterns. One is that for the same sea fish consumption, other food items of marine origin, like seafood products or shellfish, contribute significantly to the mercury levels in hair. We conclude that additional studies are needed to assess and quantify exposure to mercury from seafood products, in particular. The cluster analysis also showed that 95% of mothers who consume once per week fish only, and no other marine products, have mercury levels 0.55 μg/g. Thus, the 95th percentile of the distribution in this group is only around half the US-EPA recommended threshold of 1 μg/g mercury in hair. Consumption of freshwater fish played a minor role in contributing to mercury exposure in the studied cohort. The DEMOCOPHES data shows that there are significant differences in MeHg exposure across the EU and that exposure is highly correlated with consumption of fish and marine products. Fish and marine products are key components of a healthy human diet and are important both traditionally and culturally in many parts of Europe. Therefore, the communication of the potential risks of mercury exposure needs to be carefully balanced to take into account traditional and cultural values as well as the potential health benefits from fish consumption. European harmonized human biomonitoring programs provide an additional dimension to national HMB programs and can assist national authorities to tailor mitigation and adaptation strategies (dietary advice, risk communication, etc.) to their country's specific requirements.

A pilot study on the feasibility of European harmonized human biomonitoring: Strategies towards a common approach, challenges and opportunities

In 2004 the European Commission and Member States initiated activities towards a harmonized approach for Human Biomonitoring surveys throughout Europe. The main objective was to sustain environmental health policy by building a coherent and sustainable framework and by increasing the comparability of data across countries. A pilot study to test common guidelines for setting up surveys was considered a key step in this process. Through a bottom-up approach that included all stakeholders, a joint study protocol was elaborated. From September 2011 till February 2012, 17 European countries collected data from 1844 mother-child pairs in the frame of DEMOnstration of a study to COordinate and Perform Human Biomonitoring on a European Scale (DEMOCOPHES).(1) Mercury in hair and urinary cadmium and cotinine were selected as biomarkers of exposure covered by sufficient analytical experience. Phthalate metabolites and Bisphenol A in urine were added to take into account increasing public and political awareness for emerging types of contaminants and to test less advanced markers/markers covered by less analytical experience. Extensive efforts towards chemo-analytical comparability were included. The pilot study showed that common approaches can be found in a context of considerable differences with respect to experience and expertize, socio-cultural background, economic situation and national priorities. It also evidenced that comparable Human Biomonitoring results can be obtained in such context. A European network was built, exchanging information, expertize and experiences, and providing training on all aspects of a survey. A key challenge was finding the right balance between a rigid structure allowing maximal comparability and a flexible approach increasing feasibility and capacity building. Next steps in European harmonization in Human Biomonitoring surveys include the establishment of a joint process for prioritization of substances to cover and biomarkers to develop, linking biomonitoring surveys with health examination surveys and with research, and coping with the diverse implementations of EU regulations and international guidelines with respect to ethics and privacy.

Case study: Possible differences in phthalates exposure among the Czech, Hungarian, and Slovak populations identified based on the DEMOCOPHES pilot study results

OBJECTIVE

Phthalates and their metabolites are classified as endocrine modulators. They affect the hormonal balance in both children and adults. The aim of this publication was to compare the urinary levels of phthalate metabolites in selected populations of the Czech Republic (CZ), Slovakia (SK), and Hungary (HU) in relation to the sources of phthalate exposure identified by means of questionnaire (personal care products, floor and wall coverings, plastic toys, and some kinds of foods).

METHODS

Data were obtained through the twin projects COPHES (COnsortium to Perform Human biomonitoring on a European Scale) and DEMOCOPHES (DEMOnstration of a study to COordinate and Perform Human biomonitoring on a European Scale) from 2009 to 2012. The target groups were children aged 6-11 years old and their mothers up to 45 years of age. The metabolites of phthalates (monomethyl phthalate (MMP), monoethyl phthalate (MEP), monobenzyl phthalate (MBzP), mono-cyclohexyl phthalate (MCHP), mono-(2-ethylhexyl) phthalate (MEHP), mono-(2-ethyl-5-hydroxyhexyl) phthalate (5OH-MEHP), and mono-(2-ethyl-5-oxohexyl) phthalate (5OXO-MEHP)) were analysed in first morning urine samples. After enzymatic glucuronide cleavage, the urine sample analyses were performed using ultra-high-performance liquid chromatography-electrospray ionization tandem mass spectrometry (UHPLC-ESI-MS/MS) in one laboratory that qualified in the External Quality Assessment exercises organised by COPHES.

RESULTS

Significant differences in phthalate exposure between countries were revealed for children only but not for mothers. The concentrations of 5-OH-MEHP (P<0.001), 5OXO-MEHP (P<0.001), and their sum (P<0.001) were the highest in SK compared to CZ and HU. The health based guidance values for the sum of DEHP metabolites 5-OH MEHP and 5OXO-MEHP established by the German Commission for biomonitoring of 300 µg/L and 500 µg/L for women adults and children, respectively, were only exceeded in one mother and three boys. A significant difference was also found for MEP (P=0.0149), with the highest concentrations detected in HU. In all countries, the increasing frequency of using personal care products significantly elevated the concentrations of MEP.

CONCLUSION

Some differences were observed between countries in the concentrations of individual urinary phthalate metabolites in children. However, the questionnaire results give no direct explanation for the differences between the countries except the variation in using personal care products.

Urinary cotinine levels and environmental tobacco smoke in mothers and children of Romania, Portugal and Poland within the European human biomonitoring pilot study

The aim of this study was to explore data from the DEMOCOPHES study population for Romania, Portugal and Poland, in order to assess smoking patterns and the extent of ETS exposure and compare the national study samples with reference to the respective anti-smoking laws. The subset of the DEMOCOPHES study sample consisted of 360 children and their mothers (120 in each of the three countries - Romania (RO), Portugal (PT) and Poland (PL). Smoking was assessed using a detailed questionnaire for the participants, which addresses both active and passive smoking. This assessment uses exposure-relevant questionnaire data, in particular on the home environment and residence, socio-demographic characteristics, lifestyle such as nutrition, smoking behavior, other exposure-relevant behavior and occupational history, as well as urinary cotinine and creatinine measurements. We performed general statistical analysis and innovative receiver operating characteristic (ROC) curve analyses. Smoking prevalence as evaluated by the questionnaire was generally high, and higher than official statistics, which suggests some under-reporting in the countries, particularly in Romania. Urinary cotinine levels provided biochemical confirmation of the high and similar smoking prevalence for the three countries. Concerning ETS exposure, Romania presented significantly higher levels, for children as well as for non-smoking mothers, with Portugal showing significantly lower levels. Compared to non-smoking mothers, the children showed relatively higher ETS exposure levels in all three countries. The established country-specific optimal cut-off values in urinary cotinine to distinguish smokers from non-smokers vary more than those to discriminate ETS exposure extent in non-smoking mothers and children. Although different between countries, these values are a valuable output to monitor effectiveness of both national antismoking laws and educational programs in the three countries. The findings of this study point to the urgent need for stronger, more effective and well enforced smoke-free legislation in the three countries.

Interpreting biomarker data from the COPHES/DEMOCOPHES twin projects: Using external exposure data to understand biomarker differences among countries

In 2011 and 2012, the COPHES/DEMOCOPHES twin projects performed the first ever harmonized human biomonitoring survey in 17 European countries. In more than 1800 mother-child pairs, individual lifestyle data were collected and cadmium, cotinine and certain phthalate metabolites were measured in urine. Total mercury was determined in hair samples. While the main goal of the COPHES/DEMOCOPHES twin projects was to develop and test harmonized protocols and procedures, the goal of the current paper is to investigate whether the observed differences in biomarker values among the countries implementing DEMOCOPHES can be interpreted using information from external databases on environmental quality and lifestyle. In general, 13 countries having implemented DEMOCOPHES provided high-quality data from external sources that were relevant for interpretation purposes. However, some data were not available for reporting or were not in line with predefined specifications. Therefore, only part of the external information could be included in the statistical analyses. Nonetheless, there was a highly significant correlation between national levels of fish consumption and mercury in hair, the strength of antismoking legislation was significantly related to urinary cotinine levels, and we were able to show indications that also urinary cadmium levels were associated with environmental quality and food quality. These results again show the potential of biomonitoring data to provide added value for (the evaluation of) evidence-informed policy making.

Exposure determinants of cadmium in European mothers and their children

The metal cadmium (Cd) is a widespread environmental pollutant with documented adverse effects on the kidneys and bones from long-term environmental exposure, but with insufficiently elucidated public health consequences such as risk of cardiovascular disease, hormone-related cancer in adults and developmental effects in children. This study is the first pan-European human biomonitoring project that succeeded in performing harmonized measurements of Cd in urine in a comparable way in mother-child couples from 16 European countries. The aim of the study was to evaluate the overall Cd exposure and significant determinants of Cd exposure. A study population of 1632 women (24-52 years of age), and 1689 children (5-12 years of age), from 32 rural and urban areas, was examined within a core period of 6 months in 2011-2012. Women were stratified as smokers and non-smokers. As expected, smoking mothers had higher geometric mean (gm) urinary cadmium (UCd; 0.24 µg/g crea; n=360) than non-smoking mothers (gm 0.18 µg/g crea; n=1272; p<0.0001), and children had lower UCd (gm 0.065 µg/g crea; n=1689) than their mothers at the country level. Non-smoking women exposed to environmental tobacco smoke (ETS) at home had 14% (95% CI 1-28%) higher UCd than those who were not exposed to ETS at home (p=0.04). No influence of ETS at home or other places on UCd levels was detected in children. Smoking women with primary education as the highest educational level of the household had 48% (95% CI 18-86%) higher UCd than those with tertiary education (p=0.0008). The same observation was seen in non-smoking women and in children; however they were not statistically significant. In children, living in a rural area was associated with 7% (95% CI 1-13%) higher UCd (p=0.03) compared to living in an urban area. Children, 9-12 years had 7% (95% CI 1-13%) higher UCd (p=0.04) than children 5-8 years. About 1% of the mothers, and 0.06% of the children, exceeded the tolerable weekly intake (TWI) appointed by EFSA, corresponding to 1.0 µg Cd/g crea in urine. Poland had the highest UCd in comparison between the 16 countries, while Denmark had the lowest. Whether the differences between countries are related to differences in the degree of environmental Cd contamination or to differences in lifestyle, socioeconomic status or dietary patterns is not clear.

Mercury analysis in hair: Comparability and quality assessment within the transnational COPHES/DEMOCOPHES project

Human biomonitoring (HBM) is an effective tool for assessing actual exposure to chemicals that takes into account all routes of intake. Although hair analysis is considered to be an optimal biomarker for assessing mercury exposure, the lack of harmonization as regards sampling and analytical procedures has often limited the comparison of data at national and international level. The European-funded projects COPHES and DEMOCOPHES developed and tested a harmonized European approach to Human Biomonitoring in response to the European Environment and Health Action Plan. Herein we describe the quality assurance program (QAP) for assessing mercury levels in hair samples from more than 1800 mother-child pairs recruited in 17 European countries. To ensure the comparability of the results, standard operating procedures (SOPs) for sampling and for mercury analysis were drafted and distributed to participating laboratories. Training sessions were organized for field workers and four external quality-assessment exercises (ICI/EQUAS), followed by the corresponding web conferences, were organized between March 2011 and February 2012. ICI/EQUAS used native hair samples at two mercury concentration ranges (0.20-0.71 and 0.80-1.63) per exercise. The results revealed relative standard deviations of 7.87-13.55% and 4.04-11.31% for the low and high mercury concentration ranges, respectively. A total of 16 out of 18 participating laboratories the QAP requirements and were allowed to analyze samples from the DEMOCOPHES pilot study. Web conferences after each ICI/EQUAS revealed this to be a new and effective tool for improving analytical performance and increasing capacity building. The procedure developed and tested in COPHES/DEMOCOPHES would be optimal for application on a global scale as regards implementation of the Minamata Convention on Mercury.

First steps toward harmonized human biomonitoring in Europe: demonstration project to perform human biomonitoring on a European scale

BACKGROUND

For Europe as a whole, data on internal exposure to environmental chemicals do not yet exist. Characterization of the internal individual chemical environment is expected to enhance understanding of the environmental threats to health.

OBJECTIVES

We developed and applied a harmonized protocol to collect comparable human biomonitoring data all over Europe.

METHODS

In 17 European countries, we measured mercury in hair and cotinine, phthalate metabolites, and cadmium in urine of 1,844 children (5-11 years of age) and their mothers. Specimens were collected over a 5-month period in 2011-2012. We obtained information on personal characteristics, environment, and lifestyle. We used the resulting database to compare concentrations of exposure biomarkers within Europe, to identify determinants of exposure, and to compare exposure biomarkers with health-based guidelines.

RESULTS

Biomarker concentrations showed a wide variability in the European population. However, levels in children and mothers were highly correlated. Most biomarker concentrations were below the health-based guidance values.

CONCLUSIONS

We have taken the first steps to assess personal chemical exposures in Europe as a whole. Key success factors were the harmonized protocol development, intensive training and capacity building for field work, chemical analysis and communication, as well as stringent quality control programs for chemical and data analysis. Our project demonstrates the feasibility of a Europe-wide human biomonitoring framework to support the decision-making process of environmental measures to protect public health.

Harmonized European human biomonitoring in small countries: Challenges, opportunities and lessons learned in Cyprus and Luxembourg from the DEMOCOPHES study

Background: To advance human biomonitoring (HBM) for policy support in Europe, a harmonized approach was developed (COPHES project, FP7 2009- 2012) and evaluated in 17 countries (DEMOCOPHES project, Life+, 2010-2012). Cyprus (CY) and Luxembourg (LU) tested the hypothesis that the COPHES European Protocol is applicable to small countries.Materials and methods: In 2011-12, the European Protocol was adopted and tested by CY and LU for the harmonized biomonitoring of 60 children and their mothers for cadmium, phthalates and cotinine in urine and for mercury in scalp hair in two sampling areas (urban, rural). Results: Both small countries achieved the preset goals for recruitment, sample collection and analysis, which allowed for the first time the assessment of children’s and mothers’ exposures to the selected chemicals in comparison with other countries. Capacity building was accomplished and communication actions were particularly effective, with both countries taking advantage of their small size to access participants, policy makers, other stakeholders and the press. Time constrains and requirements for capacity building were limiting factors. Conclusion: The COPHES European Protocol for HBM surveys is attainable in small countries. The following elements are fundamental in the design of a harmonized European HBM program, from the perspective of small countries: (a) consultation with and active involvement of the implementing countries, (b) flexibility for national decisions, while not compromising harmonization, (c) elaboration of standardized methods, procedures and documents (d) quality assurance mechanisms, (e) means of training and support.

Anti-smoking legislation and its effects on urinary cotinine and cadmium levels

Anti-smoking legislation has been associated with an improvement in health indicators. Since the cadmium (Cd) body burden in the general population is markedly increased by smoke exposure, we analyzed the impact of the more restrictive legislation that came into force in Spain in 2011 by measuring Cd and cotinine in first morning urine samples from 83 adults in Madrid (Spain) before (2010) and after (2011) introduction of this law. Individual pair-wise comparisons showed a reduction of creatinine corrected Cotinine and Cd levels for non-active smokers, i. e. those which urinary cotinine levels are below 50 μg/L. After the application of the stricter law, cotinine levels in urine only decreased in non-active smokers who self-reported not to be exposed to second-hand smoke. The reduction in second hand smoke exposure was significantly higher in weekends (Friday to Sunday) than in working days (Monday to Thursday). The decrease in U-Cd was highly significant in non-active smokers and, in general, correlated with lower creatinine excretion. Therefore correction by creatinine could bias urinary Cd results, at least for cotinine levels higher than 500 μg/L. The biochemical/toxicological benefits detected herein support the stricter application of anti-smoking legislation and emphasize the need to raise the awareness of the population as regards exposure at home.

Serum PCB levels in a representative sample of the Spanish adult population: the BIOAMBIENT.ES project

This manuscript presents the levels of six indicator polychlorinated biphenyl (PCB) congeners (IUPAC nos. 28, 52, 101, 138, 153 and 180) in the serum of 1880 individuals from a representative sample of the Spanish working population recruited between March 2009 and July 2010. Three out of the six PCBs studied (180, 153 and 138) were quantified in more than 99% of participants. PCB 180 was the highest contributor, followed by PCBs 153 and 138, with relative abundances of 42.6%, 33.2% and 24.2%, respectively. In contrast, PCBs 28 and 52 were detected in only 1% of samples, whereas PCB 101 was detectable in 6% of samples. The geometric mean (GM) for ΣPCBs138/153/180 was 135.4 ng/g lipid (95% CI: 121.3-151.2 ng/g lipid) and the 95th percentile was 482.2 ng/g lipid. Men had higher PCB blood concentrations than women (GMs 138.9 and 129.9 ng/g lipid respectively). As expected, serum PCB levels increased with age and frequency of fish consumption, particularly in those participants younger than 30 years of age. The highest levels we found were for participants from the Basque Country, whereas the lowest concentrations were found for those from the Canary Islands. The Spanish population studied herein had similar levels to those found previously in Greece and southern Italy, lower levels than those in France and central Europe, and higher PCB levels than those in the USA, Canada and New Zealand. This paper provides the first baseline information regarding PCB exposure in the Spanish adult population on a national scale. The results will allow us to establish reference levels, follow temporal trends and identify high-exposure groups, as well as monitor implementation of the Stockholm Convention in Spain.

Urinary levels of eight phthalate metabolites and bisphenol A in mother-child pairs from two Spanish locations

Exposure to some phthalate diesters and bisphenol A in the general population is a cause of increasing concern because of their potential adverse effects on the reproductive and endocrine systems and their broad presence in foodstuff and consumer products. The aims of this work are to assess patterns of exposure to phthalates and bisphenol A in a pilot sample of Spanish mothers and their children, and to provide basic information to address priorities in future Spanish surveys/research. Urinary levels of eight phthalate metabolites and bisphenol A have been measured in samples from 120 mother-child pairs in one rural and one urban location in central Spain, recruited as part of the European project DEMOCOPHES. More than 96% of the participants were exposed to all the compounds studied here with generally higher levels in children than their mothers. The sum of secondary DEHP metabolites gave a GM of 33.3μg/g creatinine (95% CI 30.2-36.6) for mothers and 63.0μg/g creatinine (95% CI 56.8-69.8) for children. Mono-ethyl phthalate (MEP) was the metabolite with the highest levels, with geometric means (GM) of 150.8μg/g creatinine (95% CI 124.0-183.5) for mothers and 198.9μg/g creatinine (95% CI 165.2-239.6) for children. Bisphenol A urinary levels were relatively low with geometric means of 2.0μg/g (95% CI 1.6-2.4) for mothers and 2.01μg/g (95% CI 1.7-2.4) for children. Personal care products like body lotions and fragrances showed associations with MEHP, MEP, MnBP and cx-MiNP and canteen food with MBzP and bisphenol A. Exposure of mothers and their children are correlated, except for MEP. As phthalates and bisphenol A are non-persistent chemicals, a daily, intermittent exposure of the population is taking place.