Human health and environmental risk assessment of metals in community gardens of Winnipeg, Manitoba, Canada

Fresh produce is an important component of maintaining cognitive and physical health, particularly for children. A mechanism to increase access to fresh produce is the construction of community gardens in urban centres. While reducing barriers to nutritious food, the soil of the community garden can contain contaminants (e.g. metals) depending on the location and how the garden was constructed. This study quantified, for the first time, seven metals (As, Cd, Cr, Cu, Pb, Mn, and Ni) in soil from 83 community gardens across the City of Winnipeg in Manitoba, Canada. Concentrations of metals in soil were used to create distributions for environmental exposure and estimated daily intake, which were then used to determine exceedances of soil quality guidelines and acceptable daily intakes, respectively. Raised garden beds and gardens further from roads had typically lower concentrations of metals in surface gardens and those nearer to roads. While some concentrations of metals exceeded CCME guidelines levels for the protection of environmental health, the vast majority represent a low risk. For human health, only As posed a quantifiable risk of exceeding the USEPA acceptable daily intake via the consumption of produce from gardens, though this was < 1.2% for the whole population and < 10.2% for children aged 1 to 2 years. Overall, this study is the first to show that the concentration of the metals in soil from gardens typically poses a low risk to environmental and human health. We recommend the use of raised gardens to further mitigate risk.

Micro-distribution of arsenic in toenail clippings using laser ablation inductively coupled plasma mass spectrometry: implications for biomonitoring

Toenails are a common monitoring tool for arsenic exposure, but the risk of external contamination of toenails has cast doubt on its usefulness. The main objective of this study is to investigate the micro-distribution of arsenic through the dorsoventral plane of nail clippings to understand endogenous vs exogenous sources. We used laser-ablation inductively coupled plasma mass spectrometry to measure arsenic through a dorsoventral cross-section of the nail plate collected from reference (N = 17) and exposed individuals (N = 35). Our main results showed (1) bulk toenail concentrations measured using ICP-MS in this study ranged from 0.54 to 4.35 µg/g; (2) there was a double-hump pattern in arsenic concentrations, i.e., dorsal and ventral layers had higher arsenic than the inner layer; (3) the double-hump was more pronounced in the exposed group (ventral: 6.25 μg/g; inner: 0.75 μg/g; dorsal: 0.95 μg/g) than the reference group (ventral: 0.58 μg/g; inner: 0.15 μg/g; dorsal: 0.29 μg/g) on average; (4) the distribution was, in part, associated with different binding affinity of nail layers (i.e., ventral > dorsal > inner); (5) most individuals in the higher exposure group showed > 25% contamination in ventral and dorsal nail layers; and (6) there were no statistically significant correlations between LA-ICP-MS arsenic with either bulk toenail arsenic or urine arsenic from the same individuals. Our results on micro-distribution and binding affinity provide insight into the impact of external contamination on arsenic concentrations and show how LA-ICP-MS can access the protected inner nail layer to provide a more accurate result.

Sources of exposure to lead in Arctic and subarctic regions: a scoping review

Understanding lead exposure pathways is a priority because of its ubiquitous presence in the environment as well as the potential health risks. We aimed to identify potential lead sources and pathways of lead exposure, including long-range transport, and the magnitude of exposure in Arctic and subarctic communities. A scoping review strategy and screening approach was used to search literature from January 2000 to December 2020. A total of 228 academic and grey literature references were synthesised. The majority of these studies (54%) were from Canada. Indigenous people in Arctic and subarctic communities in Canada had higher levels of lead than the rest of Canada. The majority of studies in all Arctic countries reported at least some individuals above the level of concern. Lead levels were influenced by a number of factors including using lead ammunition to harvest traditional food and living in close proximity to mines. Lead levels in water, soil, and sediment were generally low. Literature showed the possibility of long-range transport via migratory birds. Household lead sources included lead-based paint, dust, or tap water. This literature review will help to inform management strategies for communities, researchers, and governments, with the aim of decreasing lead exposure in northern regions.

Mercury bioaccessiblity in freshwater fish species from northern Canada

Indigenous communities in northern Canada rely on locally harvested traditional foods, including fish, which provides them with nutritional, cultural, and social benefits. However, mercury exposure from fish consumption can pose a health risk for populations that consume large amounts of fish with elevated mercury concentrations. The bioaccessiblity of mercury in the tissue of northern Canadian freshwater fish is not yet known. To address this, samples from five commonly consumed freshwater fish species (Lake Trout, Northern Pike, Walleye, Lake Whitefish, and Burbot) caught from lakes in the Northwest Territories and Yukon, Canada were examined. Total mercury concentrations, fatty acid composition, and total mercury bioaccessibility differed significantly among fish species and lakes. Mean total mercury bioaccessibility using an in vitro gastrointestinal model ranged between 56 % and 96 % in muscle tissue across fish species and waterbodies examined and was 39 % in liver tissue from Burbot. Mean total mercury bioaccessibility was much lower (range: 38 % to 42 %) for a subset of samples run through only the gastric phase of the digestion model. Total mercury bioaccessibility was significantly lower (on average 40 % lower) in a subset of samples that were pan-fried in water. Thus, although cooking increased total mercury concentrations in pan-fried fish samples (likely due to moisture loss), bioaccessible concentrations of total mercury were lower (on average 32 % lower). Results from this study contribute to addressing a large knowledge gap in the literature regarding bioaccessibility of total mercury in northern freshwater fish species. To the best of our knowledge, this is the first study to examine mercury bioaccessibility in raw and cooked liver samples from freshwater fish. It also adds to the growing literature indicating that mercury bioaccessibility varies among fish species, locations, and cooking/preparation methods.

Contributions and perspectives of Indigenous Peoples to the study of mercury in the Arctic

Arctic Indigenous Peoples are among the most exposed humans when it comes to foodborne mercury (Hg). In response, Hg monitoring and research have been on-going in the circumpolar Arctic since about 1991; this work has been mainly possible through the involvement of Arctic Indigenous Peoples. The present overview was initially conducted in the context of a broader assessment of Hg research organized by the Arctic Monitoring and Assessment Programme. This article provides examples of Indigenous Peoples' contributions to Hg monitoring and research in the Arctic, and discusses approaches that could be used, and improved upon, when carrying out future activities. Over 40 mercury projects conducted with/by Indigenous Peoples are identified for different circumpolar regions including the U.S., Canada, Greenland, Sweden, Finland, and Russia as well as instances where Indigenous Knowledge contributed to the understanding of Hg contamination in the Arctic. Perspectives and visions of future Hg research as well as recommendations are presented. The establishment of collaborative processes and partnership/co-production approaches with scientists and Indigenous Peoples, using good communication practices and transparency in research activities, are key to the success of research and monitoring activities in the Arctic. Sustainable funding for community-driven monitoring and research programs in Arctic countries would be beneficial and assist in developing more research/monitoring capacity and would promote a more holistic approach to understanding Hg in the Arctic. These activities should be well connected to circumpolar/international initiatives to ensure broader availability of the information and uptake in policy development.

Biomarkers of systemic inflammation predict survival with first-line immune checkpoint inhibitors in non-small-cell lung cancer

INTRODUCTION

Pembrolizumab is an established first-line option for patients with advanced non-small-cell lung cancer (NSCLC) expressing programmed death-ligand 1 ≥50%. Durable responses are seen in a subset of patients; however, many derive little clinical benefit. Biomarkers of the systemic inflammatory response predict survival in NSCLC. We evaluated their prognostic significance in patients receiving first-line pembrolizumab for advanced NSCLC.

METHODS

Patients treated with first-line pembrolizumab for advanced NSCLC with programmed death-ligand 1 expression ≥50% at two regional Scottish cancer centres were identified. Pretreatment inflammatory biomarkers (white cell count, neutrophil count, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, albumin, prognostic nutritional index) were recorded. The relationship between these and progression-free survival (PFS) and overall survival (OS) were examined.

RESULTS

Data were available for 219 patients. On multivariate analysis, albumin and neutrophil count were independently associated with PFS (P < 0.001, P = 0.002, respectively) and OS (both P < 0.001). A simple score combining these biomarkers was explored. The Scottish Inflammatory Prognostic Score (SIPS) assigned 1 point each for albumin <35 g/l and neutrophil count >7.5 × 10⁹/l to give a three-tier categorical score. SIPS predicted PFS [hazard ratio 2.06, 95% confidence interval (CI) 1.68-2.52 (P < 0.001)] and OS [hazard ratio 2.33, 95% CI 1.86-2.92 (P < 0.001)]. It stratified PFS from 2.5 (SIPS2), to 8.7 (SIPS1) to 17.9 months (SIPS0) (P < 0.001) and OS from 5.1 (SIPS2), to 12.4 (SIPS1) to 28.7 months (SIPS0) (P < 0.001). The relative risk of death before 6 months was 2.96 (95% CI 1.98-4.42) in patients with SIPS2 compared with those with SIPS0-1 (P < 0.001).

CONCLUSIONS

SIPS, a simple score combining albumin and neutrophil count, predicts survival in patients with NSCLC receiving first-line pembrolizumab. Unlike many proposed prognostic scores, SIPS uses only routinely collected pretreatment test results and provides a categorical score. It stratifies survival across clinically meaningful time periods that may assist clinicians and patients with treatment decisions. We advocate validation of the prognostic utility of SIPS in this and other immune checkpoint inhibitor treatment settings.

Food frequency questionnaire assessing traditional food consumption in Dene/Métis communities, Northwest Territories, Canada

Food Frequency Questionnaires (FFQ) can be used to document food consumption and to estimate the intake of contaminants for Indigenous populations. The objective of this project was to refine and implement an FFQ to estimate the consumption of traditional locally harvested foods for Dene/Métis in the Northwest Territories, Canada. The strategy consisted of: 1) refining the FFQ through three focus groups and, 2) implementing the FFQ in Indigenous communities. Participants were asked to complete the FFQ using an iPad to document the types of traditional foods consumed over the past 12 months, as well as the consumption frequency, the portion size, and the preparation methods. Focus groups supported the refinement of the FFQ on the format, the list of foods, and the preparation methods listed in the questionnaire. The refined FFQ was then implemented with participants (n = 237). Findings indicated that the traditional foods most frequently consumed were moose, whitefish and lake trout. Participants who consumed fish and land animals reported, on average, a portion size for one serving of between 126 and 143 g, depending on age and sex. These findings increase knowledge of the current traditional food consumption of Dene/Métis communities and will support the assessment of contaminant exposure.

Human biomonitoring of metals in sub-Arctic Dene communities of the Northwest Territories, Canada

A human biomonitoring project investigating environmental exposures to metals from hair, blood and urine samples was implemented in the Northwest Territories, Canada, between January 2016 and March 2018. This study reports the metal biomarker levels from nine Dene communities located in the Dehcho and Sahtú regions to identify contaminants of interest. Levels of metals in the urine (n = 198), blood (n = 276) and hair (n = 443) samples were generally similar to those seen in other biomonitoring studies in Canada, but lead levels in blood (GM = 16 μg/L; 95th percentile = 71 μg/L) and urine (GM = 0.59 μg/L, 0.69 μg/g of creatinine; 95th percentile = 4.2 μg/L, 4.0 μg/g of creatinine) were higher than those observed in the Canadian Health Measure Survey (CHMS, cycles 2 and 5). Hair mercury (but not blood mercury) appeared higher than observed in participants from the CHMS cycle 5. The vast majority of participants had biomarker levels below the biomonitoring guidance values established for mercury and lead. Based on a comparative analysis of biomarker statistics relative to a nationally-representative survey, metals and essential trace elements of particular interest for follow-up research include: lead, manganese, mercury, and selenium. This project provided baseline biomarker levels in participating regions, which is essential to track changes in the future, and identify the contaminants to prioritize for further investigation of exposure determinants.

A biobank analysis of prognostic biomarkers of the systemic inflammatory response in patients presenting with malignancy of undefined primary origin

BACKGROUND

Survival prediction in patients presenting with malignancy of undefined primary origin (MUO) is challenging, with a lack of validated prognostic tools. Biomarkers of the systemic inflammatory response independently predict survival in other cancer types, but their role in MUO is unclear. The aim of this study was to assess biomarkers of the systemic inflammatory response in patients presenting with MUO.

PATIENTS AND METHODS

A biobank of 1049 patients presenting with MUO referred to a regional oncology service in Scotland was analysed. Key inflammatory biomarkers (white cell count, neutrophil count and C-reactive protein combined with albumin [to give the modified Glasgow Prognostic Score {mGPS}]) were examined. The relationship between these and survival was examined using Kaplan-Meier and Cox regression methods.

RESULTS

Data were available for 1049 patients. Median survival was 4.3 months (interquartile range: 1.7-16.0 months). On multivariate analysis mGPS was independently associated with survival and stratified survival from 13.6 months (mGPS: 0) to 2.3 months (mGPS: 2) (p < 0.001). The mGPS was predictive of survival on multivariate analysis in patients found to have a non-cancer diagnosis (p = 0.034), an identified primary cancer (0.002), cancer of unknown primary (CUP) (p = 0.011), those for whom biopsy was not done (MUO) (p = 0.036), those found to have an identified primary cancer (0.002) and even those found to have a non-cancer diagnosis (p = 0.034) after further detailed investigations. In patients with CUP mGPS predicted survival regardless of the recognised clinicopathological prognostic subgroup (p < 0.001).

CONCLUSIONS

The results of the present study demonstrate that biomarkers of the systemic inflammatory response are reliable prognostic factors in patients presenting with MUO. These simple, objective, routine clinical tests may inform clinical management.

Polycyclic aromatic hydrocarbons (PAHs) levels in urine samples collected in a subarctic region of the Northwest Territories, Canada

Traditional food consumption for Indigenous peoples is associated with improved nutrition and health but can also pose potential risks via exposure to contaminants. Polycyclic aromatic hydrocarbons (PAHs) are compounds of interest due to their widespread presence (e.g., their metabolites are detected in up to 100% of the Canadian population) and their toxicological potential. To better understand the range of exposures faced by Indigenous populations in northern Canada and to address a contaminant of emerging concern identified by the Arctic Monitoring and Assessment Programme, a multi-year biomonitoring study investigated levels of PAH exposure in subarctic First Nations communities of the Northwest Territories, Canada. Secondary data analysis of banked samples from a subset of the cross-sectional study was done. PAHs and cotinine markers in the urine samples (n = 97) of participants from two regions from the Mackenzie Valley (Dehcho and Sahtú) was completed by liquid and gas chromatography coupled with mass spectrometry. Also, participants completed a 24-hr recall food survey. When compared according to age/sex categories, the GM of several biomarkers (1-hydroxypyrene, 1-naphthol, 2-hydroxyfluorene, 2-hydroxyphenanthrene, 2-naphthol, 3-hydroxyfluorene, 3-hydroxyphenanthrene, 4-hydroxyphenanthrene, 9-hydroxyfluorene, 9-hydroxyphenanthrene) appeared higher than observed for the general Canadian population. The PAHs levels observed were, however, below clinical levels associated with adverse health outcomes. Altogether, these elevated biomarkers are metabolites of pyrene, naphthalene, fluorene and phenanthrene. Statistically significant non-parametric associations were observed between several biomarkers and i) the consumption of cooked meat in the last 24 h; and, ii) smoking status (self-reported status and adjusted on urine cotinine level). This work is the first to report PAH levels in a northern Canadian population and provides local baseline data for monitoring the effects of changes to climate and lifestyle over time. These findings will support regional and territorial decision makers in identifying environmental health priorities.

Design of a human biomonitoring community-based project in the Northwest Territories Mackenzie Valley, Canada, to investigate the links between nutrition, contaminants and country foods

Community-based projects place emphasis on a collaborative approach and facilitate research among Indigenous populations regarding local issues and challenges, such as traditional foods consumption, climate change and health safety. Country foods (locally harvested fish, game birds, land animals and plants), which contribute to improved food security, can also be a primary route of contaminant exposure among populations in remote regions. A community-based project was launched in the Dehcho and Sahtù regions of the Northwest Territories (Canada) to: 1) assess contaminants exposure and nutrition status; 2) investigate the role of country food on nutrient and contaminant levels and 3) understand the determinants of message perception on this issue. Consultation with community members, leadership, local partners and researchers was essential to refine the design of the project and implement it in a culturally relevant way. This article details the design of a community-based biomonitoring study that investigates country food use, contaminant exposure and nutritional status in Canadian subarctic First Nations in the Dehcho and Sahtù regions. Results will support environmental health policies in the future for these communities. The project was designed to explore the risks and benefits of country foods and to inform the development of public health strategies.

Pain management in patients with malignant mesothelioma: challenges and solutions

Malignant pleural mesothelioma (MPM) is an aggressive cancer with a considerable symptom burden and poor prognosis. Focus on maintaining patients’ quality of life and pain control is therefore paramount. Pain management in MPM is complex due to its multifactorial etiology resulting from direct tumor infiltration of the surrounding soft tissue, bone, and encasement of the intercostal nerves. A variety of treatment modalities, including pharmacological and non-pharmacological options, are often required to achieve adequate pain control in this challenging disease. This review article examines the current challenges and solutions available for pain management in MPM.

Groundwater Irrigation and Arsenic Speciation in Rice in Cambodia

BACKGROUND

Arsenic bioaccumulation in rice is a global concern affecting food security and public health.

OBJECTIVE

The present study examined arsenic species in rice in Cambodia to characterize health risks with rice consumption and to clarify uncertainties with Codex guidelines.

METHODS

The present study collected 61 well water samples, 105 rice samples, 70 soil samples, and conducted interviews with 44 families in Preak Russey near the Bassac River and Kandal Province along the Mekong River in Cambodia. Analyses of metals, total arsenic and arsenic species were conducted in laboratories in Canada, Cambodia and Singapore.

RESULTS

Unlike in Bangladesh, rice with the highest total arsenic concentrations in Cambodia contains mostly organic arsenic, dimethylarsinic acid (DMA), which is unregulated and much less toxic than inorganic arsenic. The present study found that storing surface runoff in ditches prior to irrigation can significantly reduce the arsenic concentration in rice. It is possible to remove > 95% of arsenic from groundwater prior to irrigation with natural reactions.

CONCLUSIONS

The provision of high quality drinking water in 2015 to Preak Russey removed about 95% of the dietary inorganic arsenic exposure. The extremes in arsenic toxicity that are still obvious in these farmers should become less common. Rice from the site with the highest documented levels of arsenic in soils and water in Cambodia passes current Codex guidelines for arsenic.

INFORMED CONSENT

Obtained.

COMPETING INTERESTS

The authors declare no competing financial interests.

Effects of Arsenic, Iron and Fertilizers in Soil on Rice in Cambodia

BACKGROUND

In parts of Cambodia, irrigation with groundwater results in arsenic accumulation in soils and rice, leading to health concerns associated with rice consumption. A high concentration of iron in groundwater can precipitate arsenic and reduce its bioavailability, however high concentrations of arsenic and iron can also reduce rice production. Furthermore, concerns have been raised about chemical contamination from inorganic fertilizers used to grow rice. The relationship between soil geochemistry and arsenic concentrations in rice is not yet fully understood.

OBJECTIVES

The primary objective of this project was to investigate the relationship between arsenic concentrations in irrigation water, soil and rice collected from different sites in Cambodia. A secondary objective was to explore arsenic and phosphorus levels in fertilizer samples obtained from the study area in Cambodia.

METHODS

The present study collected 61 well water samples, 105 rice samples, 70 soil samples, 11 inorganic fertilizer samples and conducted interviews with 44 families along the Mekong River in Cambodia. Analyses for metals, total arsenic, and arsenic species in the water and rice were conducted in Canada by inductively coupled plasma mass spectrometry. Analyses for metals, total arsenic and phosphorus in soils and inorganic fertilizers were conducted in Cambodia and Singapore by X-ray fluorescence.

RESULTS

The concentration of arsenic in rice paddy soils was highly variable and as much as 20 times higher near the irrigation wells than in more distal areas of the paddy. Two farmers in Preak Russey had integrated soil samples with arsenic levels above the concentration associated with toxicity to rice in Taiwan (40 mg/kg) and above the Dutch concentration requiring intervention or remediation (55 mg/kg). The highest total arsenic measured in soil was 95 mg/kg. In Preak Russey, the loading of arsenic from irrigation water was 3710 times greater than the loading of arsenic from inorganic fertilizers. Half of the commercial inorganic fertilizers had less than 50% of the labelled content of phosphorus.

CONCLUSIONS

Emphasis should be placed on improving the management of irrigation water, not on inactivation of arsenic in soil. The high levels of iron in groundwater mitigate arsenic toxicity, but the accumulation of iron could later result in lower rice productivity. Irrigation of rice with groundwater is not likely sustainable. To improve rice productivity, the content of phosphorus in local inorganic fertilizers must be improved to world standards. X-ray fluorescence analysis can quickly identify poor quality fertilizers.

INFORMED CONSENT

Obtained.

COMPETING INTERESTS

The authors declare no competing financial interests.

SYSTEMS-2: A randomised phase II study of radiotherapy dose escalation for pain control in malignant pleural mesothelioma

SYSTEMS-2 is a randomised study of radiotherapy dose escalation for pain control in 112 patients with malignant pleural mesothelioma (MPM). Standard palliative (20 Gy/5#) or dose escalated treatment (36 Gy/6#) will be delivered using advanced radiotherapy techniques and pain responses will be compared at week 5. Data will guide optimal palliative radiotherapy in MPM.

Exposure and risk characterization for dietary methylmercury from seafood consumption in Kuwait

Seafood is an important source of essential nutrients; however, it can also confer health risks from methylmercury (MeHg). In this paper, we evaluate the levels of potential methylmercury exposure among Kuwaiti seafood consumers in order to support the development of dietary recommendations for fish consumption in Kuwait. Total mercury (HgT) concentration for most of the studied fish and shellfish species were on average below the 0.5μgg^-1 Codex guideline. The notable exception to this was Hamoor (Epinephelus coioides), which averaged 1.29μgg^-1 HgT and 0.55μgg^-1 MeHg. A dietary survey of 2393 households demonstrated that large quantities of fish and shellfish are commonly consumed in Kuwait (average consumption: 103gd^-1). Most participants (53.6%) exceeded the Tolerable Daily Intake of MeHg; this percent exceedance was as high as 78% in children 6-12years of age. The majority (Mean: 50-51%) of Kuwaiti's dietary MeHg exposure comes from the consumption of Hamoor; therefore, advisories to limit the consumption of Hamoor may be necessary. Nutrient:Methylmercury ratios are reported herein; these ratios may assist efforts to create dietary advice that limits contaminant risk while promoting the nutritional benefits of seafood in Kuwait.

A Comparative Assessment of Arsenic Risks and the Nutritional Benefits of Fish Consumption in Kuwait: Arsenic Versus Omega 3-Fatty Acids

Inorganic and organic forms of arsenic (As), as well as omega-3 fatty acids were measured in 578 fish/seafood samples that belong to 15 species of commonly consumed seafood in Kuwait. Arsenic speciation data, with the toxicological profile of inorganic arsenic (iAs) and fish consumption rates were applied in a probabilistic risk assessment to estimate the risk from exposure to iAs. The nutritional benefits of omega-3-fatty acid levels in various species of fish were taken into consideration. Results showed that the mean daily intake of iAs through fish consumption among the Kuwaiti population was 0.058 µg/kg/day, and the 95th percentile was 0.15 µg/kg/day. Although the mean intake level did not exceed the incremental lifetime cancer risk (ILCR) at 1 × 10^-4, the 95th percentile of iAs intake showed an ILCR of 2.7 × 10^-4. Kuwaiti children (aged 6-12 years) were found to have a higher mean intake of iAs at 0.10 µg/kg/day with 68% of children in this category, exceeding the risk specific dose associated with an ILCR of 1 × 10^-4. The fish species, hammor (grouper; Epinephelus coioides), is the top contributor to iAs intake, and tuna is the major source of omega 3-fatty acids for the Kuwaiti population.

Food, health, and complexity: towards a conceptual understanding to guide collaborative public health action

BACKGROUND

What we eat simultaneously impacts our exposure to pathogens, allergens, and contaminants, our nutritional status and body composition, our risks for and the progression of chronic diseases, and other outcomes. Furthermore, what we eat is influenced by a complex web of drivers, including culture, politics, economics, and our built and natural environments. To date, public health initiatives aimed at improving food-related population health outcomes have primarily been developed within 'practice silos', and the potential for complex interactions among such initiatives is not well understood. Therefore, our objective was to develop a conceptual model depicting how infectious foodborne illness, food insecurity, dietary contaminants, obesity, and food allergy can be linked via shared drivers, to illustrate potential complex interactions and support future collaboration across public health practice silos.

METHODS

We developed the conceptual model by first conducting a systematic literature search to identify review articles containing schematics that depicted relationships between drivers and the issues of interest. Next, we synthesized drivers into a common model using a modified thematic synthesis approach that combined an inductive thematic analysis and mapping to synthesize findings.

RESULTS

The literature search yielded 83 relevant references containing 101 schematics. The conceptual model contained 49 shared drivers and 227 interconnections. Each of the five issues was connected to all others. Obesity and food insecurity shared the most drivers (n = 28). Obesity shared several drivers with food allergy (n = 11), infectious foodborne illness (n = 7), and dietary contamination (n = 6). Food insecurity shared several drivers with infectious foodborne illness (n = 9) and dietary contamination (n = 9). Infectious foodborne illness shared drivers with dietary contamination (n = 8). Fewer drivers were shared between food allergy and: food insecurity (n = 4); infectious foodborne illness (n = 2); and dietary contamination (n = 1).

CONCLUSIONS

Our model explicates potential interrelationships between five population health issues for which public health interventions have historically been siloed, suggesting that interventions targeted towards these issues have the potential to interact and produce unexpected consequences. Public health practitioners working in infectious foodborne illness, food insecurity, dietary contaminants, obesity, and food allergy should actively consider how their seemingly targeted public health actions may produce unintended positive or negative population health impacts.

Characteristics of the case mix, organisation and delivery in cancer palliative care: a challenge for good-quality research

OBJECTIVES

Palliative care (PC) services and patients differ across countries. Data on PC delivery paired with medical and self-reported data are seldom reported. Aims were to describe (1) PC organisation and services in participating centres and (2) characteristics of patients in PC programmes.

METHODS

This was an international prospective multicentre study with a single web-based survey on PC organisation, services and academics and patients' self-reported symptoms collected at baseline and monthly thereafter, with concurrent registrations of medical data by healthcare providers. Participants were patients ≥18 enrolled in a PC programme.

RESULTS

30 centres in 12 countries participated; 24 hospitals, 4 hospices, 1 nursing home, 1 home-care service. 22 centres (73%) had PC in-house teams and inpatient and outpatient services. 20 centres (67%) had integral chemotherapy/radiotherapy services, and most (28/30) had access to general medical or oncology inpatient units. Physicians or nurses were present 24 hours/7 days in 50% and 60% of centres, respectively. 50 centres (50%) had professorships, and 12 centres (40%) had full-time/part-time research staff. Data were available on 1698 patients: 50% females; median age 66 (range 21-97); median Karnofsky score 70 (10-100); 1409 patients (83%) had metastatic/disseminated disease; tiredness and pain in the past 24 hours were most prominent. During follow-up, 1060 patients (62%) died; 450 (44%) <3 months from inclusion and 701 (68%) within 6 months. ANOVA and χ² tests showed that hospice/nursing home patients were significantly older, had poorer performance status and had shorter survival compared with hospital-patients (p<.0.001).

CONCLUSIONS

There is a wide variation in PC services and patients across Europe. Detailed characterisation is the first step in improving PC services and research.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01362816.

Epidermal growth factor receptor-inhibition (EGFR-I) in the treatment of neuropathic pain

BACKGROUND

Neurobiological work has demonstrated that expression of mitogen-activated protein kinases (MAPK) is upregulated on neurones and glial cells after nerve damage. Furthermore, the epidermal growth factor receptor (EGFR) has been identified as having a key role in this process and subsequent interruption of this using EGFR-Inhibitors (EGFR-I), may improve neuropathic pain. The aim of this report was to explore if EGFR-I attenuated neuropathic pain in humans.

METHODS

A selection of patients with neuropathic pain were treated off-label with one of four EGFR-Is, approved for the treatment of cancer. All patients had chronic and severe neuropathic pain (as defined by diagnostic criteria). Pain intensity, interference with function, and adverse events were prospectively registered.

RESULTS

Twenty patients were treated. Eighteen patients experienced clinically significant pain relief after treatment with EGFR-I. Median observed pain reduction for all patients was 8.5 (IQR=5-9.5) points on a 0-10 numeric rating scale. Neuropathic pain spike duration and frequency also improved. Pain relief was most often achieved within 24 h and was more rapid in cases of i.v. than oral administration. All four EGFR-I that were tested were of equal efficacy. The duration of pain relief was consistent with the individual drugs' half-lives. No cases of drug-tolerance were observed. Side-effects were predominantly skin reactions. One grade 3 adverse event was registered. Median follow-up for responders was 7 months (Range 1-37).

CONCLUSIONS

EGFR-I improves neuropathic pain and this is in keeping with basic science work. Controlled clinical trials are now eagerly awaited to assess this further.

Does chemotherapy improve health-related quality of life in advanced pancreatic cancer? A systematic review

Chemotherapy is increasingly being used in advanced pancreatic cancer, but side-effects are common. The aim of this systematic review was to assess whether chemotherapy improves health-related quality of life (HRQoL), pain or cachexia. Thirty studies were reviewed. Four of 23 studies evaluating HRQoL, 7 of 24 studies evaluating pain and 0 of 8 studies evaluating cachexia found differences between treatment arms. Change in HRQoL from baseline was evaluated in 14 studies: five studies reported an improvement in at least one treatment arm; three a worsening and the remaining stable scores. Change in pain intensity from baseline was evaluated in eight studies, and improvement was observed in seven. Of the four studies reporting improved survival, three reported improved HRQoL or pain. In conclusion, chemotherapy can stabilize HRQoL and improve pain control. Effects on cachexia are hard to elucidate. Improved survival does not come at the expense of HRQoL or pain control.

Development of a strategic plan for food security and safety in the Inuvialuit Settlement Region, Canada

BACKGROUND

Current social and environmental changes in the Arctic challenge the health and well-being of its residents. Developing evidence-informed adaptive measures in response to these changes is a priority for communities, governments and researchers.

OBJECTIVES

To develop strategic planning to promote food security and food safety in the Inuvialuit Settlement Region (ISR), Northwest Territories (NWT), Canada.

DESIGN

A qualitative study using group discussions during a workshop.

METHODS

A regional workshop gathered Inuit organizations and community representatives, university-based researchers from the Inuit Health Survey (IHS) and NWT governmental organizations. Discussions were structured around the findings from the IHS. For each key area, programs and activities were identified and prioritized by group discussion and voting.

RESULTS

The working group developed a vision for future research and intervention, which is to empower communities to promote health, well-being and environmental sustainability in the ISR. The group elaborated missions for the region that address the following issues: (a) capacity building within communities; (b) promotion of the use of traditional foods to address food security; (c) research to better understand the linkages between diseases and contaminants in traditional foods, market foods and lifestyle choices; (d) and promotion of affordable housing. Five programs to address each key area were developed as follows: harvest support and traditional food sharing; education and promotion; governance and policy; research; and housing. Concrete activities were identified to guide future research and intervention projects.

CONCLUSIONS

The results of the planning workshop provide a blueprint for future research and intervention projects.

Radiotherapy for the treatment of pain in malignant pleural mesothelioma: a systematic review

Radiotherapy is commonly used to treat pain in malignant pleural mesothelioma (MPM). The purpose of this systematic review is to examine the evidence for this practice. Medline (1946-2013), Embase (1974-2013) and Central (The Cochrane Library Issue 9, 2012) databases were searched. Eligible studies met the following criteria: MPM (histological or radiological diagnosis), radiotherapy given with the intent of improving pain, response rates to radiotherapy reported, dose and fractionation reported and the relationship between radiotherapy and pain response explored. All studies had independent review and were graded according to evidence level. Eight studies met the eligibility criteria. Two studies were prospective single arm phase II studies while the remainder were retrospective case series. All were graded as either Level 2 or Level 3 evidence. Due to marked heterogeneity among studies, quantitative synthesis of results was not possible. No high quality evidence currently exists to support radiotherapy in treating pain in MPM. Studies focusing on clear pain endpoints and improving target delineation are needed. Such studies should also use modern radiotherapy techniques and concentrate on dose escalation.

Potential life-threatening events in schools involving rescue inhalers, epinephrine autoinjectors, and glucagon delivery devices: reports from school nurses

The purpose of this research is to use the reports of school nurses to facilitate the understanding of how schools experience and manage asthmatic, anaphylactic, and diabetic emergencies by quantitative and qualitative analysis of online surveys. E-mails with a link to SurveyMonkey® were sent to all U.S. members of the National Association of School Nurses (13,695). Subjects were asked to describe their self-reported knowledge, opinions, practices, and experiences with such emergencies and the devices used to manage them. Regarding the frequency of emergencies in a given school year, the medians were 8 for asthma, 0 for anaphylaxis, and 10 for hypoglycemia. Twenty-two, five, and one subjects, respectively, reported that events like these resulted in deaths during their careers as school nurses. These diseases create substantial potential for emergencies in schools, and the schools represented by these nurses appear to be somewhat, but not ideally, equipped to handle such crises.

Detectability of fifteen aquatic micro/mesocosms

Zooplankton abundance and species richness in 15 untreated 12,000 L outdoor microcosms (n = 15) were monitored over the course of 1 year to document the inherent variability and statistical detectability between replicates. Statistical power analysis were applied to derive the statistically minimal detectable difference (MDD) between replicates with default values set at; alpha = 0.1 and beta = 0.2. Copepod abundance and species richness generally demonstrated the best detectability at 0.31 and 0.16, respectively, (n = 15); 0.59 and 0.33 (n = 3). Total zooplankton abundance and species richness had the lowest detectabilities at 0.19 and 0.14, respectively, (n = 15); 0.35 and 0.3 (n = 3). Rotifers, due to their opportunistic and rapid life traits, had the lowest single-species abundance detectabilities at 0.54 (n = 15); 0.8 (n = 3), whereas macroinvertebrate species richness had the lowest detectability at 0.43 (n = 15); 0.7 (n = 3) over 1 year. We recommend a priori calibration of the study design relative to relevant MDDs. Moreover, it is suggested to consider alternatives to statistical null hypothesis testing.

Assessment of the environmental fate and effects of ivermectin in aquatic mesocosms

Pharmaceuticals in the environment have been subject to increasing public concern and scientific investigation over the past years. More than 100 active pharmaceutical ingredients have been detected in surface waters worldwide at the ng to microg L(-1) range. At these low levels it is commonly assumed that only chronic and/or mixture toxic effects will be discernible in aquatic ecosystems and that there are orders of magnitude between exposure and effect concentrations. Assessment of potential ecosystem risk of pharmaceuticals are recommended but rarely performed in mesocosms, so for most risk assessments the final tier to reduce extrapolation uncertainty is missing. This paper describes the fate and effects of the anthelmintic drug ivermectin for a 265-day period following treatment (nominal concentration levels of 0, 30, 100, 1000 ng L(-1) (or parts per trillion (ppt)) in fifteen 12,000 L outdoor aquatic mesocosms. Although it is established that ivermectin is highly toxic towards invertebrates, it has been believed that ivermectin does not present notable risks to aquatic systems due to the rapid dissipation of the compound and binding to the sediment. Hence, fate and exchange of ivermectin between water and sediment were evaluated in this study. The ivermectin DT(50aqueous) in water was found to be 3-5 days, but concentrations increased and appeared to be stabile in the sediment at 20-30 ng kg(-1) with no assessable DT(50sed). Acute effects (first week) following ivermectin exposure were identified and cladocerans were particularly sensitive (nom. 100 ppt). Chronic responses (<day 97) were observed for the ecosystem structure and function (nom. 30 ppt). Long-term effects (>229 days) were identified for more sediment-active organisms (e.g. Chydoriae and Ephemeroptera) (nom. 1000 ppt). This is the first study to demonstrate the potential environmental risk of ivermectin at or below the predicted environmental concentration using a standardized test methodology (mesocosm) with minimal extrapolation uncertainty.

Phase Equilibria in Carbon Dioxide Expanded Solvents: Experiments and Molecular Simulations

We present complementary molecular simulations and experimental results of phase equilibria for carbon dioxide expanded acetonitrile, methanol, ethanol, acetone, acetic acid, toluene, and 1-octene. The volume expansion measurements were done using a high-pressure Jerguson view cell. Molecular simulations were performed using the Gibbs ensemble Monte Carlo method. Calculations in the canonical ensemble (NVT) were performed to determine the coexistence curve of the pure solvent systems. Binary mixtures were simulated in the isobaric-isothermal distribution (NPT). Predictions of vapor-liquid equilibria of the pure components agree well with experimental data. The simulations accurately reproduced experimental data on saturated liquid and vapor densities for carbon dioxide, methanol, ethanol, acetone, acetic acid, toluene, and 1-octene. In all carbon dioxide expanded liquids (CXL's) studied, the molecular simulation results for the volume expansion of these binary mixtures were found to be as good as, and in many cases superior to, predictions based on the Peng-Robinson equation of state, demonstrating the utility of molecular simulation in the prediction of CXL phase equilibria.

Assessing salivary cortisol in studies of child development

In a series of studies, we evaluated the susceptibility of radioimmunoassays (RIA) for saliva cortisol to interference effects caused by oral stimulants used to facilitate saliva collection in studies with children. When added directly to saliva samples, oral stimulants (drink mix crystals) artificially inflated estimated cortisol concentrations. The magnitude of the interference effect was concentration-dependent and more pronounced for some stimulants and RIA procedures than for others. Analysis of samples collected using oral stimulants from child and adult participants confirmed stimulant interference as an extraneous source of variability in measured saliva cortisol. Associations between serum and saliva cortisol and between saliva cortisol and "behavioral" variables were attenuated by stimulant interference. A survey of six large child studies estimated interference effects, indexed by low sample pH, to be present in 14.7% of the 1,148 total saliva samples, or 2%-54% (M = 22%) of samples within each study. Recommendations to minimize the impact of stimulant interference in studies involving salivary cortisol in the context of child health and development are outlined.

Daycare tonsillectomy and/or adenoidectomy at the British Columbia Children's Hospital

The fact that tonsillectomy (T), or tonsillectomy with adenoidectomy (T & A) or adenoidectomy (A) can be performed safely in selected children on a daycare or outpatient basis is well proven. This article illustrates the approach that the British Columbia Children's Hospital (B.C.C.H.) took to confirm that the procedures were safe locally. A pilot project was started in June of 1984 to perform daycare adenoidectomies only, using two full-time pediatric otolaryngologists. When this proved successful, other otolaryngologists were encouraged to use the program. In June of 1988, a second pilot project was started for daycare tonsillectomies (or tonsillectomy and adenoidectomy). Criteria were established for patient selection, preparation, anesthesia, post-anesthetic recovery (PAR), Daycare Unit (DCU) nursing, and discharge. Follow-up information was obtained. Daycare tonsillectomy with or without adenoidectomy and daycare adenoidectomy are now routine procedures at B.C.C.H.