Virus inactivation in low ozone exposure water reuse applications

In drinking water applications, an ozone exposure (Ct) based framework has been historically used to validate ozone disinfection. However, significant viral inactivation can be achieved with little to no measurable ozone exposure. Additionally, ozone exposure depends on multiple water quality variables as well as the calculation/ozone measurement method used. In this study, we evaluated alternative ozone monitoring frameworks as well as the impact of water quality variables on ozone decay kinetics and virus/coliform inactivation. Here we show that both change in UV254 absorbance and applied O3:TOC were well correlated with viral inactivation and these frameworks were resilient to changes in water quality. Both increasing temperature (12-30 ⁰C) and pH (5.5-8.4) was shown to significantly increase the ozone decay rate and decreased the resulting ozone exposure by as much as ∼90% in the case of pH. However, due to the increased reaction rate of ozone with viruses at elevated temperature and pH, there was only a minor impact (∼20% in the case of pH) in overall disinfection performance for a given O3:TOC. These frameworks were also considered for variable source water with TOC (5-11 mg/L) and TSS (1.2-5.8 mg/L). Change in UV254 absorbance or applied ozone dose (mg/L) were the strongest indicators of disinfection performance for source waters of variable TOC, however site-specific testing may be needed to apply this framework. Challenge testing with influent nitrite indicated that ozone disinfection performance is significantly impacted (>50% reduction in inactivation) in the presence of nitrite thus enforcing the importance of accounting for this value in the applied ozone dose. Multi-point ozone dissolution was investigated as an alternative ozone application method that may present a benefit with respect to overall disinfection performance especially if nitrite was present. Developing and validating these alternative monitoring frameworks and ozone application methods is imperative in water reuse applications where unnecessary elevated ozone exposure may lead to harmful byproduct formation.

Triage of V-V ECMO referrals for COVID-19 respiratory failure

BACKGROUND

As the pandemic progressed, the use of extracorporeal membrane oxygenation (ECMO) for COVID-19-related acute respiratory distress syndrome increased, and patient triage and transfer to ECMO centers became important to optimize patient outcomes. Our objectives are to identify predictors of patient transfer for veno-venous extracorporeal membrane oxygenation (V-V ECMO) evaluation as well as to describe the outcomes of accepted patients.

METHODS

This is a single-center, retrospective analysis of V-V ECMO transfer requests for adult patients with known or suspected COVID-19 and respiratory failure from March 2020 until March 2021. Data were collected prospectively during the triage process for transfer requests as part of clinical patient care at our institution.

RESULTS

Of 341 referred patients, 112 (33%) were accepted for transfer to our facility, whereas 229 (67%) patients were declined for transfer. The Classification and Regression Tree analysis showed that patients' high pressure during airway pressure release ventilation (APRV) and age were the variables most significantly associated with the decision to accept or decline patients for transfer.

CONCLUSIONS

Our triage process enabled one-third of referred patients to be transferred for evaluation, with nearly 70% of those patients ultimately receiving ECMO support. High ventilator settings on APRV and young age were associated with acceptance for transfer. Accepted patients also had a higher incidence of adjunctive therapies (proning and paralysis) prior to transfer request, less cardiac or renal dysfunction, and a shorter duration of mechanical ventilation. Further research is warranted to investigate the outcomes of nontransferred patients.

Leaf Spot Disease Development and Its Effect on Yield of Essential Oil-Producing Hemp Cultivars in Kentucky

Leaf spot diseases are common on field hemp, causing defoliation, and blighting. The most prevalent leaf spot diseases of hemp in Kentucky are Bipolaris leaf spot (Bipolaris gigantea), Cercospora leaf spot (Cercospora flagellaris), and Septoria leaf spot (Septoria cannabis). In this study, disease progression, cultivar susceptibility, and yield loss were examined using cultivars from four relatedness groups at two locations and in two growing seasons. Septoria leaf spot was the first leaf spot disease to be observed in the field, followed by Bipolaris leaf spot. Both diseases reduced canopy density. Cercospora leaf spot developed in the late reproductive stages as harvest approached. A wide range of susceptibility was documented, suggesting genetic variability across cultivars. Trump group cultivars were the most susceptible, while Otto II group cultivars were the least susceptible. Most importantly, leaf spot diseases had minimal influence on floral biomass and no effect on CBD yield, suggesting that, regardless of disease severity, leaf spot diseases may seldom warrant management. While the importance of foliar disease and corresponding yield loss can shift over time, variation in disease progress among leaf spot diseases and susceptibility of hemp cultivars documented in this study suggest potential disease management through cultural practices such as cultivar and planting date selections.

Optimizing Ozone Disinfection in Water Reuse: Controlling Bromate Formation and Enhancing Trace Organic Contaminant Oxidation

The use of ozone/biofiltration advanced treatment has become more prevalent in recent years, with many utilities seeking an alternative to membrane/RO based treatment for water reuse. Ensuring efficient pathogen reduction while controlling disinfection byproducts and maximizing oxidation of trace organic contaminants remains a major barrier to implementing ozone in reuse applications. Navigating these challenges is imperative in order to allow for the more widespread application of ozonation. Here, we demonstrate the effectiveness of ozone for virus, coliform bacteria, and spore forming bacteria inactivation in unfiltered secondary effluent, all the while controlling the disinfection byproduct bromate. A greater than 6-log reduction of both male specific and somatic coliphages was seen at specific ozone doses as low as 0.75 O3:TOC. This study compared monochloramine and hydrogen peroxide as chemical bromate control measures in high bromide water (Br- = 0.35 ± 0.07 mg/L). On average, monochloramine and hydrogen peroxide resulted in an 80% and 36% decrease of bromate formation, respectively. Neither bromate control method had any appreciable impact on virus or coliform bacteria disinfection by ozone; however, the use of hydrogen peroxide would require a non-Ct disinfection framework. Maintaining ozone residual was shown to be critical for achieving disinfection of more resilient microorganisms, such as spore forming bacteria. While extremely effective at controlling bromate, monochloramine was shown to inhibit TrOC oxidation, whereas hydrogen peroxide enhanced TrOC oxidation.

Critical Review on Bromate Formation during Ozonation and Control Options for Its Minimization

Ozone is a commonly applied disinfectant and oxidant in drinking water and has more recently been implemented for enhanced municipal wastewater treatment for potable reuse and ecosystem protection. One drawback is the potential formation of bromate, a possible human carcinogen with a strict drinking water standard of 10 μg/L. The formation of bromate from bromide during ozonation is complex and involves reactions with both ozone and secondary oxidants formed from ozone decomposition, i.e., hydroxyl radical. The underlying mechanism has been elucidated over the past several decades, and the extent of many parallel reactions occurring with either ozone or hydroxyl radicals depends strongly on the concentration, type of dissolved organic matter (DOM), and carbonate. On the basis of mechanistic considerations, several approaches minimizing bromate formation during ozonation can be applied. Removal of bromate after ozonation is less feasible. We recommend that bromate control strategies be prioritized in the following order: (1) control bromide discharge at the source and ensure optimal ozone mass-transfer design to minimize bromate formation, (2) minimize bromate formation during ozonation by chemical control strategies, such as ammonium with or without chlorine addition or hydrogen peroxide addition, which interfere with specific bromate formation steps and/or mask bromide, (3) implement a pretreatment strategy to reduce bromide and/or DOM prior to ozonation, and (4) assess the suitability of ozonation altogether or utilize a downstream treatment process that may already be in place, such as reverse osmosis, for post-ozone bromate abatement. A one-size-fits-all approach to bromate control does not exist, and treatment objectives, such as disinfection and micropollutant abatement, must also be considered.

Variations in the Management of Closed Salter-Harris II Distal Tibia Fractures

BACKGROUND

There are no formal practice guidelines for the surgical management of closed, Salter-Harris (SH) II distal tibia fractures. The purpose of this study was to survey the indications for operative and nonoperative management of this injury across pediatric tertiary care centers.

METHODS

We surveyed pediatric orthopedic surgeons at 20 tertiary care level-1 pediatric trauma centers. Surgeons were provided with 16 clinical scenarios that varied based on patient age and sex, and highlighted the following surgical indications: translation <3 mm, translation ≥3 mm, sagittal plane angulation >5 degrees, and coronal plane angulation >5 degrees. Each case's scenario and radiographs after closed reduction were presented in a randomized manner. Consensus was defined as 80% agreement, and descriptive statistics were used to summarize the results.

RESULTS

In total, 33 of 37 surgeons completed the survey (89% response rate). All surgeons took trauma call at a level-1 pediatric trauma center and had an average of 8.8 years (SD: 6.5 y) of experience. Consensus was reached in 4 of 16 scenarios. Specifically, nonoperative management was recommended for all scenarios showing <3 mm of translation after closed reduction. The majority of surgeons recommended operative management in scenarios showing coronal plane angulation after closed reduction, but none of these scenarios reached consensus. There was a near-equal split in operative and nonoperative management in 8 of 16 scenarios. These scenarios showed ≥3 mm translation after closed reduction and sagittal plane angulation after closed reduction. Surgeons with 6 to 10 years in practice were the most likely to recommend surgery, especially in the case of >5 degrees coronal plane angulation postreduction ( P <0.05).

CONCLUSIONS

There is considerable variation regarding the indications for operative and nonoperative management of closed, SHII distal tibia fractures. Consensus was reached for nonoperative management in patients with <3 mm of translation after closed reduction; however, with greater deformity consensus regarding optimal treatment was unable to be achieved. The variation in the management of distal tibia SHII fractures is significant, suggesting that perhaps clinical equipoise exists between operative and nonoperative management.

LEVEL OF EVIDENCE

V.

Electron beam treatment for the removal of 1,4-dioxane in water and wastewater

Electron beam (e-beam) treatment uses accelerated electrons to form oxidizing and reducing radicals when applied to water without the use of external chemicals. In this study, electron beam treatment was used to degrade 1,4-dioxane in several water matrices. Removal improved in the progressively cleaner water matrices and removals as high as 94% to 99% were observed at a dose of 2.3 kGy in secondary effluent. 1,4-dioxane removal was confirmed to be primarily through hydroxyl radical oxidation. The calculated electrical energy per order was found to be 0.53, 0.26, and 0.08 kWh/m³/order for secondary effluent (Avg. total organic carbon (TOC) 9.25 mg/L), granular activated carbon effluent (TOC 3.46 mg/L), and ultrapure water, respectively, with a 70% generation and transfer efficiency applied.

Turning a lost reef ecosystem into a national restoration program

Achieving a sustainable socioecological future now requires large-scale environmental repair across legislative borders. Yet, enabling large-scale conservation is complicated by policy-making processes that are disconnected from socioeconomic interests, multiple sources of knowledge, and differing applications of policy. We considered how a multidisciplinary approach to marine habitat restoration generated the scientific evidence base, community support, and funding needed to begin the restoration of a forgotten, functionally extinct shellfish reef ecosystem. The key actors came together as a multidisciplinary community of researchers, conservation practitioners, recreational fisher communities, and government bodies that collaborated across sectors to rediscover Australia's lost shellfish reefs and communicate the value of its restoration. Actions undertaken to build a case for large-scale marine restoration included synthesizing current knowledge on Australian shellfish reefs and their historical decline, using this history to tell a compelling story to spark public and political interest, integrating restoration into government policy, and rallying local support through community engagement. Clearly articulating the social, economic, and environmental business case for restoration led to state and national funding for reef restoration to meet diverse sustainability goals (e.g., enhanced biodiversity and fisheries productivity) and socioeconomic goals (e.g., job creation and recreational opportunities). A key lesson learned was the importance of aligning project goals with public and industry interests so that projects could address multiple political obligations. This process culminated in Australia's largest marine restoration initiative and shows that solutions for large-scale ecosystem repair can rapidly occur when socially valued science acts on political opportunities.

Ozone disinfection of waterborne pathogens and their surrogates: A critical review

Viruses, Giardia cysts, and Cryptosporidium parvum oocysts are all major causes of waterborne diseases that can be uniquely challenging in terms of inactivation/removal during water and wastewater treatment and water reuse. Ozone is a strong disinfectant that has been both studied and utilized in water treatment for more than a century. Despite the wealth of data examining ozone disinfection, direct comparison of results from different studies is challenging due to the complexity of aqueous ozone chemistry and the variety of the applied approaches. In this systematic review, an analysis of the available ozone disinfection data for viruses, Giardia cysts, and C. parvum oocysts, along with their corresponding surrogates, was performed. It was based on studies implementing procedures which produce reliable and comparable datasets. Datasets were compiled and compared with the current USEPA Ct models for ozone. Additionally, the use of non-pathogenic surrogate organisms for prediction of pathogen inactivation during ozone disinfection was evaluated. Based on second-order inactivation rate constants, it was determined that the inactivation efficiency of ozone decreases in the following order: Viruses >> Giardia cysts > C. parvum oocysts. The USEPA Ct models were found to be accurate to conservative in predicting inactivation of C. parvum oocysts and viruses, respectively, however they overestimate inactivation of Giardia cysts at ozone Ct values greater than ∼1 mg min L-1. Common surrogates of these pathogens, such as MS2 bacteriophage and Bacillus subtilis spores, were found to exhibit different inactivation kinetics to mammalian viruses and C. parvum oocysts, respectively. The compilation of data highlights the need for further studies on disinfection kinetics and inactivation mechanisms by ozone to better fit inactivation models as well as for proper selection of surrogate organisms.

Evaluation of preformed monochloramine for bromate control in ozonation for potable reuse

Bromate, a regulated disinfection byproduct, forms during the ozonation of bromide through reactions with both ozone and hydroxyl radical. In this study, preformed monochloramine was evaluated for use as a bromate suppression method in pilot testing of wastewater reuse with an average bromide concentration of 422±20 µg/L. A dose of 3 mg/L NH₂Cl-Cl₂ decreased bromate formation by an average of 82% and was sufficient to keep bromate below the MCL at ozone doses up to 8.6 mg/L (1.2 O₃:TOC). Removal of 1,4-dioxane through ozonation decreased with increasing NH₂Cl dose, confirming that monochloramine suppresses bromate formation, at least in part, by acting as a hydroxyl radical scavenger. This may negatively impact oxidation objectives of ozonation in reuse applications. Increasing monochloramine contact time did not improve bromate suppression, indicating that monochloramine probably did not mask bromide as NHBrCl or other haloamines prior to ozonation. However, NHBrCl and NH₂Br may be formed from reactions between HOBr and NH₂Cl and excess free ammonia during ozonation. NDMA was formed by ozonation at concentrations up to 79 ng/L and was not enhanced by NH₂Cl addition.

Demonstration-scale evaluation of ozone-biofiltration-granular activated carbon advanced water treatment for managed aquifer recharge

The Sustainable Water Initiative for Tomorrow (SWIFT) program is the effort of the Hampton Roads Sanitation District to implement indirect potable reuse to recharge the depleted Potomac Aquifer. This initiative is being demonstrated at the 1-MGD SWIFT Research Center with a treatment train including coagulation/flocculation/sedimentation (floc/sed), ozonation, biofiltration (BAF), granular activated carbon (GAC) adsorption, and UV disinfection, followed by managed aquifer recharge. Bulk total organic carbon (TOC) removal occurred via multiple treatment barriers including, floc/sed (26% removal), ozone/BAF (30% removal), and adsorption by GAC. BAF acclimation was observed during the first months of plant operation which coincided with the establishment of biological nitrification and dissolved metal removal. Bromate formation during ozonation was efficiently controlled below 10 µg/L using preformed monochloramine and preoxidation with free chlorine. N-nitrosodimethylamine (NDMA) was formed at an average concentration of 53 ng/L post-ozonation and was removed >70% by the BAFs after several months of operation. Contaminants of emerging concern were removed by multiple treatment barriers including oxidation, biological degradation, and adsorption. The breakthrough of these contaminants and bulk TOC will likely determine the replacement interval of GAC. The ozone/BAC/GAC treatment process was shown to meet all defined treatment goals for managed aquifer recharge. PRACTITIONER POINTS: Floc/sed, biofiltration, and GAC adsorption provide important barriers in carbon-based treatment trains for bulk TOC and trace organic contaminant removal. Biofilter acclimation was observed during the first three months of operation in each operating period as evidenced by the establishment of nitrification. Bromate was effectively controlled during ozonation of a high bromide water with monochloramine doses of 3-5 mg/L. NDMA was formed at an average concentration of 53 ng/L by ozonation and complete removal was achieved by BAFs after several months of biological acclimation. An average 25% removal of 1,4-dioxane was achieved via oxidation by hydroxyl radicals during ozonation.

Using Chemical Structure Information to Develop Predictive Models for In Vitro Toxicokinetic Parameters to Inform High-throughput Risk-assessment

The toxicokinetic (TK) parameters fraction of the chemical unbound to plasma proteins and metabolic clearance are critical for relating exposure and internal dose when building in vitro-based risk assessment models. However, experimental toxicokinetic studies have only been carried out on limited chemicals of environmental interest (~1000 chemicals with TK data relative to tens of thousands of chemicals of interest). This work evaluated the utility of chemical structure information to predict TK parameters in silico; development of cluster-based read-across and quantitative structure-activity relationship models of fraction unbound or fub (regression) and intrinsic clearance or Cl_int (classification and regression) using a dataset of 1487 chemicals; utilization of predicted TK parameters to estimate uncertainty in steady-state plasma concentration (C_ss); and subsequent in vitro-in vivo extrapolation analyses to derive bioactivity-exposure ratio (BER) plot to compare human oral equivalent doses and exposure predictions using androgen and estrogen receptor activity data for 233 chemicals as an example dataset. The results demonstrate that fub is structurally more predictable than Cl_int. The model with the highest observed performance for fub had an external test set RMSE/σ=0.62 and R²=0.61, for Cl_int classification had an external test set accuracy = 65.9%, and for intrinsic clearance regression had an external test set RMSE/σ=0.90 and R²=0.20. This relatively low performance is in part due to the large uncertainty in the underlying Cl_int data. We show that C_ss is relatively insensitive to uncertainty in Cl_int. The models were benchmarked against the ADMET Predictor software. Finally, the BER analysis allowed identification of 14 out of 136 chemicals for further risk assessment demonstrating the utility of these models in aiding risk-based chemical prioritization.

Cytochrome b Mutations F129L and G143A Confer Resistance to Azoxystrobin in Cercospora nicotianae, the Frogeye Leaf Spot Pathogen of Tobacco

Azoxystrobin is the only synthetic, systemic fungicide labeled in the United States for management of frogeye leaf spot (FLS) of tobacco (Nicotiana tabacum L.), caused by Cercospora nicotianae. Though traditionally considered a minor disease in the United States, FLS has recently become yield and quality limiting. In 2016 and 2017, 100 C. nicotianae isolates were collected from symptomatic tobacco from eight counties in Kentucky, United States. Prior to azoxystrobin sensitivity testing, some C. nicotianae isolates were found to utilize the alternative oxidase pathway and, after assay comparisons, conidial germination was utilized to evaluate sensitivity in C. nicotianae as opposed to mycelial growth. Azoxystrobin sensitivity was determined by establishing the effective concentration to inhibit 50% conidial germination (EC50) for 47 (in 2016) and 53 (in 2017) C. nicotianae isolates. Distributions of C. nicotianae EC50 values indicated three qualitative levels of sensitivity to azoxystrobin. Partial cytochrome b sequence, encompassing the F129L and G143A mutation sites, indicated single-nucleotide polymorphisms (SNPs) conferring the F129L mutation in C. nicotianae of moderate resistance (azoxystrobin at 0.177 ≤ EC50 ≤ 0.535 µg/ml) and the G143A mutation in isolates with an azoxystrobin-resistant phenotype (azoxystrobin EC50 > 1.15 µg/ml). Higher frequencies of resistant isolates were identified from greenhouse transplant (4 of 17) and conventionally produced (58 of 62) tobacco samples, as compared with field-grown tobacco (<4 weeks prior to harvest; 4 of 62) or organically produced samples (1 of 7), respectively. Together, these results suggest that resistance to azoxystrobin in C. nicotianae occurs broadly in Kentucky, and generate new hypotheses about selection pressure affecting resistance mutation frequencies.

Assessing Toxicokinetic Uncertainty and Variability in Risk Prioritization

High(er) throughput toxicokinetics (HTTK) encompasses in vitro measures of key determinants of chemical toxicokinetics and reverse dosimetry approaches for in vitro-in vivo extrapolation (IVIVE). With HTTK, the bioactivity identified by any in vitro assay can be converted to human equivalent doses and compared with chemical intake estimates. Biological variability in HTTK has been previously considered, but the relative impact of measurement uncertainty has not. Bayesian methods were developed to provide chemical-specific uncertainty estimates for 2 in vitro toxicokinetic parameters: unbound fraction in plasma (fup) and intrinsic hepatic clearance (Clint). New experimental measurements of fup and Clint are reported for 418 and 467 chemicals, respectively. These data raise the HTTK chemical coverage of the ToxCast Phase I and II libraries to 57%. Although the standard protocol for Clint was followed, a revised protocol for fup measured unbound chemical at 10%, 30%, and 100% of physiologic plasma protein concentrations, allowing estimation of protein binding affinity. This protocol reduced the occurrence of chemicals with fup too low to measure from 44% to 9.1%. Uncertainty in fup was also reduced, with the median coefficient of variation dropping from 0.4 to 0.1. Monte Carlo simulation was used to propagate both measurement uncertainty and biological variability into IVIVE. The uncertainty propagation techniques used here also allow incorporation of other sources of uncertainty such as in silico predictors of HTTK parameters. These methods have the potential to inform risk-based prioritization based on the relationship between in vitro bioactivities and exposures.

Predicting Return to Work in a Heterogeneous Sample of Recently Injured Workers Using the Brief ÖMPSQ-SF

Purpose (1) to examine the ability of the Örebro Musculoskeletal Pain Screening Questionnaire-short version (ÖMPSQ-SF) to predict time to return to pre-injury work duties (PID) following a work-related soft tissue injury (regardless of body location); and (2) to examine the appropriateness of 50/100 as a suitable cut-off score for case identification. Methods Injured workers (IW) from six public hospitals in Sydney, Australia, who had taken medically-sanctioned time off work due to their injury, were recruited by insurance case managers within 5-15 days of their injury. Eligible participants (N = 213 in total) were administered the ÖMPSQ-SF over the telephone by the case manager. For objective (1) Cox proportional hazards regression analysis was used to predict days to return to PID using the ÖMPSQ-SF. For objective (2) receiver operator characteristic (ROC) analysis was used to determine the ÖMPSQ-SF total score that optimises sensitivity and specificity in detecting whether or not participants had returned to PID within 2-7 weeks. Results The total ÖMPSQ-SF score significantly predicted number of days to return to PID, such that for every 1-point increase in the total ÖMPSQ-SF score the predicted chance of returning to work reduced by 4% (i.e., hazard ratio = 0.96), p < 0.001. Sensitivity and specificity for the ROC analysis comparing ÖMPSQ-SF total score to return to PID within 2-7 weeks suggested 48 as the optimal cut off (sensitivity = 0.65, specificity = 0.79). Conclusion The results provide strong support for the use of the ÖMPSQ-SF in an applied setting for identifying those IW likely to have delayed RTW when administered within 15 days of the injury. While a score of 48/100 was the optimal cut point for sensitivity and specificity, pragmatically, 50/100 should be acceptable as a cut-off in future studies of this type.

Monitoring melanoma recurrence with circulating tumor DNA: a proof of concept from three case studies

BACKGROUND

A significant number of melanoma patients experience recurrence to distant sites, despite having had surgical treatment of the primary lesion, with curative intent. Monitoring of patients for early evidence of disease recurrence would significantly improve management of the disease, allowing timely therapeutic intervention. Circulating tumor DNA (ctDNA) is becoming a well-recognized biomarker for monitoring malignancies and has, in a few studies, been shown to signify disease recurrence earlier than conventional methods.

METHODS

We performed a retrospective analysis of plasma ctDNA using droplet digital PCR (ddPCR) in 30 primary melanoma patients with tumors harboring BRAF, NRAS or TERT promoter mutations. Mutant specific ctDNA, measured during clinical disease course, was compared with disease status in patients with confirmed disease recurrence (n = 3) and in those with no evidence of disease recurrence (n = 27).

RESULTS

Mutant specific ctDNA was detected in all three patients with disease recurrence at the time of clinically confirmed progression. In one case, plasma ctDNA detection preceded clinical identification of recurrence by an interval of 4 months. CtDNA was not detected in patients who were asymptomatic and had no radiological evidence of recurrence.

CONCLUSIONS

This study demonstrates promising results for the use of ctDNA as an informative monitoring tool for melanoma patients having undergone tumor resection of an early stage primary tumor. The clinical utility of ctDNA for monitoring disease recurrence warrants investigation in prospective studies as it may improve patient outcome.

Prognostic Relevance of CCDC88C (Daple) Transcripts in the Peripheral Blood of Patients with Cutaneous Melanoma

A loss of balance between G protein activation and deactivation has been implicated in the initiation of melanomas, and non-canonical Wnt signaling via the Wnt5A/Frizzled (FZD) pathway has been shown to be critical for the switch to an invasive phenotype. Daple [CCDC88C], a cytosolic guanine nucleotide exchange modulator (GEM) which enhances non-canonical Wnt5A/FZD signaling via activation of trimeric G protein, Gαi, has been shown to serve opposing roles-as an inducer of EMT and invasiveness and a potent tumor suppressor-via two isoforms, V1 (full-length) and V2 (short spliced isoform), respectively. Here we report that the relative abundance of these isoforms in the peripheral circulation, presumably largely from circulating tumor cells (CTCs), is a prognostic marker of cutaneous melanomas. Expression of V1 is increased in both the early and late clinical stages (p < 0.001, p = 0.002, respectively); V2 is decreased exclusively in the late clinical stage (p = 0.003). The two isoforms have opposing prognostic effects: high expression of V2 increases relapse-free survival (RFS; p = 0.014), whereas high expression of V1 tends to decrease RFS (p = 0.051). Furthermore, these effects are additive, in that melanoma patients with a low V2-high V1 signature carry the highest risk of metastatic disease. We conclude that detection of Daple transcripts in the peripheral blood (i.e., liquid biopsies) of patients with melanoma may serve as a prognostic marker and an effective strategy for non-invasive long-term follow-up of patients with melanoma.

Long-lived immunity to canine core vaccine antigens in UK dogs as assessed by an in-practice test kit

OBJECTIVES

To determine the utility of an in-practice test kit to detect protective serum antibody against canine distemper virus, canine adenovirus and canine parvovirus type 2 in a sample of the UK dog population.

MATERIALS AND METHODS

Serum samples from 486 dogs, last vaccinated between less than 1 month and 124 months previously, were tested with the VacciCheck™ test kit for protective antibodies against distemper, adenovirus and parvovirus type 2.

RESULTS

A high proportion of the dogs tested (93·6%) had protective antibody against all three of the core vaccine antigens: 95·7% of the dogs were seropositive against canine distemper virus, 97·3% against canine adenovirus and 98·5% against canine parvovirus type 2. The small number of dogs that were seronegative for one or more of the antigens (n = 31) may have had waning of previous serum antibody or may have been rare genetic non-responders to that specific antigen.

CLINICAL SIGNIFICANCE

UK veterinarians can be reassured that triennial revaccination of adult dogs with core vaccines provides long-lived protective immunity. In-practice serological test kits are a valuable tool for informing decision-making about canine core revaccination.

Graphene gas sensing using a non-contact microwave method

We report a non-contact CVD graphene gas sensing method that utilises a high Q microwave dielectric resonator perturbation technique. A graphene sample is coupled to the evanescent field of a dielectric resonator whereupon nitrogen dioxide (NO₂), a p-doping gas, is detected by monitoring the change in the linewidth and frequency of the resonant mode. The resonant peak shape is dependent on the number of carriers in the graphene sheet. Therefore, the linewidth perturbation can be converted to a measurement of the graphene sheet resistance. To demonstrate the strength of this technique, sensor response curves for NO₂ at different concentrations and temperatures are measured showing sub ppm sensitivity. This technique eliminates interactions between the trace gas and metal contacts that otherwise effect the sensor response of the graphene device.

An Intuitive Approach for Predicting Potential Human Health Risk with the Tox21 10k Library

In vitro-in vivo extrapolation (IVIVE) analyses translating high-throughput screening (HTS) data to human relevance have been limited. This study represents the first report applying IVIVE approaches and exposure comparisons using the entirety of the Tox21 federal collaboration chemical screening data, incorporating assay response efficacy and quality of concentration-response fits, and providing quantitative anchoring to first address the likelihood of human in vivo interactions with Tox21 compounds. This likelihood was assessed using a maximum blood concentration to in vitro response ratio approach (C_max/AC₅₀), analogous to decision-making methods for clinical drug-drug interactions. Fraction unbound in plasma (f_up) and intrinsic hepatic clearance (CL_int) parameters were estimated in silico and incorporated in a three-compartment toxicokinetic (TK) model to first predict C_max for in vivo corroboration using therapeutic scenarios. Toward lower exposure scenarios, 36 compounds of 3925 unique chemicals with curated activity in the HTS data using high-quality dose-response model fits and ≥40% efficacy gave "possible" human in vivo interaction likelihoods lower than median human exposures predicted in the United States Environmental Protection Agency's ExpoCast program. A publicly available web application has been designed to provide all Tox21-ToxCast dose-likelihood predictions. Overall, this approach provides an intuitive framework to relate in vitro toxicology data rapidly and quantitatively to exposures using either in vitro or in silico derived TK parameters and can be thought of as an important step toward estimating plausible biological interactions in a high-throughput risk-assessment framework.

How Source Affects Response to Public Service Advertising

Advertising Council produces highest evaluation but lowest behavioral response of three sources used for PSAs

Clinical pharmacist review: a randomised controlled trial

OBJECTIVES

To determine if medication review by a clinical pharmacist of older patients in the ED impacted on admission to hospital and other outcomes.

METHODS

A stratified, randomised controlled study comparing the intervention to current practice. A tertiary referral ED in New South Wales, Australia. Older people (>70 years) living at home who initially reported taking greater than five medications. Medication review by an experienced hospital pharmacist within the ED. Rate of admission, rate of readmission, length of stay and admission to an aged care facility at 4 months post presentation, and rate of general practitioner acceptance of pharmacist recommendations.

RESULTS

The odds of admission decreased for those receiving the intervention (odds ratio [OR] = 0.68, 95% confidence interval [CI]: 0.53, 0.87; P = 0.002). There was no evidence that the intervention affected hospital length of stay for admitted patients (0.09 days change, 95% CI -0.08, 0.25; P = 0.31), the rate of re-presentation (0.08% change, 95% CI -0.12, 0.28; P = 0.44) or admission to an aged care facility. The odds of admission to an aged care facility increased with the Identification of Seniors at Risk score. General practitioners adopted 49% of pharmacists' recommendations.

CONCLUSIONS

The presence of an experienced pharmacist in the ED reduced hospital admissions. Further study is required to determine longer term impacts of General Medical Practitioner acceptance of pharmacists' recommendations.

Toxicokinetic Triage for Environmental Chemicals

Toxicokinetic (TK) models link administered doses to plasma, blood, and tissue concentrations. High-throughput TK (HTTK) performs in vitro to in vivo extrapolation to predict TK from rapid in vitro measurements and chemical structure-based properties. A significant toxicological application of HTTK has been "reverse dosimetry," in which bioactive concentrations from in vitro screening studies are converted into in vivo doses (mg/kg BW/day). These doses are predicted to produce steady-state plasma concentrations that are equivalent to in vitro bioactive concentrations. In this study, we evaluate the impact of the approximations and assumptions necessary for reverse dosimetry and develop methods to determine whether HTTK tools are appropriate or may lead to false conclusions for a particular chemical. Based on literature in vivo data for 87 chemicals, we identified specific properties (eg, in vitro HTTK data, physico-chemical descriptors, and predicted transporter affinities) that correlate with poor HTTK predictive ability. For 271 chemicals we developed a generic HT physiologically based TK (HTPBTK) model that predicts non-steady-state chemical concentration time-courses for a variety of exposure scenarios. We used this HTPBTK model to find that assumptions previously used for reverse dosimetry are usually appropriate, except most notably for highly bioaccumulative compounds. For the thousands of man-made chemicals in the environment that currently have no TK data, we propose a 4-element framework for chemical TK triage that can group chemicals into 7 different categories associated with varying levels of confidence in HTTK predictions. For 349 chemicals with literature HTTK data, we differentiated those chemicals for which HTTK approaches are likely to be sufficient, from those that may require additional data.

Circulating Melanoma Cell Subpopulations: Their Heterogeneity and Differential Responses to Treatment

Metastatic melanoma is a highly heterogeneous tumor; thus, methods to analyze tumor-derived cells circulating in blood should address this diversity. Taking this into account, we analyzed, using multiparametric flow cytometry, the co-expression of the melanoma markers melanoma cell adhesion molecule and melanoma-associated chondroitin sulphate proteoglycan and the tumor-initiating markers ATP-binding cassette sub-family B member 5 (ABCB5), CD271, and receptor activator of NF-κβ (RANK) in individual circulating tumor cells (CTCs) from 40 late-stage (III-IV) and 16 early-stage (I-II) melanoma patients. CTCs were heterogeneous within and between patients, with limited co-expression between the five markers analyzed. Analysis of patient matched blood and metastatic tumors revealed that ABCB5 and RANK subpopulations are more common among CTCs than in the solid tumors, suggesting a preferential selection for these cells in circulation. Pairwise comparison of CTC subpopulations longitudinally before and 6-13 weeks after treatment initiation showed that the percentage of RANK(+) CTCs significantly increased in the patients undergoing targeted therapy (N=16, P<0.01). Moreover, the presence of ⩾5 RANK(+) CTCs in the blood of patients undergoing targeted therapies was prognostic of shorter progression-free survival (hazards ratio 8.73, 95% confidence interval 1.82-41.75, P<0.01). Taken together, our results provide evidence of the heterogeneity among CTC subpopulations in melanoma and the differential response of these subpopulations to targeted therapy.

Low energy fractures of the acetabulum

INTRODUCTION

Acetabular fractures due to high energy injuries are common and well documented; those secondary to low energy mechanisms are less well described. We undertook a retrospective study of the acetabular fracture referrals to our unit to evaluate the proportion of injuries resulting from a low energy mechanism.

METHODS

A total of 573 acetabular fractures were evaluated from 1 January 2005 to 31 December 2008. The plain radiography and computed tomography of those sustaining a low energy fracture were assessed and the fracture patterns classified.

RESULTS

Of the 573 acetabular fractures, 71 (12.4%) were recorded as being a result of a low energy mechanism. The male-to-female ratio was 2.4:1 and the mean patient age was 67.0 years (standard deviation: 19.1 years). There was a significantly higher number of fractures (p<0.001) involving the anterior column (with or without a posterior hemitransverse component) than in a number of previously conducted large acetabular fracture studies.

CONCLUSIONS

Our results demonstrate that low energy fractures make up a considerable proportion of acetabular fractures with a distinctly different fracture pattern distribution. With the continued predicted rise in the incidence of osteoporosis, life expectancy and an aging population, it is likely that this type of fracture will become increasingly more common, posing difficult management decisions and leading to procedures that are technically more challenging.

The use, misuse and abuse of dabigatran

The tale of dabigatran sounds some cautionary notes about proper critical appraisal of new randomised controlled trials,care in deciding on the generalisability of results, judicious screening of patients and lessons about the politics around increasingly lucrative drugs. The old lesson of caveat utilitor still holds: let the user beware!

Evidence for a GVL effect following reduced-intensity allo-SCT in ALL: a British Society of Blood and Marrow Transplantation study

Myeloablative allo-SCT decreases relapse incidence (RI) in ALL. Reduced intensity conditioning (RIC) may extend allo-SCT to older and less fit patients. Sixty-nine ALL patients reported to the BSBMT underwent fludarabine-based RIC allo-SCT, 38 from unrelated donors (UD). Forty-four patients received alemtuzumab. ALL was in CR in 64 patients (93%). This was a second or third SCT in 23 patients. Two-year OS and PFS were 36% and 32%, respectively. In multivariate analysis male recipients demonstrated better OS and PFS (hazard ratio (HR) = 0.42, P = 0.008 and HR = 0.45, P = 0.012, respectively). Two-year TRM was 29%: higher with younger age (HR = 0.97/year, P = 0.041), female recipient (HR = 2.55, P = 0.049) and increasing grade of acute GVHD (HR = 1.87, P = 0.001). Two-year RI was 38% and was lower in patients with acute and chronic GVHD (HR = 0.62 per increasing grade, P = 0.035 and HR = 0.52, P = 0.025, respectively). Long-term ALL-free survival is achievable following fludarabine-based RIC allo-SCT. The association between GVHD and decreased RI suggests the presence of a GVL effect.

Markers of circulating tumour cells in the peripheral blood of patients with melanoma correlate with disease recurrence and progression

BACKGROUND

Multimarker quantitative real-time polymerase chain reaction (qRT-PCR) represents an effective method for detecting circulating tumour cells in the peripheral blood of patients with melanoma.

OBJECTIVES

To investigate whether the phenotype of circulating melanoma cells represents a useful indicator of disease stage, recurrence and treatment efficacy.

METHODS

  Peripheral blood was collected from 230 patients with melanoma and 152 healthy controls over a period of 3years and 9months. Clinical data and blood samples were collected from patients with primary melanoma (early stages, 0-II, n=154) and metastatic melanoma (late stages, III-IV, n=76). Each specimen was examined by qRT-PCR analysis for the expression of five markers: MLANA, ABCB5, TGFβ2, PAX3d and MCAM.

RESULTS

 In total, 212 of the patients with melanoma (92%) expressed markers in their peripheral blood. Two markers, MLANA and ABCB5, had the greatest prognostic value, and were identified as statistically significant among patients who experienced disease recurrence within our study period, being expressed in 45% (MLANA) and 49% (ABCB5) of patients with recurrence (P=0·001 and P=0·031, respectively). For patients administered nonsurgical treatments, MCAM expression correlated with poor treatment outcome.

CONCLUSIONS

Circulating tumour cells were detectable at all stages of disease and long after surgical treatment, even when patients were considered disease free. Specifically, expression of ABCB5 and MLANA had significant prognostic value in inferring disease recurrence, while MCAM expression was associated with poor patient outcome after treatment, confirming multimarker qRT-PCR as a potential technique for monitoring disease status.