The key characteristics of cardiotoxicity for the pervasive pollutant phenanthrene

The key characteristic (KCs) framework has been used previously to assess the carcinogenicity and cardiotoxicity of various chemical and pharmacological agents. Here, the 12 KCs of cardiotoxicity are used to evaluate the previously reported cardiotoxicity of phenanthrene (Phe), a tricyclic polycyclic aromatic hydrocarbon (PAH), and major component of fossil fuel-derived air pollution. Phe is a semi-volatile pollutant existing in both the gas phase and particle phase through adsorption onto or into particulate matter (PM). Phe can translocate across the airways and gastrointestinal tract into the systemic circulation, enabling body-wide effects. Our evaluation based on a comprehensive literature review, indicates Phe exhibits 11 of the 12 KCs for cardiotoxicity. These include adverse effects on cardiac electromechanical performance, the vasculature and endothelium, immunomodulation and oxidative stress, and neuronal and endocrine control. Environmental agents that have similarly damaging effects on the cardiovascular system are heavily regulated and monitored, yet globally there is no air quality regulation specific for PAHs like Phe. Environmental monitoring of Phe is not the international standard with benzo[a]pyrene being frequently used as a proxy despite the two PAH species exhibiting significant differences in sources, concentration variations and toxic effects. The evidence summarised in this evaluation highlights the need to move away from proxied PAH measurements and develop a monitoring network capable of measuring Phe concentration. It also stresses the need to raise awareness amongst the medical community of the potential cardiovascular impact of PAH exposure. This will allow the production of mitigation strategies and possibly the development of new policies for the protection of the societal groups most vulnerable to cardiovascular disease.

Nutrition: Malnutrition and Dietary Intake Modification

The average adult needs 1 to 2 g protein/kg of body weight and 25 to 30 kcal/kg of body weight per day. Caloric needs in adults differ based on height, weight, activity level, and disease state. Malnutrition is defined as an imbalance of nutrition, including lack of adequate calories, protein, and/or other nutrients required for body functioning. Protein-calorie malnutrition is a specific type of malnutrition defined as deficient intake or uptake of protein and energy that leads to physiologic alterations such as inflammation, loss in fat-free mass, and/or decreased response to medical treatment. Worldwide, 20% to 50% of hospitalized patients have malnutrition preadmission, and up to 90% of older adult patients are at increased risk. All patients should be screened for malnutrition within 24 hours of hospital admission. If malnutrition is suspected in the outpatient setting, patients should be screened with assistance from a registered dietitian nutritionist. The treatment strategy for protein and calorie supplementation involves provision of additional calories via oral nutritional supplements, enteral tube feedings, or parenteral nutrition. Oral nutritional supplements are indicated for patients with mild cases of malnutrition who are able to consume food orally. Meal replacement products are a convenient way to modify macronutrient intake, including use as a temporary solution to increase intake in patients with malnutrition and as an intervention for weight loss.

Nutrition: Macronutrients

Macronutrients are nutrients the body needs in large quantities, such as fats, carbohydrates, fiber, protein, and water. The exact quantity of macronutrients needed for an individual depends on multiple factors such as height, weight, sex, physical activity level, and medical conditions. For adequate intake, the Dietary Guidelines for Americans, 2020-2025 (DGA) recommend an overall healthy eating pattern rather than specific macronutrient amounts. A healthy eating pattern includes consumption of minimally processed, nutrient-dense foods and beverages such as vegetables, fruits, grains, dairy, proteins, and oils. Nutrition labels on food packaging can be used to guide food choices. Healthy dietary patterns have been shown to reduce the risk of diet-related chronic diseases. Consumption of foods containing unsaturated fats, complex carbohydrates, and high levels of fiber is recommended. Protein should be obtained from a variety of sources, particularly plant-based sources. Intake of foods and beverages higher in added sugars, saturated fat, and sodium should be limited. Family physicians should obtain a nutrition history for every patient regardless of body mass index. The evaluation should include a diet assessment questionnaire and information about patient nutrition insight and motivation, dietary intake pattern, metabolic demands, comorbid conditions, and dietary supplement and substance use (eg, caffeine, alcohol). Physicians can counsel patients by sharing current DGA recommendations for following a healthy eating pattern.

Nutrition: Chronic Disease Management

Dietary modifications can help to prevent and manage many chronic diseases. The Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets emphasize consumption of fruits and vegetables while reducing intake of red meat. These diets are supported by well-established evidence for patients with cardiovascular disease and hypertension, respectively. Whole-food, plant-based diets have been shown to result in reduced body weight, lower A1c levels, and decreased insulin resistance in patients with diabetes. Patients with diabetes and hypertension should adhere to a heart-healthy diet, such as the DASH diet. For patients with diabetes and at risk of diabetes, key nutritional recommendations include emphasizing intake of nonstarchy vegetables, minimizing intake of added sugars and refined grains, and choosing whole foods instead of processed foods. The Dietary Guidelines for Americans, 2020-2025 recommend that adults limit sodium intake to less than 2,300 mg/day. Patients with chronic kidney or liver disease should follow sodium restriction and protein intake guidelines. Patients with irritable bowel syndrome should follow a low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet with fiber supplementation. For patients with gastrointestinal symptoms, fiber can effectively manage constipation and stool irregularity. Probiotic supplements or foods can be useful for digestive problems.

Nutrition: Micronutrients

Micronutrients are nutrients the body needs in small quantities, such as vitamins and minerals. Micronutrient deficiencies can occur when an individual is restricting calorie intake for weight loss or management, not consuming an adequate amount of food to meet energy requirements due to poor appetite or illness, eliminating one or more food groups from the diet on a regular basis, or consuming a diet low in micronutrient-rich foods despite adequate or excessive energy intake. Patient groups at risk include older adults, pregnant patients, patients with alcohol use disorder, patients with vegetarian or vegan diets, and patients with increased requirements secondary to medical conditions or long-term drug use that alters nutrient absorption, metabolism, or excretion. The micronutrients that most commonly require supplementation are vitamin D, iron, vitamin A, zinc, folate, and iodine. Results of large-scale randomized trials have shown no overall benefit of multivitamins for the majority of patients. However, a daily multivitamin may be beneficial, particularly for patients who do not consistently consume a well-balanced diet. Although dietary supplements can be helpful in correcting deficiencies, higher than recommended doses can cause adverse effects. Patients should be advised to take recommended dosages of supplements and consult their physician if they notice any adverse effects. Physicians should advise patients to consult drug labels and/or pharmacists about potential supplement interactions with drugs or other supplements.

BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment

Excess deaths from cardiovascular disease are a major contributor to the significant reduction in life expectancy experienced by people with schizophrenia. Important risk factors in this are smoking, alcohol misuse, excessive weight gain and diabetes. Weight gain also reinforces service users' negative views of themselves and is a factor in poor adherence with treatment. Monitoring of relevant physical health risk factors is frequently inadequate, as is provision of interventions to modify these. These guidelines review issues surrounding monitoring of physical health risk factors and make recommendations about an appropriate approach. Overweight and obesity, partly driven by antipsychotic drug treatment, are important factors contributing to the development of diabetes and cardiovascular disease in people with schizophrenia. There have been clinical trials of many interventions for people experiencing weight gain when taking antipsychotic medications but there is a lack of clear consensus regarding which may be appropriate in usual clinical practice. These guidelines review these trials and make recommendations regarding appropriate interventions. Interventions for smoking and alcohol misuse are reviewed, but more briefly as these are similar to those recommended for the general population. The management of impaired fasting glycaemia and impaired glucose tolerance ('pre-diabetes'), diabetes and other cardiovascular risks, such as dyslipidaemia, are also reviewed with respect to other currently available guidelines.These guidelines were compiled following a consensus meeting of experts involved in various aspects of these problems. They reviewed key areas of evidence and their clinical implications. Wider issues relating to primary care/secondary care interfaces are discussed but cannot be resolved within guidelines such as these.

Erdheim-chester disease

Erdheim-Chester disease (ECD) is a rare histiocytic infiltrative disease, characterized by long bone sclerosis. We describe two confirmed cases of ECD, both of which demonstrate non-malignant retroperitoneal and peri-renal infiltration causing dilatation of the upper renal tracts. The cases are illustrated with contrast studies, computed tomography (CT) and magnetic resonance imaging (MRI). Typical sclerosis of the long bones was apparent on radiography. Both cases have been treated conservatively to date.A brief review of the literature regarding the manifestations of ECD is included. In cases of non-malignant retroperitoneal infiltration, ECD should be considered as a diagnosis and radiographs of the long bones performed.

A comparison of solid sampler methods for the determination of hexamethylene-based isocyanates in spray-painting operations

A polyurethane foam sponge impregnated with 1-(2-methoxyphenyl) piperazine in dimethylsulfoxide was mounted in both cassette and inhalable organic monitor samplers and these were then compared with a dual-filter cassette. The samplers were used for the collection of hexamethylene diisocyanate (HDI) monomer and oligomers during actual spray-painting operations. The dual filter cassettes were positioned on a mannequin. The polyurethane foam cassette (PUF CAS) and polyurethane foam inhalable organic monitor (PUF IOM) samplers were positioned on a cart in the same maximum overspray area. Data from this pilot study suggest that there is no significant difference (P < 0.05, n = 6) in the amount of HDI monomer obtained with the PUF IOM sampler when compared with the amount obtained from the dual filter cassette. The data also suggest that the PUF IOM sampler yields a higher amount of HDI oligomer than either the dual filter cassette or the PUF CAS sampler, neither of which exhibited a significant difference (P < 0.05, n = 6) from each other.

Metal exposure among abrasive blasting workers at four U.S. Air Force facilities

Button Aerosol Samplers were used to monitor the personal exposure of workers performing abrasive blasting operations at four U.S. Air Force facilities. Inhalable aerosols containing 25 metals, including cadmium, lead, and chromium, were investigated. The Button Aerosol Sampler was chosen because of its ability to successfully withstand mechanical stress, prevent very large particles from collection, and protect the filter from overloading and shredding by rebound particles. In addition, previous studies have shown that the sampling efficiency of this personal Aerosol Sampler exhibits low sensitivity to the ambient air conditions and that it adequately follows the inhalability convention. Inductively coupled plasma (ICP) was used to analyze the collected samples for all 25 metals. In addition, visual absorption spectrophotometry (VAS) was used to analyze for hexavalent chromium because of the presence of strontium chromate. The collected samples yielded 8-hr time-weighted average (TWA) concentrations that were up to 250, 6, and 5 times higher than the permissible exposure limits (PELs) for cadmium, lead, and hexavalent chromium, respectively. Also, the chromium levels measured by the ICP and VAS exceeded the strontium chromate threshold limit value (TLV) by up to 640 and 950 times, respectively. No correlation was found between the ICP and VAS hexavalent chromium concentrations. The likely reasons of this were the presence of Cr (II) and (III) that cannot be detected by the VAS, and the chemical interference from iron and some other metals in the samples. The Button Aerosol Sampler was shown to be useful for the monitoring of workers' exposure to heavy metals during abrasive blasting operations.

Comparison of sampling methods for monomer and polyisocyanates of 1,6-hexamethylene diisocyanate during spray finishing operations

A comparison study of isocyanate sampling methods for 1,6-hexamethylene diisocyanate (HDI) monomer and HDI-based polyisocyanates was conducted in spray painting environments. This study compared the performance of the Iso-chek sampler against existing and proposed National Institute of Occupational Safety and Health (NIOSH) and Occupational Safety and Health Administration (OSHA) monitoring methods for HDI-based isocyanates. Six methods for monitoring HDI monomer and polyisocyanate levels were compared. Fifty-eight sampling sets were collected during spray painting of aircraft and aircraft parts at four U.S. Air Force bases. Impinger and cassette samplers were mounted side-by-side on a mannequin located in paint overspray areas. For HDI monomer sampling results, there were no significant differences between NIOSH 5521, NIOSH 5522, OSHA 42, MAP (the proposed NIOSH method), and the Iso-Chek. For HDI-based polyisocyanates, NIOSH 5522, NIOSH 5521, Iso-Chek, and the Total Aerosol Mass Method (TAMM) were significantly different from one another. There was no significant difference between MAP and the NIOSH 5522 polyisocyanate sampling results. This study suggests the Iso-Chek and MAP sampling methods compare favorably with established methods for monitoring in HDI spray painting environments and the Total Aerosol Mass Method provides a reasonable upper boundary for estimating HDI polyisocyanate concentrations. The results also reemphasize aerosol sampling physics and sampler geometries must be carefully considered and appropriate samplers used when measuring exposures in spray paint environments where particulates are of the inhalable size.

Determination of hexamethylene diisocyanate-based isocyanates in spray-painting operations. Part 2. Comparison of high performance liquid chromatography with capillary zone electrophoresis

A capillary zone electrophoresis (CZE) approach was developed for the determination of hexamethylene diisocyanate (HDI) monomer and HDI-based oligomers. A comparison of CZE with high performance liquid chromatography (HPLC) indicates that the CZE separation completely isolates isocyanates from excess solvent, derivatizing reagent and pigment while offering a fivefold increase in sensitivity. The CZE approach allows for the quantification of HDI monomer and oligomer within a 1 min time window under the run conditions selected. For the determination of HDI-based oligomer, provided that the relative response with respect to HDI monomer is calculated, there is no significant difference (p < 0.05, n = 10) in the isocyanate air concentration when using either HPLC or CZE. The results are significant because they indicate that CZE has advantages for the determination of both HDI-based oligomer and HDI monomer generated during spray-painting operations.

Fracture of the penis--review with case report

Fracture of the penis is a rare injury. Controversy exists regarding conservative versus operative management. A case of penile fracture managed conservatively is reported with a brief review of the literature.