A comparative study of 43 patients with mirror-like intracranial aneurysms: risk factors, treatment, and prognosis

BACKGROUND AND OBJECTIVE

Mirror-like intracranial aneurysms (MirAn) occur symmetrically at the corresponding intracranial arteries and are a subgroup of multiple intracranial aneurysms. The aim of this study was to analyze the risk factors, treatment, and prognosis of MirAn.

METHODS

We retrospectively analyzed 43 cases of MirAn diagnosed between January 2000 and December 2009. The control groups comprised patients with non-mirror-like multiple aneurysms (nMirAn) and single aneurysms (SingAn). Sex, age, localization of MirAn, hypertension, diabetes, smoking, and rupture were identified as potential risk factors for MirAn.

RESULTS

The male to female ratio of the MirAn patients was 1.0:5.1, which was significantly different from that of the nMirAn patients (1.0:1.9, P=0.037) and SingAn patients (1.0:1.3, P<0.001). There was no difference in age (P=0.8741), smoking (P=0.301), diabetes (P=0.267), or hypertension (P=0.874) between the MirAn and nMirAn patients. The aneurysms in 28 MirAn patients (65.1%) involved the internal carotid-posterior communicating arteries; in these patients, the rupture risk was significantly higher for larger aneurysms compared with smaller aneurysms (P<0.05).

CONCLUSION

More women suffered from MirAn than nMirAn or SingAn. The most common MirAn sites were the internal carotid-posterior communicating arteries. Our results suggest that MirAn was not associated with age, smoking, hypertension, or diabetes.

Minimum resection margin should be based on tumor size in hepatectomy for hepatocellular carcinoma in hepatoviral infection patients

AIM

In patients with hepatoviral infection, although a wide resection margin can eradicate the microsatellite lesions around hepatocellular carcinoma (HCC), a large-volume hepatectomy may diminish remaining liver function and become an obstacle for treating recurrent HCC. The optimal width of the resection margin for these patients is still controversial. This study was conducted to investigate the optimal resection margin in hepatectomy for hepatoviral infection patients.

METHODS

We retrospectively investigated the influences of the resection margin status on recurrence patterns and long-term prognosis in a group of 311 HCC patients with hepatoviral infection who had a solitary HCC without perioperative anti-HCC treatment.

RESULTS

The resection margin status did not statistically influence the postoperative recurrence-free and overall survival rates (3-year recurrence-free survival of 61.0% vs 55.1%, P = 0.33; 5-year overall survival of 74.9% vs 81.5%, P = 0.77 in without a margin vs with a margin, respectively), although resection without a margin increased the local recurrence with marginal significance (P = 0.055). Regarding the width of the resection margin, in 30-mm or smaller HCC, resection margin did not significantly improve the prognosis among hepatoviral infection patients. However, for tumors larger than 30 mm, a resection margin wider than 3 mm showed significant impacts on the prevention of recurrence in spite of the influence of multicentric carcinogenesis.

CONCLUSION

The resection margin used for eradication of microsatellite lesions showed differences that were dependent on tumor size in hepatoviral infection patients. Resection margin should be based on not only background liver function but also tumor characteristics.

Evaluation of poisoning deaths in the Cukurova Region, Turkey, 2007-2011

Complications of substances detected in poisoning deaths are important in order to observe changes in poisoning patterns and to monitor effects of preventive work. The aim of the present study was to describe the characteristics of substances investigated and detected in poisoning deaths by Adana Group Authority of the Council of Forensic Medicine, Department of Forensic Chemistry, Cukurova, Turkey, between 2007 and 2011 retrospectively. A total of 7681 examinations were performed, of which, 7% (n = 564) determined positive for at least one compound investigated. Ages of the cases ranged from 1 to 97 years (mean ± SD: 36.10 ±19.16). Carbon monoxide (CO) poisonings were found most frequently with an incidence of 27.0%, followed by prescription medications with 25.0%. Illegal drug poisonings were present in 20.0% of blood and urine samples analyzed. Pesticides, mostly endosulfan, were found in 13.0% of the 564 cases investigated. In the blood samples analyzed, methyl and ethyl alcohol were detected in 14.0% and volatile substances in 1.0%. Overall, this study has managed to contribute substantial additional information regarding the epidemiology of poisoning in Cukurova region, Southern Turkey. The results confirm other epidemiological data that indicate CO as the major cause of poisoning deaths in Turkey.

Caregivers of patients with dementia in Chinese mainland: a retrospective analysis

OBJECTIVE

We aimed to systematically search and summary the publications from 1990 to 2012 on Chinese dementia caregivers to understand the development in this field.

METHODS

We searched Pubmed and Chinese medical databases for all the original publications on the dementia caregivers in Chinese mainland until December 31st, 2012.

RESULTS

126 papers involved 117 studies with 11178 participants were analyzed. The earliest study on Chinese caregivers with dementia patients was published in 1990. Most studies (92%) were reported in Chinese. 85% of studies were published between 2006 and 2012, while 42% were carried out in the most developed regions.

CONCLUSIONS

In spite of the late start, the number of publications on Chinese dementia caregivers has rapidly increased since 2006. However, the quality of studies is still need to improve in sample size, intervention and outcome design. More attentions, policies and funds should be given to support the future study in dementia caregivers.

Semiparametric odds ratio model for case-control and matched case-control designs

We propose a semiparametric odds ratio model that extends Umbach and Weinberg's approach to exploiting gene-environment association model for efficiency gains in case-control designs to both discrete and continuous data. We directly model the gene-environment association in the control population to avoid estimating the intercept in the disease risk model, which is inherently difficult because of the scarcity of information on the parameter with the sampling designs. We propose a novel permutation-based approach to eliminate the high-dimensional nuisance parameters in the matched case-control design. The proposed approach reduces to the conditional logistic regression when the model for the gene-environment association is unrestricted. Simulation studies demonstrate good performance of the proposed approach. We apply the proposed approach to a study of gene-environment interaction on coronary artery disease.

Chronic pain in survivors of critical illness: a retrospective analysis of incidence and risk factors

INTRODUCTION

Chronic pain has been reported in survivors of critical illness for many years after discharge from hospital. This study investigates the incidence and site of chronic pain in survivors of critical illness between 6 months and 1 year after hospitalization, including ICU admission. A retrospective analysis of the risk factors for chronic pain in this patient group was also completed.

METHODS

A questionnaire method was used to investigate the incidence of chronic pain and the specific body parts affected. A retrospective study and multivariable analysis were used to investigate the risk factors for chronic pain in this patient group. All survivors of a general intensive care unit (ICU) in South Wales in a 6-month period were included in this study.

RESULTS

Chronic pain was reported in 44% of all respondents. The shoulder was the most commonly reported joint affected by pain (22%). Risk factors for chronic pain between 6 months and 1 year after ICU discharge were increasing patient age and severe sepsis.

CONCLUSIONS

Chronic pain is a problem in survivors of critical illness, especially in the shoulder joint, and further studies are needed investigating therapeutic interventions that address this long-term problem.

A retrospective analysis of serial measurement of serum cholinesterase in acute poisoning with organophosphate compounds

Objectives:

Retrospective analysis of the utility of serial measurements of serum acetylcholinesterase (AChE) in predicting the duration of stay in the intensive care unit (ICU), duration of mechanical ventilation (MV) and outcome of the patient from MV in organophosphate (OP) compound poisoning patients.

Materials and Methods:

The medical records of patients who presented to tertiary care hospital with symptomatic insecticidal poisoning from January 2009 to December 2010 were utilized for the study purpose. Forty four patients with history of poisoning were admitted during this period. Out of these 37 patients with history of OP poisoning, without any underlying diseases and whose serial AChE activity levels were available were included in the study. Data regarding clinical manifestation at presentation, AChE activity results and its interpretation, details of patient management and data on outcomes of patients were noted.

Results:

Serum acetycholinesterase levels below 1,250IU/L, 1,789IU/L and 2,764IU/L on day three, day four and five respectively indicates longer duration of stay in the ICU. Patients with serum AChE levels below 975IU/L, 876IU/L, 1,245IU/L, 1,395IU/L and 1,875IU/L on day one, two, three, four and five respectively take a longer time to be out of mechanical ventilation. Levels below 870IU/L, 1,110IU/L, 1,020IU/L and 885IU/L on day two, three, four and five respectively indicate poor prognosis of the patient and mortality.

Conclusion:

We conclude that the serial measurements of serum acetylcholinesterase levels can be useful in predicting the length of ICU stay, duration of mechanical ventilation and the prognosis of the patient with OP poisoning.

Patients with celiac disease have an increased risk for pancreatitis

BACKGROUND & AIMS

Patients with celiac disease have been reported to be at increased risk for pancreatitis and pancreatic insufficiency, but the risk might have been overestimated because of patient selection and limited numbers of patients for analysis. Furthermore, no distinction has been made between patients with gallstone-related and non-gallstone-related pancreatitis. We performed a nationwide study to determine the risk for any pancreatitis or subtype of pancreatitis among patients with biopsy-verified celiac disease.

METHODS

We analyzed data from patients in Sweden with celiac disease (n = 28,908) who were identified on the basis of small intestinal biopsy records from 28 pathology departments (those with villous atrophy, Marsh 3). Biopsies were performed from 1969 to 2008, and biopsy report data were collected from 2006 to 2008. Patients with pancreatitis were identified on the basis of diagnostic codes in the Swedish Patient Register and records of pancreatic enzyme use in the Swedish Prescribed Drug Register. Data were matched with those from 143,746 individuals in the general population; Cox regression was used to estimate hazard ratios (HRs) for pancreatitis.

RESULTS

We identified 406 patients with celiac disease who were later diagnosed with pancreatitis (and 143 with expected pancreatitis) (HR, 2.85; 95% confidence interval [CI], 2.53-3.21). The absolute risk of any pancreatitis among patients with celiac disease was 126/100,000 person-years, with an excess risk of 81/100,000 person-years. The HR for gallstone-related acute pancreatitis was 1.59 (95% CI, 1.06-2.40), for non-gallstone-related acute pancreatitis HR was 1.86 (95% CI, 1.52-2.26), for chronic pancreatitis HR was 3.33 (95% CI, 2.33-4.76), and for supplementation with pancreatic enzymes HR was 5.34 (95% CI, 2.99-9.53). The risk of any pancreatitis within 5 years of diagnosis was 2.76 (95% CI, 2.36-3.22).

CONCLUSIONS

Based on an analysis of medical records from Sweden, patients with celiac disease have an almost 3-fold increase in risk of developing pancreatitis, compared with the general population.

Use of transdermal and intravenous granisetron and the ability of the Hesketh score to assess nausea and vomiting induced by multiday chemotherapy

Purpose

Hesketh scores define emetogenicity of single-agent and multiagent single-day chemotherapy. This analysis determined the emetogenicity of multiagent, multiday chemotherapy and the Granisetron Transdermal System (GTDS; Sancuso^®).

Methods

This was a retrospective analysis of a multicenter, randomized, double-blind, phase III noninferiority trial of GTDS versus oral granisetron in patients receiving 3 days of multiagent moderately or highly emetogenic chemotherapy, regardless of granisetron formulation. Emesis was defined as vomiting/retching or the use of rescue medication. Logistic regression and classification trees were used to determine the optimal combination of Hesketh scores over the multiagent, multiday regimens for the prediction of emesis.

Results

Of 393 patients, 272 (69.2%) were chemotherapy naïve. The most common types of cancer were lung (30.5%) and gynecologic (21.9%). The most common chemotherapeutic regimen (in 14.2% of patients) was cisplatin plus etoposide on days 1–3. The best binary emesis predictor was day 1 Hesketh score. Patients with a day 1 Hesketh score of 5 had the highest rate of emesis (62.5%) versus patients with a score < 5 (31.7%). For patients with day 1 Hesketh score < 5, only 14.3% of those receiving only one drug on day 1 experienced emesis.

Conclusion

Hesketh emetogenicity scores of individual agents are applicable to multiday, multiagent chemotherapeutic regimens in patients receiving antiemetics.

Systematic review of three decades of Spanish cardiovascular epidemiology: improving translation for a future of prevention

BACKGROUND

In order to improve national cardiovascular disease (CVD) epidemiology and prevention, we systematically reviewed and analyzed the relevant literature produced in the last three decades for Spain.

DESIGN

Systematic Review.

METHODS

We searched for all the articles aiming to monitor CVD clinical endpoints and risk factors in the Spanish general population that were indexed in MEDLINE and EMBASE. Based on international recommendations, we analyzed each article with a three-level scoring system (low to high) for the following criteria: data quality, representativeness and translation of results into preventive interventions.

RESULTS

We reviewed 2565 articles, selecting 314 for in-depth analysis. Articles about diet, blood pressure, obesity and smoking represented 53% of all published CVD studies, whereas those about physical activity or psychosocial factors represented only 5%. Low data quality was found in 67% and 60% of the articles about physical activity and smoking, respectively. High data quality was found in 77% and 61% of the articles dedicated to diet and blood pressure, respectively. Representativeness was low for 41%, 31% and 25% of the studies focusing on diet, smoking and diabetes, respectively. Translation of research results into prevention scored lowest of all three criteria, as 41% of all 314 articles scored low. None of the articles on obesity, diabetes, lipids, physical activity or psychosocial factors identified any specific preventive intervention.

CONCLUSION

Future Spanish CVD epidemiology research will benefit from improving not just the quality and representativeness of the data measured, but drastically improving the translation of research results into future preventive interventions. The lack of a translational focus remains the fundamental gap in CVD research.

Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice

Background

Botulinum toxin type A treatment has been used for over 20 years to enhance the appearance of the face. There are several commercially available botulinum toxin type A products used in aesthetic clinical practice. The aim of this retrospective analysis was to compare the clinical efficacy of the most commonly used botulinum toxin type A preparations in daily practice.

Methods

Physicians from 21 centers in Germany completed questionnaires based on an inspection of subject files for subjects 18 years of age or over who had received at least two, but not more than three, consecutive treatments with incobotulinumtoxinA, onabotulinumtoxinA, or abobotulinumtoxinA within a 12-month period in the previous 2 years. Data on subject and physician satisfaction, treatment intervals, dosages, and safety were collected from 1256 subjects.

Results

There were no statistically significant differences between incobotulinumtoxinA and onabotulinumtoxinA with respect to physician and subject satisfaction, dosages, and adverse effects experienced. Both botulinum toxin type A preparations were well tolerated and effective in the treatment of upper facial lines. Due to low treatment numbers, abobotulinumtoxinA was not included in the statistical analysis.

Conclusion

The results of this retrospective analysis confirm the results of prospective clinical trials by demonstrating that, in daily practice, incobotulinumtoxinA and onabotulinumtoxinA are used at a 1:1 dose ratio and display comparable efficacy and safety.

A retrospective analysis of maxillofacial injuries in patients reporting to a tertiary care hospital in East Delhi

BACKGROUND AND AIM

Maxillofacial trauma is frequently encountered in the Accident and Emergency department of hospitals either as an isolated injury or as a part of multiple injuries to the head, neck, chest, and abdomen. This study aimed to assess retrospectively the profile of maxillofacial injuries in patients reporting to a tertiary care hospital in East Delhi.

MATERIALS AND METHODS

The study was conducted in the Department of Dentistry, UCMS and GTB Hospital, Delhi. Dental case record sheets of 1000 medicolegal cases reporting to the hospital emergency were scrutinized and various demographic and epidemiologic factors, including the patient's age and gender, time and day of reporting, and the etiology and nature of injury were recorded.

RESULTS

The peak incidence of maxillofacial injury was observed in the age group of 21-30 years, with males outnumbering females in all age groups. Maximum number of trauma cases reported in late evening hours, especially on weekends. Interpersonal assault was the primary etiological factor followed by road traffic accidents. Soft tissue injuries were very common and maxillofacial fractures, when present, were most frequently observed in the mandible followed by the midface.

CONCLUSION

The changing trend of the etiology of maxillofacial injuries in East Delhi necessitates strict legislation against violence and education in alcohol abuse. Periodic review of driving skills and stricter implementation of traffic rules in this area is a must to minimize the physical, psychological, and emotional distress associated with maxillofacial trauma.

Experience of first- and subsequent-line systemic therapy in the treatment of non-small cell lung cancer

INTRODUCTION

The treatment of advanced non-small cell cancer (NSCLC) has changed with multiple new treatment algorithms proposed based on histological and molecular subtyping but low mutation rates will ensure the dominance of cytotoxic chemotherapy. Accordingly, we undertook a detailed review of our practice delivering multiple lines of systemic therapy.

METHOD

We undertook a retrospective review of consecutive patients presenting with advanced (stage IIIb/IV) NSCLC treated with systemic therapy at two UK hospitals during a 2-year period, January 2007 to December 2008.

RESULTS

A total of 130 patients were identified, treated with predominantly carboplatin/gemcitabine (20 initially radically). Fifty of 110 patients (45%) treated with first-line systemic therapy subsequently received second-line therapy, of which 10 patients received third-line and two patients fourth-line therapy. Sixty three of 110 first-line patients (58%) achieved clinical benefit, 19 out of 50 (38%) in the second-line, 6 out of 10 (60%) in third-line but both patients progressed at fourth-line. Median overall survival for 110 patients was 10 months (95% confidence interval [CI] 8.6-11.4); but 16 months (95% CI 14-17.9) in those receiving multiple lines. Median survival from the first cycle of last-line treatment to death in the multiple therapy lines was 5 months (95% CI 2.6-7.3) and the majority of patients spent more time off treatment.

CONCLUSION

Overall our outcomes are consistent with published data and show good survival times can be achieved. The future of advanced NSCLC is in selecting the best treatment approach on a histological and genotypic basis.

Retrospective analysis of stevens-johnson syndrome and toxic epidermal necrolysis over a period of 10 years

Background:

Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN), are the acute emergencies in dermatology practice. Prompt diagnosis and management may reduce the morbidity and mortality in SJS/TEN patients. Early identification of the offending drug is necessary for early withdrawal and to prevent the recurrences of such a devastating illness.

Aims

To study the demography, offending agents, clinical and laboratory features, treatment, complications, morbidity and mortality of SJS/TEN in our hospital.

Materials and Methods:

In this retrospective study, we reviewed the medical records of SJS, TEN, SJS/TEN overlap of inpatients over a period of 10 years

Results:

Maximum number of SJS/TEN cases were in the age group of 11-30 years. Males predominated in the SJS group with a ratio of 1.63:1, whereas females predominated the TEN group with a ratio of 1:2.57.Nonsteroidal anti-inflammatory drugs (NSAIDs) were the commonest group of drugs among the SJS group in 5/21 patients (23.8%). Antimicrobials were the commonest group of drugs causing TEN in 11/25 patients (44%). Mucosal lesions preceded the onset of skin lesions in nearly 50%. Our study had one patient each of SJS/TEN due to amlodipine and Phyllanthus amarus, an Indian herb. The most common morbidity noted in our study was due to ocular sequelae and sepsis leading to acute renal failure respectively. Kaposi's varicelliform eruption was found in three of our patients.

Conclusion:

Antimicrobials and NSAIDS are the common offending agents of SJS/TEN in our study.

Adherence and persistence with branded antidepressants and generic SSRIs among managed care patients with major depressive disorder

OBJECTIVE

THIS STUDY COMPARED ADHERENCE AND PERSISTENCE OF THREE BRANDED ANTIDEPRESSANTS: the serotonin and norepinephrine reuptake inhibitors (SNRIs) duloxetine and venlafaxine XR, and the selective serotonin reuptake inhibitor (SSRI) escitalopram; and generic selective SSRIs, and examined demographic and clinical predictors of adherence and persistence in patients with major depressive disorder in usual care settings.

METHOD

A total of 44,026 patients (18 to 64 years) from a large commercial administrative claims database were classified as initiators of duloxetine (n = 7,567), venlafaxine XR (n = 6,106), escitalopram (n = 10,239), or generic SSRIs (n = 20,114) during 2006. Adherence was defined as the medication possession ratio of ≥0.8 and persistence as the length of therapy without exceeding a 15-day gap. Pairwise comparisons from multivariate logistic regression and Cox proportional hazards models were performed to examine predictors of adherence and persistence.

RESULTS

Adherence rate after one year was significantly higher in duloxetine recipients (38.1%) than patients treated with venlafaxine XR (34.0%), escitalopram (25.4%), or generic SSRIs (25.5%) (all P < 0.01). Duloxetine recipients stayed on medication longer (158.5 days) than those receiving venlafaxine XR (149.6 days), escitalopram (129.1 days), or generic SSRIs (130.2 days) (all P < 0.001). Compared with patients treated with escitalopram or generic SSRIs, venlafaxine XR recipients had better adherence and longer persistence (P < 0.001). In addition, being aged 36 years or more, hypersomnia, anxiety disorders, and prior use of antidepressants were associated with increased adherence and persistence, while the opposite was true for comorbid chronic pain conditions, alcohol and drug dependence, and prior use of amphetamine.

CONCLUSION

Compared with SSRIs, the SNRIs appear to have better adherence and persistence. Among SNRIs, duloxetine had statistically significantly better adherence and persistence than venlafaxine XR, though differences were relatively small and further research is needed to assess whether these translate into clinically and economically meaningful outcomes. Adherence and persistence with antidepressant therapy were associated with age, multiple comorbid conditions, and prior use of medications.

Changes in health care costs over time following the cessation of intimate partner violence

BACKGROUND

Research has documented greater health care costs attributable to intimate partner violence (IPV) among women during and after exposure. However, no studies have determined whether health care costs for abused women return to baseline levels at some point after their abuse ceases.

OBJECTIVE

We examine whether health care costs among women exposed to IPV converge with those of non-abused women during a 10-year period following the end of exposure.

DESIGN

Retrospective cohort analysis.

SETTING

Group Health Cooperative, a large integrated health care system in the Pacific Northwest.

PARTICIPANTS

Random sample of English-speaking women aged 18-64 enrolled within Group Health and who participated in a telephone survey between June 2003 and August 2005.

MEASUREMENTS

Total health care costs over an 11-year period from January 1, 1992 to December 31, 2002 were compiled using automated health plan data and comparisons made among women exposed to IPV since age 18 and those who never experienced IPV. IPV included physical, sexual, or psychological violence involving an intimate partner, and was assessed using five questions from the Behavioral Risk Factor Surveillance System.

RESULTS

Relative to women with no IPV history, total health care costs were significantly higher during IPV exposure, costs that were sustained for 3 years following the end of exposure. By the 4th year following the end of exposure to IPV, health care costs among IPV-exposed women were similar to non-abused women, and this pattern held for the remainder of the 10-year study period.

CONCLUSIONS

Policy makers should consider the ongoing needs of victims following abuse exposure. Interventions to reduce the prevalence of IPV or to mitigate the impact of IPV have the potential to reduce the rate of growth of health care costs.

A blueprint for the problem formulation phase of EPA-type ecological risk assessments for 316(b) determinations

The difference between management objectives focused on sustainability of fish populations and the indigenous aquatic community, and a management objective focused on minimizing entrainment and impingement losses accounts for much of the ongoing controversy surrounding paragraph 316(b). We describe the EPA's ecological risk assessment framework and recommend that this framework be used to more effectively address differences in management objectives and structure paragraph 316(b) determinations. We provide a blueprint for the problem formulation phase of EPA-type ecological risk assessments for cooling-water intake structures (CWIS) at existing power plant facilities. Our management objectives, assessment endpoints, conceptual model, and generic analysis plan apply to all existing facilities. However, adapting the problem formulation process for a specific facility requires consideration of the permitting agency's guidelines and level of regulatory concern, as well as site-specific ecological and technical differences. The facility-specific problem formulation phase is designed around the hierarchy of biological levels of organization in the generic conceptual model and the sequence of cause-effect events and risk hypotheses represented by this model. Problem formulation is designed to be flexible in that it can be tailored for facilities where paragraph 316(b) regulatory concern is low or high. For some facilities, we anticipate that the assessment can be completed based on consideration of susceptibility alone. At the other extreme, a high level of regulatory concern combined with the availability of extensive information and consideration of costly CWIS mitigation options may result in the ecological risk assessment relying on analyses at all levels. Decisions on whether to extend the ecological risk assessment to additional levels should be based on whether regulatory or generator concerns merit additional analyses and whether available information is adequate to support such analyses. In making these decisions, the functional dependence between levels of analysis must be considered in making the transition to the analysis phase and risk estimation component of the ecological risk assessment. Regardless of how the generic analysis plan is modified to develop a facility-specific analysis plan, the resulting plan should be viewed as a tool for comparing representative species and alternative CWIS options by focusing on relative changes (i.e., proportional or percent changes) in various measures. The analysis plan is specifically designed to encourage consideration of multiple lines of evidence and to characterize uncertainties in each line of evidence. Multiple lines of evidence from different levels of analysis, obtained using both prospective and retrospective techniques, provide a broader perspective on the magnitude of potential effects and associated uncertainties and risks. The implications of the EPA's recent (April 2002) proposed regulations for existing facilities on the applicability of this blueprint are briefly considered.