The toxicologic hazard of superfund hazardous-waste sites

Uncontrolled hazardous-waste sites are a major environmental and public health concern in the United States and elsewhere. The remediation of and public health responses to these sites is mandated by the federal Superfund statute. Approximately 40,000 uncontrolled waste sites have been reported to U.S. federal agencies. About 1,300 of these sites constitute the current National Priorities List (NPL) of sites for remediation. Findings from a national database on NPL sites show approximately 40% present completed exposure pathways, although this figure rose to 80% in 1996. Data from 1992 through 1996 indicate that 46% of sites are a hazard to public health. Thirty substances are found at 6% or more of sites with completed pathways. Eighteen of the substances are known human carcinogens or reasonably anticipated to be carcinogenic. Many of the 30 substances also possess systemic toxicity. The high percentage of sites with completed exposure pathways and the toxicity potential of substances in these pathways show that uncontrolled hazardous-waste sites are a major environmental threat to human health. Findings from the United States' experience in responding to uncontrolled waste sites are relevant to other countries as they address similar environmental and public health concerns.

Epidemiology of sepsis syndrome in 8 academic medical centers

CONTEXT

Sepsis syndrome is a leading cause of mortality in hospitalized patients. However, few studies have described the epidemiology of sepsis syndrome in a hospitalwide population.

OBJECTIVE

To describe the epidemiology of sepsis syndrome in the tertiary care hospital setting.

DESIGN

Prospective, multi-institutional, observational study including 5-month follow-up.

SETTING

Eight academic tertiary care centers.

METHODS

Each center monitored a weighted random sample of intensive care unit (ICU) patients, non-ICU patients who had blood cultures drawn, and all patients who received a novel therapeutic agent or who died in an emergency department or ICU. Sepsis syndrome was defined as the presence of either a positive blood culture or the combination of fever, tachypnea, tachycardia, clinically suspected infection, and any 1 of 7 confirmatory criteria. Estimates of total cases expected annually were extrapolated from the number of cases, the period of observation, and the sampling fraction.

RESULTS

From January 4, 1993, to April 2, 1994, 12759 patients were monitored and 1342 episodes of sepsis syndrome were documented. The extrapolated, weighted estimate of hospitalwide incidence (mean+/-95% confidence limit) of sepsis syndrome was 2.0+/-0.16 cases per 100 admissions, or 2.8+/-0.17 per 1000 patient-days. The unadjusted attack rate for sepsis syndrome between individual centers differed by as much as 3-fold, but after adjustment for institutional differences in organ transplant populations, variation from the expected number of cases was reduced to 2-fold and was not statistically significant overall. Patients in ICUs accounted for 59% of total extrapolated cases, non-ICU patients with positive blood cultures for 11%, and non-ICU patients with negative blood cultures for 30%. Septic shock was present at onset of sepsis syndrome in 25% of patients. Bloodstream infection was documented in 28%, with gram-positive organisms being the most frequent isolates. Mortality was 34% at 28 days and 45% at 5 months.

CONCLUSIONS

Sepsis syndrome is common in academic hospitals, although the overall rates vary considerably with the patient population. A substantial fraction of cases occur outside ICUs. An understanding of the hospitalwide epidemiology of sepsis syndrome is vital for rational planning and treatment of hospitalized patients with sepsis syndrome, especially as new and expensive therapeutic agents become available.

Microbiological cultures of heart valves and valve tags are not valuable for patients without infective endocarditis who are undergoing valve replacement

We evaluated the significance of the results of microbiological cultures of heart valves and identification tags from newly inserted prosthetic valves that were removed from patients with valvular heart disease; none of these patients had a preoperative diagnosis of endocarditis. We reviewed the charts of patients with positive cultures for evidence of infections before or after surgery. Cultures were positive for 11.9% of 219 valves (206 native valves and 13 prosthetic or bioprosthetic valves) and 11.6% of 224 tags. The most common isolates were coagulase-negative staphylococci. Typical agents of endocarditis--viridans streptococcus, Enterococcus faecalis, and Staphylococcus aureus--were cultured from five specimens, and Mycobacterium avium complex was identified in six valves. None of the patients with positive valve or tag cultures developed postsurgical endocarditis or wound infection. Findings on histopathologic examination of the valves were not consistent with endocarditis. We conclude that the results of cultures of valves from patients without preoperative diagnoses of endocarditis lack clinical significance, and positive tag cultures are not predictive of postsurgical infection. Positive cultures are most likely a result of contamination during surgery or thereafter.

Natural history of infrainguinal vein graft stenosis relative to bypass grafting technique

PURPOSE

To determine whether the incidence of vein graft stenosis is related to bypass grafting technique and thus modification of postoperative surveillance protocols may be required.

METHODS

From 1991 to 1996, 338 infrainguinal vein bypasses constructed using in situ (n = 131), reversed (n = 120), nonreversed translocated (n = 48), or spliced/upper extremity vein (n = 39) grafting techniques were evaluated by intraoperative duplex scanning to optimize bypass construction and serially thereafter to detect developing vein graft stenoses. Bypass procedures were performed in 322 patients for critical limb ischemia (83%), claudication (13%), or popliteal aneurysm (4%). Using life-table analysis, graft patency and revision/failure rates were compared relative to grafting technique, need for operative revision, and intraoperative duplex scan results.

RESULTS

Three-year primary and secondary graft patency rates were higher (p < 0.001) for in situ bypass grafts (85%/97%) compared with reversed (57%/83%), nonreversed translocated (62%/78%), or alternative (51%/76%) vein bypass grafts. During a mean follow-up interval of 19 months, the incidence of graft revision was higher for reversed saphenous (23%) and alternative (28%) vein bypass grafts compared with in situ (10%) or nonreversed (16%) saphenous vein bypass grafts. Despite a normal intraoperative graft duplex scan, the revision/failure rate of reversed vein grafts was 2.5 times greater than in situ/nonreversed translocated vein conduits (primary patency rate at 3 years, 60% vs 87%, p = 0.009). Bypass grafts modified at operation on the basis of duplex scanning were two times more likely to require postoperative revision than grafts with normal intraoperative scans.

CONCLUSIONS

The incidence of postoperative graft stenosis and need for revision varies with bypass grafting technique. Reversed vein bypasses and grafts modified at operation may be more prone than in situ vein bypass grafts to develop stenosis and thus require intensive surveillance. Infrainguinal vein graft failure and the need for revision may be reduced by the adoption of bypass grafting techniques that include valve lysis and intraoperative duplex scan assessment.

Feasibility of obtaining pulmonary venous flow velocity in cardiac patients using transthoracic pulsed wave Doppler technique

The purpose of this study was to determine, in an adult population, the percentage of patients in whom high quality pulmonary venous flow velocity recordings can be obtained using current transthoracic pulsed wave Doppler techniques. Pulmonary venous and mitral flow velocity variables obtained with a pulsed wave Doppler method were used for the indirect assessment of left ventricular (LV) diastolic function and LV filling pressures. The general clinical use of these methods, however, remains uncertain because the transthoracic success rate of obtaining all components of pulmonary venous flow velocity has been variable, and sometimes reported to be as low as 30% to 60%. Mitral and pulmonary venous flow velocity variables were obtained using pulsed wave Doppler signals in 200 consecutive adult patients (mean age 68.2 +/- 11.4 years) in normal sinus rhythm who were referred for echocardiographic study. Six cardiac sonographers and five ultrasound systems were used. The success rate for obtaining pulmonary venous systolic and diastolic flow velocity was 95%, reverse flow velocity at atrial contraction was 90%, and the duration of reverse flow at atrial contraction was 89%. In the 5% to 11% of patients in whom pulmonary flow velocities could not be adequately recorded, the most common reasons were depth limitations of the pulsed wave Doppler machine, marked cardiac enlargement, or left atrial wall motion artifact. The success rate also was influenced by the ultrasound equipment used, individual variation among sonographers, and even the type (impaired, pseudonormal, restricted) of associated mitral filling pattern. Given current machine technology, sonographer education, and daily practice, high quality, complete recordings of pulmonary venous flow velocity can be obtained in approximately 90% of adult patients using the precordial transthoracic Doppler technique. These results suggest that using these variables as an aid for evaluating LV diastolic function and filling pressures may have broader clinical applicability than previously appreciated.

The Triennial International Symposium on Neurobehavioral Methods: the history and hope

In 1982 in Milan, Italy, a series of triennial international symposia on neurobehavioral methods and their application commenced. Five of these symposia have been conducted. This paper reviews the origin of this neurobehavioral symposium and recounts the key findings and observations produced during each. In particular, the commitment of the symposium's organizers to meeting the needs of developing countries is discussed. An examination of the five symposia found that more than 250 papers have been published as proceedings. Furthermore, the symposia have maintained the original intent to assist developing countries. The symposium continues to emphasize the need to relate basic mechanisms of neurotoxicity to various neurobehavioral test batteries and methods.

Congenital aphakia: a clinicopathologic report of three cases

BACKGROUND

Congenital aphakia is a rare condition that has been classified as primary when no lens induction of the surface ectoderm occurs and secondary when lens development takes place but later is resorbed or expelled in utero.

METHODS

The authors report the clinical and pathologic findings in three infants with congenital aphakia whose eyes were enucleated either at surgery at 11 months or at autopsy after 1 and 3 days of life.

RESULTS

Two cases classified as primary congenital aphakia had severe microphthalmos, anterior segment aplasia, or anomalous development and posterior choroidal and optic disc colobomas. One was in a case believed to be Waardenburg's recessive anophthalmia syndrome and the other had 18 trisomy. A case of secondary congenital aphakia had findings of Peter's syndrome and features suggesting rubella, which had been observed in some previous reports.

CONCLUSIONS

Primary congenital aphakia can result from a variety of teratogenic events in the first 4 weeks of embryogenesis and results in microphthalmos and severe anterior segment aplasia/dysplasia. Secondary congenital aphakia is associated with less severe ocular anomalies. The possible role of deletion or mutation involving the PAX6 gene in anterior segment anomalies and induction of lens development is discussed. In addition to chromosomal influences, in utero viral infection, particularly rubella, may play a role in some cases.

Public health implications of hazardous waste sites: findings, assessment and research

In this paper we present an overview of the chemicals released from hazardous waste sites (HWS) and some of the mixtures of substances that have been released into environmental media. We describe how this information can be used to assess the public health hazard of releases of chemical mixtures from waste sites. Wherever possible, research on chemical mixtures should use chemical mixtures actually identified in, or representative of, mixtures in environmental media. A narrative, weight-of-evidence approach to characterize the toxicity of mixtures that incorporates mechanistic insights on chemical interactions is described. The utility of this information in the context of risk analysis and public health practice is discussed.

A comparison of three subjective tests for astigmatism and their interexaminer reliabilities

BACKGROUND

Astigmatism is a common cause of blurred vision and asthenopia. Several different tests for the measurement of astigmatism have been described in the literature, but there are few studies that have compared the results of various tests.

METHODS

The results of three astigmatism tests performed on 40 subjects by two examiners were compared. Two of the tests, the Jackson cross cylinder (JCC) and the Humphriss immediate contrast (HIC), utilized distance targets; one test, the Pratt test, involved a near target.

RESULTS

The mean differences between all tests were less than 0.25D. There was a slight tendency for higher cylinder power to be found on the Pratt test. The three tests agreed within +/- 0.25D on cylinder power 80 to 98 percent of the time and within 10 degrees of cylinder axis 85 to 98 percent of the time. Interexaminer reliability showed mean differences less than 0.12D for each of the three tests, agreement within +/- 0.25D on cylinder power 88 to 90 percent of the time and within 10 degrees on cylinder axis 85 to 93 percent of the time.

CONCLUSIONS

The results suggested that any of the three techniques could be substituted for another for astigmatism testing. On theoretical grounds, a binocular refraction method for cylinder axis determination, such as the HIC, is advisable for patients with cyclophorias and significant amounts of astigmatism. The results showed good reliability for each of the three methods.

Nature and management of duplex abnormalities encountered during infrainguinal vein bypass grafting

PURPOSE

This study was undertaken to evaluate the application of duplex scanning during infrainguinal vein grafting procedures to verify vein conduit preparation, anastomotic patency, and graft hemodynamics.

METHODS

Between 1991 and 1995, 275 infrainguinal vein bypasses (in situ, 114; reversed, 82; nonreversed translocated, 48; spliced alternative/arm vein, 31) to the popliteal (n = 116) or an infrageniculate artery (n = 159) were scanned during surgery for sites of color Doppler flow abnormality. Duplex-detected defects were graded with peak systolic velocity and velocity ratio criteria. Sites that demonstrated highly disturbed flow (peak systolic velocity > 180 cm/sec, velocity ratio > 2.4) were immediately revised by direct repair, patch angioplasty, or interposition grafting.

RESULTS

Intraoperative duplex scanning prompted revision of 50 abnormalities in 43 of the 275 grafts (16%), including 32 vein and seven anastomotic stenoses, nine vein segments with platelet thrombus, and two bypasses with low flow. The intraoperative revision rate was lowest (p < 0.02) for reversed saphenous vein bypasses (7%) compared with other grafting techniques (in situ, 20%; nonreversed translocated, 15%; spliced alternative vein, 23%). The revision rates of popliteal and tibial bypasses were similar (14% vs 17%). A normal result shown by intraoperative scan (235 bypasses) was associated with a low 90-day thrombosis (0.4%) and revision (2%) rate, whereas six of 15 grafts (40%) with residual and 13 of 25 grafts (52%) with unrepaired duplex abnormalities required corrective procedures (p < 0.001). One graft failed within 3 months (secondary patency rate, 99%).

CONCLUSIONS

Intraoperative duplex scanning accurately predicted the technical adequacy of infrainguinal vein grafts and was particularly useful in assessing bypasses constructed with valve lysis techniques or alternative veins. Early graft revisions indicated by duplex monitoring for thrombosis or stenosis were the result of a progression of residual defects and platelet thrombus formation rather than inadequate graft run-off flow.

Neurophysiological and neuropathological evaluation of primates exposed to ethylene oxide and propylene oxide

Over 500,000 workers in the United States are exposed to ethylene oxide and propylene oxide. These two solvents are used as chemical intermediates, as well as components in the manufacture of fumigants and food preparation. The neurophysiologic and neuropathologic effects of these two organic oxides were investigated in five groups of 12 primates after exposure to 50 or 100 ppm ethylene oxide, 100 or 300 ppm propylene oxide, or no chemical (sham-exposed). Animals were exposed for 7 h/day, 5 days/wk for 24 months. Body weights, electroencephalograms, and motor nerve conduction velocities of the sciatic and ulnar nerves were assessed six times throughout the exposure period. Although the monkeys exposed to 100 ppm ethylene oxide had significantly lower mean weights, nerve conduction velocities did not differ significantly among the groups. Following termination of exposures, ten animals (two from each exposure group) were sacrificed for neuropathological examinations. Multiple axonal bodies were found in the nucleus gracilis in seven of eight oxide-exposed animals, and demyelination was found in two monkeys exposed to ethylene oxide. In contrast, a single axonal body was found in one of the two sham-control monkeys. However, the lack of a dose-response relationship suggests that this effect may not be related to oxide exposure. In a follow-up study, nerve conduction velocity and neuropathology were assessed in the remaining monkeys seven years after exposure terminated, but again, treatment-related effects could not be detected.

In situ repair of mycotic abdominal aortic aneurysms with rifampin-bonded gelatin-impregnated Dacron grafts: a preliminary case report

Treatment of mycotic aortic aneurysm by excision and extraanatomic bypass is difficult to apply when the infectious process involves the visceral arteries. On the basis of experimental studies in our laboratory that demonstrated prolonged antistaphylococcal activity of rifampin-bonded, gelatin-impregnated Dacron grafts after implantation in the arterial circulation, this conduit was successfully used for in situ replacement of a native aortic infection in two patients. Both patients had fever, leukocytosis, abdominal or back pain, and a computed tomographic scan that demonstrated contained rupture of a mycotic aneurysm. Preoperative computed tomography-guided aspiration and culture of periaortic fluid from one patient grew Staphylococcus aureus. Treatment consisted of prolonged (6 weeks) culture-specific parenteral antibiotic therapy, excision of involved aorta, oxychlorosene irrigation of the aortic bed, and restoration of aortic continuity by in situ prosthetic replacement. A preliminary right axillobifemoral bypass was performed in the patient who had an infection involving the suprarenal and infrarenal aorta. In both patients intraoperative culture of aorta wall recovered S. aureus. Patients were discharged at 20 and 21 days. Clinical follow-up and computed tomographic imaging of the replacement graft beyond 10 months after surgery demonstrated no signs of residual aortic infection. In the absence of gross pus and frank sepsis, the use of an antibiotic-bonded prosthetic graft with antistaphylococcal activity should be considered in patients who have arterial infections caused by S. aureus when excision and ex situ bypass are not feasible.

Elevated levels of recombinational DNA repair in human somatic cells expressing the Saccharomyces cerevisiae RAD52 gene

The Saccharomyces cerevisiae RAD52 gene was introduced into the human fibrosarcoma-derived cell line HT1080. Transfected cell lines that expressed the yeast transgene catalyzed inter-plasmid homologous DNA recombination at frequencies approx. 12-fold higher than did control cells. Additional experiments revealed that yeast RAD52 gene expression increased the level of resistance to the DNA damaging agents diepoxybutane, and methyl methanesulfonate, but did not alter sensitivity to ultraviolet radiation. These results indicate that the S. cerevisiae Rad52 protein can function in a human somatic cell background and provide support for the idea that a homologous recombination-based DNA repair process functions in mammalian somatic cells.

Anatomic patterns of carotid endarterectomy healing

BACKGROUND

Restenosis after carotid endarterectomy is a dynamic process likely influenced by surgical technique as well as by anatomic, hemodynamic, and patient factors.

METHODS

To characterize the healing of carotid endarterectomy sites, intraoperative and serial postoperative color duplex scans were performed in 126 patients (136 repairs). Vessel-wall imaging, midstream spectral analysis, and measurements of diameter and cross-sectional area from common carotid artery (CCA) and internal carotid artery (ICA) segments were compared (at 3, 6, 15, and 30 months) and severity of lumen stenosis was determined.

RESULTS

After primary closure (n = 15), patch angioplasty (n = 121), or intraoperative revision based on duplex scanning (n = 5), 12 repairs had mild residual flow abnormalities and 1 repair had a moderate flow abnormality. Mean ICA bulb diameter was greater in patched repairs (0.81 cm, range 0.6 to 1.1 cm) than primary closed repairs (0.7 cm, range 0.45 to 0.8 cm). No ICA occluded during follow-up (mean 24 months), and three repairs, two in the ICA and one in the CCA, demonstrated 50% to 75% diameter reduction at 9 months. Lumen cross-sectional area of vein-patched repairs increased 0.6 cm2 to 0.76 cm2 (P < 0.01) in the ICA and 0.69 cm2 to 1.1 cm2 (P < 0.01) in the CCA segments by 3 months compared with intraoperative measurement. Four patients with progressive dilatation of the patch segment to a mean of 1.77 cm2 developed asymptomatic posterior wall mural thrombus. Postoperative blood flow velocities measured through the repair were similar to intraoperative values. Minor intraoperative hemodynamic abnormalities were not associated with the development of restenosis, and changes in repair site anatomy occurred within 3 months with little change thereafter.

CONCLUSIONS

We have found intraoperative scanning useful for detection of anatomic defects and associated turbulence, lesions that should be immediately corrected. Surgical technique that achieves normal intraoperative carotid flow hemodynamics and B-mode ultrasonic vessel wall appearance should predict an endarterectomized segment free of significant residual plaques and neointimal hyperplasia. Tailoring of the vein patches to achieve lumen diameters < 1 cm is recommended because of the dilataton likely to develop after surgery that may lead to vessel wall mural thrombus.

Strategic elements of ATSDR's Great Lakes Human Health Effects Research Program

The goal of the Agency for Toxic Substances and Disease Registry's (ATSDR) Great Lakes Human Health Effects Research Program is to identify at-risk populations and to prevent potential human health effects associated with exposure to chemical contaminants in the Great Lakes basin. While this research effort is mandated by the Great Lakes Critical Programs Act of 1990, it also represents a significant opportunity to define a broader model or strategy for other regional or systems-level studies of potential health effects in at-risk populations. This article describes the strategy developed by ATSDR for this purpose in the Great Lakes Basin, as well as the program's specific research objectives and current status. It also outlines the projected implications of this research effort for greater comprehension of the potential health effects of exposure to contaminants in the Great Lakes Basin.

Rosai-Dorfman disease presenting with multiple orbital and intracranial masses

Rosai-Dorfman disease is an idiopathic histocytic proliferative disorder typically characterized by painless cervical adenopathy, fever, and weight loss. Extranodal manifestations are responsible for presentation in approximately 25% of patients. Orbital involvement has been described in about 10% of patients. There have been only 16 reported cases of Rosai-Dorfman disease presenting with an intracranial mass. We report an unusual case of a patient presenting with bilateral orbital tumors as well as multiple intracranial masses. Clinical, magnetic resonance imaging, and histopathological features are discussed.

Identification of a human RAD52 pseudogene located on chromosome 2

A human testis cDNA library was screened with a hybridization probe encoding the mouse RAD52 gene. Two classes of clones were identified, one derived from the human RAD52 homolog (hRAD52), the other derived from a pseudogene. In addition to many point mutations, several of which encode stop codons, the pseudogene contains a number of frame shifts and a 103-bp deletion. We further determined that the pseudogene is processed and is located on human chromosome 2, in contrast to hRAD52 which is found on chromosome 12. Reverse transcription-PCR analysis of cultured human diploid fibroblasts, as well as fibrosarcoma cells, revealed that while hRAD52 is expressed at low, but detectable levels in these cells, the pseudogene is not.

Brca1 deficiency results in early embryonic lethality characterized by neuroepithelial abnormalities

The breast and ovarian cancer susceptibility gene, BRCA1, has been cloned and shown to encode a zinc-finger protein of unknown function. Mutations in BRCA1 account for at least 80% of families with both breast and ovarian cancer, as well as some non-familial sporadic ovarian cancers. The loss of wild-type BRCA1 in tumours of individuals carrying one nonfunctional BRCA1 allele suggests that BRCA1 encodes a tumour suppressor that may inhibit the proliferation of mammary epithelial cells. To examine the role of BRCA1 in normal tissue growth and differentiation, and to generate a potential model for the cancer susceptibility associated with loss of BRCA1 function, we have created a mouse line carrying a mutation in one Brca1 allele. Analysis of mice homozygous for the mutant allele indicate that Brca1 is critical for normal development, as these mice died in utero between 10 and 13 days of gestation (E10-E13). Abnormalities in Brca1-deficient embryos were most evident in the neural tube, with 40% of the embryos presenting with varying degrees of spina bifida and anencephaly. In addition, the neuroepithelium in Brca1-deficient embryos appeared disorganized, with signs of both rapid proliferation and excessive cell death.

Optic nerve elongation: does it exist?

The length of the optic nerves is a reflection of normal postnatal cranio-orbital development. Unilateral elongation of an optic nerve has been observed in two patients with orbital and skull base neoplasms. In the first case as compared to the patient's opposite, normal optic nerve, an elongated length of the involved optic nerve of 45 mm was present. The involved optic nerve in the second patient was 10 mm longer than the normal opposite optic nerve. The visual and extraocular function was preserved in the second patient. The first patient had only light perception in the affected eye. In this paper, the embryology, anatomy, and physiology of the optic nerve and its mechanisms of stretch and repair are discussed.

Chemical mixtures released from hazardous waste sites: implications for health risk assessment

Uncontrolled hazardous waste sites (HWS) and exposure to hazardous substances continue to pose complex public health problems. This paper presents an overview of chemicals, including chemical mixtures, that have been released into environmental media in the vicinity of HWS. We describe how this type of information is being used to assess the public health implications of exposures to chemical mixtures and to develop an integrated program of applied research to more accurately characterize the potential health effects of chemical mixtures. A narrative, weight-of-evidence approach, incorporating mechanistic insights on chemical interactions is described. The utility of this information in the context of risk analysis and public health practice is discussed.

ATSDR's information databases to support human health risk assessment of hazardous substances. Agency for Toxic Substances and Disease Registry

The American public, like persons in many other nations, is concerned about the potential adverse impacts of uncontrolled hazardous wastes. The concerns are often predicated on the fear that adverse health effects will occur because of releases of hazardous substances into community environments. To respond to these concerns, government agencies and private sector organizations must rely on credible, accessible, up-to-date information databases. These databases should be relevant to the needs of the people who respond to uncontrolled releases of hazardous substances. Of particular importance are databases that profile the toxicity of hazardous substances and other information useful to physicians and other health care providers. This paper describes how the federal Agency for Toxic Substances and Diseases Registry (ATSDR) has developed several toxicologic and human health information databases under mandates in the Superfund statute for responding to the public's concerns about hazardous substances.