Metabolic, neurotoxic and immunotoxic effects of PFAAs and their mixtures on the proteome of the head kidney and plasma from rainbow trout (Oncorhynchus mykiss)

PFAAs (Perfluoroalkyl acids) are a class of bioaccumulative, persistent and ubiquitous environmental contaminants which primarily occupy the hydrosphere and its sediments. Currently, a paucity of toxicological information exists for short chain PFAAs and complex mixtures. In order to address these knowledge gaps, we performed a 3-week, aqueous exposure of rainbow trout to 3 different concentrations of a PFAA mixture (50, 100 and 500 ng/L) modeled after the composition determined in Lake Ontario. We conducted an additional set of exposures to individual PFAAs (25 nM each of PFOS (12,500 ng/L), PFOA (10,300 ng/L), PFBS (7500 ng/L) or PFBA (5300 ng/L) to evaluate differences in biological response across PFAA congeners. Untargeted proteomics and phosphorylated metabolomics were conducted on the blood plasma and head kidney tissue to evaluate biological response. Plasma proteomic responses to the mixtures revealed several unexpected outcomes including Similar proteomic profiles and biological processes as the PFOS exposure regime while being orders of magnitude lower in concentration and an atypical dose response in terms of the number of significantly altered proteins (FDR < 0.1). Biological pathway analysis revealed the low mixture, medium mixture and PFOS to significantly alter (FDR < 0.05) a number of processes including those involved in lipid metabolism, oxidative stress and the nervous system. We implicate plasma increases in PPARD and PPARG as being directly related to these biological processes as they are known to be important regulators in all 3 processes. In contrast to the blood plasma, the high mixture and PFOA exposure regimes caused the greatest change to the head kidney proteome, altering many proteins being involved in lipid metabolism, oxidative stress and inflammation. Our findings support the pleiotropic effect PFAAs have on aquatic organisms at environmentally relevant doses including those on PPAR signaling, metabolic dysregulation, immunotoxicity and neurotoxicity.

P10.12.A CDK12/CDK13 inhibition disrupts a transcriptional program critical for glioblastoma survival

Background

Glioblastoma multiforme (GBM) is the most prevalent and aggressive malignant tumor of the central nervous system. With a median survival of only one year, GBM patients have a particularly poor prognosis, highlighting a clear need for novel therapeutic strategies to target this disease. Transcriptional cyclin-dependent kinases (CDK), which phosphorylate key residues of RNA polymerase II (RNAPII) C-terminal domain (CTD), play a major role in sustaining aberrant transcriptional programs that are key to development and maintenance of cancer cells.

Material and Methods

We used pharmacological inhibition and genetic ablation to study effects of CDK12/CDK13 depletion on the proliferatory and migratory capacity of GBM cells and mouse xenografts. SLAM-seq, CUT&RUN and cell cycle assays were used to study the mechanistic effects of CDK12/CDK13 depletion in GBM cells.

Results

CDK12/CDK13 depletion markedly reduced the proliferatory and migratory capacity of GBM cells, as well as in vivo growth. CDK12/CDK13 inhibition potentiated existing chemotherapeutic treatments. Mechanistically, inhibition of CDK12/CDK13 leads to a genome-wide abrogation of RNAPII CTD phosphorylation, which in turn disrupts transcription and cell cycle progression in GBM cells.

Conclusion

These results provide proof-of-concept for the potential of CDK12 and CDK13 as therapeutic targets for GBM.

Non-Lethal Blood Sampling of Fish in the lab and Field With Methods for Dried Blood Plasma Spot Omic Analyses

There is global acknowledgment that humane methods in animal research are a priority, but few environmental effects monitoring programs use nonlethal methods for fish. The goal of the present study was to determine the impacts of sampling small volumes of blood in larger-bodied fish on survival and healing. In addition to evaluating survival following blood sampling, we evaluated the utility of dried blood spots as an alternative for sample processing and storage in the field. In our approach, we housed 80 rainbow trout (Oncorhynchus mykiss) in our flow-through aquatic facility. We then anaesthetized using MS-222 and sampled 1 μl/g bw of blood via puncture of the caudal vasculature. We tested four different post-blood sampling treatments on the puncture wound: 1. application of liquid bandage; 2. a swab of betadine; 3. a swab of fish mucous; and 4. compared survival outcomes to a group where no post-treatment was performed (negative control). Overall, we observed 90% survival among all treatments, with the most effective approach being the negative control (100% survival). Based upon these results, we repeated the blood sampling with no-post treatment by housing 20 rainbow trout (not previously tested upon) in cages at a nearby creek and monitored survival for 2 weeks post sampling. The survival rate was 95% with full healing of the puncture site in all subjects. In addition to this, we tested the efficacy of dry blood spotting on proteomic, lipidomic and amino acid analysis as an alternative method for blood sample processing and storage. It was found that dried plasma spotting using parafilm in conjunction with a modified Bligh-Dyer extraction offered the best balance for good recovery of protein, lipid and amino acids relative to wet plasma and Noviplex dried plasma spot cards. In this article, we will present the detailed results of these combined studies and describe what we have determined to be the safest non-lethal blood sampling protocol.

Paternal Exposure to Carbamazepine Impacts Zebrafish Offspring Reproduction Over Multiple Generations

Chronic low-concentration chemical exposures may have both direct health outcomes on adults and indirect effects on their offspring. Using zebrafish, we examined the impacts of chronic, low-concentration carbamazepine (CBZ) exposure on a suite of male reproductive endpoints in the parents and four generations of offspring reared in clean water. CBZ is one of the most frequently detected pharmaceutical residues in water, is a histone deacetylase inhibitor in mammals, and is reported to lower androgens in mammals and fish. Exposure of adult zebrafish to 10 μg/L CBZ for 6 weeks decreased reproductive output, courtship and aggressive behaviors, 11-ketotestosterone (11KT), and sperm morphology but did not impact milt volume or sperm swimming speed. Pairwise breeding generated lineages of offspring with both parents exposed and two lineages where only one parent was exposed; the control lineage had unexposed parents. Reproductive output and male reproductive indices were assessed in F₁-F₄ offspring to determine whether parental CBZ exposure had transgenerational impacts. The offspring of CBZ-exposed males had lower 11KT, reproductive output, altered courtship, aggression, and sperm morphology compared to the lineage from unexposed parents. Our results indicate that parental carbamazepine exposure history impacts the unexposed progeny up to the F₄ generations and that paternal, but not maternal, exposure is most important for the reproductive health of male offspring.

Parental gemfibrozil exposure impacts zebrafish F1 offspring, but not subsequent generations

Gemfibrozil (GEM) is a fibrate lipid regulator and one of the most commonly occurring fresh water pharmaceuticals. The negative effects of fibrates including GEM on fish reproduction have been frequently reported including effects of F₀ GEM exposure on reproduction of the unexposed F₁ offspring. We predicted that chronic, direct exposure of zebrafish with low concentrations of GEM would adversely affect parental male reproduction and unexposed offspring for multiple generations. Adult zebrafish were exposed to 10 μg/L GEM for 6 weeks and a range of reproductive indices were analyzed. The F₁-F₄ offspring were reared in clean water from 3 distinct lineages where only a single or both parents were exposed and compared to a control lineage where parents were unexposed. Reproductive indices were examined in unexposed F₁-F₄ offspring to test the hypothesis of multi- or trans- generational impacts. Exposure to GEM caused a decline in breeding success and mean embryo production in F₀ parents and a reduction in whole body 11-ketotestosterone (11-KT), altered male courtship, aggression and sperm morphology. Our results indicate that paternal exposure alone is sufficient to result in reproductive effects in unexposed male offspring but that effects are mostly limited to F₁. We suggest that GEM may act as a reproductive endocrine disruptor in fish and that chronic exposure reduced male reproductive fitness but not over multiple generations.

U.K. Foot and Mouth Disease: A Systemic Risk Assessment of Existing Controls

This article details a systemic analysis of the controls in place and possible interventions available to further reduce the risk of a foot and mouth disease (FMD) outbreak in the United Kingdom. Using a research-based network analysis tool, we identify vulnerabilities within the multibarrier control system and their corresponding critical control points (CCPs). CCPs represent opportunities for active intervention that produce the greatest improvement to United Kingdom's resilience to future FMD outbreaks. Using an adapted 'features, events, and processes' (FEPs) methodology and network analysis, our results suggest that movements of animals and goods associated with legal activities significantly influence the system's behavior due to their higher frequency and ability to combine and create scenarios of exposure similar in origin to the U.K. FMD outbreaks of 1967/8 and 2001. The systemic risk assessment highlights areas outside of disease control that are relevant to disease spread. Further, it proves to be a powerful tool for demonstrating the need for implementing disease controls that have not previously been part of the system.

The burden of nonadherence among adults with asthma: a role for shared decision-making

A shared approach to decision-making framework has been suggested for chronic disease management especially where multiple treatment options exist. Shared decision-making (SDM) requires that both physician and patients are actively engaged in the decision-making process, including information exchange; expressing treatment preferences; as well as agreement over the final treatment decision. Although SDM appears well supported by patients, practitioners and policymakers alike, the current challenge is to determine how best to make SDM a reality in everyday clinical practice. Within the context of asthma, adherence rates are poor and are linked to outcomes such as reduced asthma control, increased symptoms, healthcare expenditures, and lower patient quality of life. It has been suggested that SDM can improve treatment adherence and that ignoring patients' personal goals and preferences may result in reduced rates of adherence. Furthermore, understanding predictors of poor treatment adherence is a necessary step toward developing effective strategies to improve the patient-reported and clinically important outcomes. Here, we describe why a shared approach to treatment decision-making for asthma has the potential to be an effective tool for improving adherence, with associated clinical and patient-related outcomes. In addition, we explore insights into the reasons why SDM has not been implemented into routine clinical practice.

Confluence and Contours: Reflexive Management of Environmental Risk

Government institutions have responsibilities to distribute risk management funds meaningfully and to be accountable for their choices. We took a macro-level sociological approach to understanding the role of government in managing environmental risks, and insights from micro-level psychology to examine individual-level risk-related perceptions and beliefs. Survey data from 2,068 U.K. citizens showed that lay people's funding preferences were associated positively with beliefs about responsibility and trust, yet associations with perception varied depending on risk type. Moreover, there were risk-specific differences in the funding preferences of the lay sample and 29 policymakers. A laboratory-based study of 109 participants examined funding allocation in more detail through iterative presentation of expert information. Quantitative and qualitative data revealed a meso-level framework comprising three types of decisionmakers who varied in their willingness to change funding allocation preferences following expert information: adaptors, responders, and resistors. This research highlights the relevance of integrated theoretical approaches to understanding the policy process, and the benefits of reflexive dialogue to managing environmental risks.

China's soil and groundwater management challenges: Lessons from the UK's experience and opportunities for China

There are a number of specific opportunities for UK and China to work together on contaminated land management issues as China lacks comprehensive and systematic planning for sustainable risk based land management, encompassing both contaminated soil and groundwater and recycling and reuse of soil. It also lacks comprehensive risk assessment systems, structures to support risk management decision making, processes for verification of remediation outcome, systems for record keeping and preservation and integration of contamination issues into land use planning, along with procedures for ensuring effective health and safety considerations during remediation projects, and effective evaluation of costs versus benefits and overall sustainability. A consequence of the absence of these overarching frameworks has been that remediation takes place on an ad hoc basis. At a specific site management level, China lacks capabilities in site investigation and consequent risk assessment systems, in particular related to conceptual modelling and risk evaluation. There is also a lack of shared experience of practical deployment of remediation technologies in China, analogous to the situation before the establishment of the independent, non-profit organisation CL:AIRE (Contaminated Land: Applications In Real Environments) in 1999 in the UK. Many local technology developments are at lab-scale or pilot-scale stage without being widely put into use. Therefore, a shared endeavour is needed to promote the development of technically and scientifically sound land management as well as soil and human health protection to improve the sustainability of the rapid urbanisation in China.

Evolution of strategic risks under future scenarios for improved utility master plans

Integrated, long-term risk management in the water sector is poorly developed. Whilst scenario planning has been applied to singular issues (e.g. climate change), it often misses a link to risk management because the likelihood of impacts in the long-term are frequently unaccounted for in these analyses. Here we apply the morphological approach to scenario development for a case study utility, Empresa Portuguesa das Águas Livres (EPAL). A baseline portfolio of strategic risks threatening the achievement of EPAL's corporate objectives was evolved through the lens of three future scenarios, 'water scarcity', 'financial resource scarcity' and 'strong economic growth', built on drivers such as climate, demographic, economic, regulatory and technological changes and validated through a set of expert workshops. The results represent how the baseline set of risks might develop over a 30 year period, allowing threats and opportunities to be identified and enabling strategies for master plans to be devised. We believe this to be the first combined use of risk and futures methods applied to a portfolio of strategic risks in the water utility sector.

A randomised phase IIb trial to assess the efficacy of ReCharge ice cream in preventing chemotherapy-induced diarrhoea

PURPOSE

Chemotherapy-induced diarrhoea (CID) has a significant impact. A medicinal food product (ReCharge) containing iron-saturated lactoferrin and anhydrous milk fat reduces the detrimental effects of chemotherapy on the gut in animals. We report results of a randomised blinded placebo-controlled phase IIb trial investigating the efficacy and safety of ReCharge in preventing CID.

METHODS

Eligible patients were adults due to start the first cycle of a 2- or 3-week-cycle chemotherapy regimen, had an Eastern Cooperative Oncology Group (ECOG) status of 3 or less, had adequate haematological, liver and renal function and provided written informed consent. Patients (197) were randomised to ReCharge or placebo. They consumed 100-g study product for 2 weeks before and 6 weeks after starting chemotherapy, completed daily diaries for 8 weeks and attended clinic visits until 12 weeks (2-week cycles) or 14 weeks (3-week cycles). The primary outcome was days with CID.

RESULTS

The mean number of days with diary-recorded CID was marginally but not statistically significantly lower on ReCharge than placebo (-2.0, 95 % CI (-4.7 to 0.7), p = 0.2). The proportion reporting diarrhoea in the previous cycle at the clinic visit was 30 % lower (p = 0.012) on ReCharge. Missing diary data may have contributed to the discrepancy. No significant differences were found in quality of life or other adverse events.

CONCLUSIONS

We found no clear evidence that ReCharge reduced CID as measured by patient self-report diary. The converse finding of benefit as recorded at clinic visits and incomplete adherence to diary completion indicates that further research is required into methods for measuring CID.

Assessing interdependent operational, tactical and strategic risks for improved utility master plans

Risk management plays a key role in water utilities. Although risk tools are well-established at operational levels, approaches at the strategic level are rarely informed by systemic assessments of the water supply and lack a long-term perspective. Here, we report a baseline strategic risk analysis, founded on a systemic analysis of operational risks developed 'bottom-up' and validated in a large water utility. Deploying an action-oriented research method, supported by semi- structured interviews with in-house water utility risk experts, deep connections are established between operational risk and strategic risk that surpass those existing elsewhere in the sector. Accessible presentational formats - influence diagrams, risk "heat-maps" and supporting narratives are used to promote Board-level risk discussions, and characterise a baseline set of strategic risks core to forward utility master planning. Uniquely, the influence of operational events, exposures and potential harms, together with the mitigating measures in place to mediate these risks are linked to corporate objectives on business sustainability, profitability, water quality, water quantity, supply disruption and reputation.

A systems approach to the policy-level risk assessment of exotic animal diseases: network model and application to classical swine fever

Exotic animal diseases (EADs) are characterized by their capacity to spread global distances, causing impacts on animal health and welfare with significant economic consequences. We offer a critique of current import risk analysis approaches employed in the EAD field, focusing on their capacity to assess complex systems at a policy level. To address the shortcomings identified, we propose a novel method providing a systematic analysis of the likelihood of a disease incursion, developed by reference to the multibarrier system employed for the United Kingdom. We apply the network model to a policy-level risk assessment of classical swine fever (CSF), a notifiable animal disease caused by the CSF virus. In doing so, we document and discuss a sequence of analyses that describe system vulnerabilities and reveal the critical control points (CCPs) for intervention, reducing the likelihood of U.K. pig herds being exposed to the CSF virus.

A randomized phase II study comparing capecitabine alone with capecitabine and oral cyclophosphamide in patients with advanced breast cancer-cyclox II

BACKGROUND

Capecitabine and cyclophosphamide are active in patients with advanced breast cancer, have non-overlapping toxic effects and synergy pre-clinically. We explored the efficacy and toxic effect of an all-oral combination of capecitabine with cyclophosphamide versus capecitabine alone in a multicentre, randomized, phase II study.

PATIENTS AND METHODS

Patients with locally advanced or metastatic breast cancer were randomized to treatment with capecitabine given continuously (666 mg/m(2) b.i.d. days 1-28) alone (C) or with oral cyclophosphamide (100 mg/m(2) days 1-14 of a 28-day cycle) (CCy) for up to six cycles.

RESULTS

Eighty-two patients were randomized. There was no complete response. The proportions with partial response were 36% on C and 44% on CCy, a difference of 7.9% [95% confidence interval (CI) -13.4 to 29.1]. Significant toxic effect was uncommon: grade ≥3 diarrhoea in 4 (10%) versus 1 (3%) patients; grade ≥3 fatigue in 2 (5%) versus 5 patients (13%) and grade ≥2 hand-foot syndrome in 7 (17%) versus 11 (28%) patients receiving C versus CCy, respectively. Median progression-free survival was 3.1 months on C and 6.9 months on CCy, not significantly different statistically. There was no difference in overall survival.

CONCLUSION

The difference in tumour response suggests a reasonable chance that CCy is superior to C alone.

Solid recovered fuel: materials flow analysis and fuel property development during the mechanical processing of biodried waste

Material flows and their contributions to fuel properties are balanced for the mechanical section of a mechanical-biological treatment (MBT) plant producing solid recovered fuel (SRF) for the UK market. Insights for this and similar plants were secured through a program of sampling, manual sorting, statistics, analytical property determination, and material flow analysis (MFA) with error propagation and data reconciliation. Approximately three-quarters of the net calorific value (Q(net,p,ar)) present in the combustible fraction of the biodried flow is incorporated into the SRF (73.2 ± 8.6%), with the important contributors being plastic film (30.7 MJ kg(ar)(-1)), other packaging plastic (26.1 MJ kg(ar)(-1)), and paper/card (13.0 MJ kg(ar)(-1)). Nearly 80% w/w of the chlorine load in the biodried flow is incorporated into SRF (78.9 ± 26.2%), determined by the operation of the trommel and air classifier. Through the use of a novel mass balancing procedure, SRF quality is understood, thus improving on the understanding of quality assurance in SRF. Quantification of flows, transfer coefficients, and fuel properties allows recommendations to be made for process optimization and the production of a reliable and therefore marketable SRF product.

Solid recovered fuel: influence of waste stream composition and processing on chlorine content and fuel quality

Solid recovered fuel (SRF) produced by mechanical-biological treatment (MBT) of municipal waste can replace fossil fuels, being a CO(2)-neutral, affordable, and alternative energy source. SRF application is limited by low confidence in quality. We present results for key SRF properties centered on the issue of chlorine content. A detailed investigation involved sampling, statistical analysis, reconstruction of composition, and modeling of SRF properties. The total chlorine median for a typical plant during summer operation was 0.69% w/w(d), with lower/upper 95% confidence intervals of 0.60% w/w(d) and 0.74% w/w(d) (class 3 of CEN Cl indicator). The average total chlorine can be simulated, using a reconciled SRF composition before shredding to <40 mm. The relative plastics vs paper mass ratios in particular result in an SRF with a 95% upper confidence limit for ash content marginally below the 20% w/w(d) deemed suitable for certain power plants; and a lower 95% confidence limit of net calorific value (NCV) at 14.5 MJ kg(ar)(-1). The data provide, for the first time, a high level of confidence on the effects of SRF composition on its chlorine content, illustrating interrelationships with other fuel properties. The findings presented here allow rational debate on achievable vs desirable MBT-derived SRF quality, informing the development of realistic SRF quality specifications, through modeling exercises, needed for effective thermal recovery.

Evaluation of inflammatory effects of airborne endotoxin emitted from composting sources

Because of the lack of effective methodology, the biological effects of environmental endotoxin have not been assessed. Here we have collected and measured airborne endotoxin at different locations around composting sites. Increased endotoxin concentrations were observed close to composting activities and also at nearby boundary areas. Analysis of proinflammatory effects of the environmental endotoxin on interleukin (IL)-8 and IL-6 release from human D562 pharyngeal epithelial and MM6 monocytic cell cultures showed an association between endotoxin level and cytokine induction. The cytokine-inducing effect of bioaerosol extracts was inhibited by polymyxin B, indicating that endotoxin was the cause of cytokine responses we found. The environmental endotoxin was also more active for stimulating cytokines in airway epithelial cells than commercially purified Escherichia coli endotoxin. Our results suggest that these in vitro inflammatory cell models may contribute to the assessment of health impacts of environmental endotoxin.

When is a soil remediated? Comparison of biopiled and windrowed soils contaminated with bunker-fuel in a full-scale trial

A six month field scale study was carried out to compare windrow turning and biopile techniques for the remediation of soil contaminated with bunker C fuel oil. End-point clean-up targets were defined by human risk assessment and ecotoxicological hazard assessment approaches. Replicate windrows and biopiles were amended with either nutrients and inocula, nutrients alone or no amendment. In addition to fractionated hydrocarbon analysis, culturable microbial characterisation and soil ecotoxicological assays were performed. This particular soil, heavy in texture and historically contaminated with bunker fuel was more effectively remediated by windrowing, but coarser textures may be more amendable to biopiling. This trial reveals the benefit of developing risk and hazard based approaches in defining end-point bioremediation of heavy hydrocarbons when engineered biopile or windrow are proposed as treatment option.

Removal of steroid estrogens in carbonaceous and nitrifying activated sludge processes

A carbonaceous (heterotrophic) activated sludge process (ASP), nitrifying ASP and a nitrifying/denitrifying ASP have been studied to examine the role of process type in steroid estrogen removal. Biodegradation efficiencies for total steroid estrogens (Sigma(EST)) of 80 and 91% were recorded for the nitrifying/denitrifying ASP and nitrifying ASP respectively. Total estrogen biodegradation (Sigma(EST)) was only 51% at the carbonaceous ASP, however, the extent of biodegradation in the absence of nitrification clearly indicates the important role of heterotrophs in steroid estrogen removal. The low removal efficiency did not correlate with biomass activity for which the ASP(carbonaceous) recorded 80 microg kg(-1) biomass d(-1) compared to 61 and 15 microg kg(-1) biomass d(-1) at the ASP(nitrifying) and ASP(nitrifying/denitrifying) respectively. This finding was explained by a moderate correlation (r(2)=0.55) between total estrogen loading (Sigma(EST) mgm(-3)d(-1)) and biomass activity (microg Sigma(EST) degraded kg(-1) d(-1)) and has established the impact of loading on steroid estrogen removal at full-scale. At higher solids retention time (SRT), steroid estrogen biodegradation of>80% was observed, as has previously been reported. It is postulated that hydraulic retention time (HRT) is as important as SRT as this governs both reaction time and loading. This observation is based on the high specific estrogen activity determined at the ASP(carbonaceous) plant, the significance of estrogen loading and the positive linear correlation between SRT and HRT.

An international review of the challenges associated with securing 'buy-in' for water safety plans within providers of drinking water supplies

Since publication of the 3rd Edition of the World Health Organisation (WHO) Drinking Water Quality guidelines, global adoption of water safety plans (WSPs) has been gathering momentum. Most guidance lists managerial commitment and 'buy-in' as critical to the success of WSP implementation; yet the detail on how to generate it is lacking. This commentary discusses aspects of managerial commitment to WSPs. We argue that the public health motivator should be clearer and a paramount objective and not lost among other, albeit legitimate, drivers such as political or regulatory pressures and financial efficiency.

Endotoxin emissions from commercial composting activities

This paper describes an exploratory study of endotoxin emissions and dispersal from a commercial composting facility. Replicated samples of air were taken by filtration at different locations around the facility on 10 occasions. Measurements were made of endotoxin and associated culturable microorganisms. The inflammatory response of cell cultures exposed to extracts from the filters was measured. Endotoxin was detected in elevated concentrations close to composting activities. A secondary peak, of lesser magnitude than the peak at source was detected at 100-150 m downwind of the site boundary. Unexpectedly high concentrations of endotoxin were measured at the most distant downwind sampling point. Extracted endotoxin was found to stimulate human monocytes and a human lung epithelial cell line to produce significant amounts of pro-inflammatory cytokines. On a weight basis, endotoxin extracted from the composting source has a greater inflammatory cytokine inducing effect than commercial E. coli endotoxin.

Adding omalizumab to the therapy of adolescents with persistent uncontrolled moderate--severe allergic asthma

OBJECTIVE

This study aimed to evaluate the effectiveness of omalizumab among adolescents with moderate-severe allergic asthma inadequately controlled with inhaled corticosteroids.

PATIENTS AND METHODS

Data from patients 12 to 17 years of age were pooled from 5 placebo-controlled registration trials of omalizumab. Impact on asthma control was assessed by need for rescue bursts of oral corticosteroids, lung function, symptom scores, and unscheduled office visits.

RESULTS

In adolescents (n = 146), addition of omalizumab decreased mean number of rescue bursts (0.3 vs 0.9) versus placebo; relative risk 0.47 (95% confidence interval [CI], 0.22-0.99; P = .047). At study conclusion, mean forced expiratory volume in 1 second increased 268 mL (13.8%) in omalizumab-treated subjects versus 98 mL (5.5%) for placebo (least squares mean treatment difference 146 mL [95% CI, 19.4-272.6; P = .024]). Omalizumab significantly improved asthma symptom scores and reduced unscheduled office visits.

CONCLUSION

Omalizumab added to baseline therapy improves measures of asthma control in adolescents with persistent moderate-severe allergic asthma.

Influence of operating parameters on the biodegradation of steroid estrogens and nonylphenolic compounds during biological wastewater treatment processes

This study investigated operational factors influencing the removal of steroid estrogens and nonylphenolic compounds in two sewage treatment works, one a nitrifying/denitrifying activated sludge plant and the other a nitrifying/denitrifying activated sludge plant with phosphorus removal. Removal efficiencies of >90% for steroid estrogens and for longer chain nonylphenol ethoxylates (NP4-12EO) were observed at both works, which had equal sludge ages of 13 days. However, the biological activity in terms of milligrams of estrogen removed per day per tonne of biomass was found to be 50-60% more efficient in the nitrifying/denitrifying activated sludge works compared to the works which additionallyincorporated phosphorusremoval. A temperature reduction of 6 degrees C had no impact on the removal of free estrogens, but removal of the conjugated estrone-3-sulfate was reduced by 20%. The apparent biomass sorption (LogKp) values were greater in the nitrifying/denitrifying works than those in the nitrifying/denitrifying works with phosphorus removal for both steroid estrogens and honylphenolic compounds possibly indicating a different cell surface structure and therefore microbial population. The difference in biological activity (mg tonne(-1) d(-1)) identified in this study, of up to seven times, suggests thatthere is the potential for enhancing the removal of estrogens and nonylphenols if more detailed knowledge of the factors responsible for these differences can be identified and maximized, thus potentially improving the quality of receiving waters.

A role for human reliability analysis (HRA) in preventing drinking water incidents and securing safe drinking water

The prevalence of water quality incidents and disease outbreaks suggests an imperative to analyse and understand the roles of operators and organisations in the water supply system. One means considered in this paper is through human reliability analysis (HRA). We classify the human errors contributing to 62 drinking water accidents occurring in affluent countries from 1974 to 2001; define the lifecycle of these incidents; and adapt Reason's 'Swiss cheese' model for drinking water safety. We discuss the role of HRA in human error reduction and drinking water safety and propose a future research agenda for human error reduction in the water sector.

Wastes as co-fuels: the policy framework for solid recovered fuel (SRF) in Europe, with UK implications

European Union (EU) member states are adopting the mechanical-biological treatment (MBT) of municipal solid waste (MSW) to comply with EU Landfill Directive (LD) targets on landfill diversion. We review the policy framework for MSW-derived solid recovered fuel (SRF), composed of paper, plastic, and textiles, in the energy-intensive industries. A comparatively high calorific value (15-18 MJ/ kg) fuel, SRF has the potential to partially replace fossil fuel in energy-intensive industries, alongside MSW in dedicated combustion facilities. Attempts by the European standards organization (CEN) to classify fuel properties consider net calorific value (CV) and chlorine and mercury content. However, the particle size, moisture content, and fuel composition also require attention and future studies must address these parameters. We critically review the implications of using SRF as a co-fuel in thermal processes. A thermodynamic analysis provides insight into the technical and environmental feasibility of co-combusting SRF in coal-fired power plants and cement kilns. Results indicate the use of SRF as co-fuel can reduce global warming and acidification potential significantly. This policy analysis is of value to waste managers, policy specialists, regulators, and the waste management research community.

Modeling human exposures to air pollution control (APC) residues released from landfills in England and Wales

Human exposures to air pollution control (APC) residues released from 6 landfills were modeled and assessed. Following a qualitative risk characterisation, direct and indirect exposures were quantified. Site-specific air dispersion modeling was conducted for PM(10), PCDDs/PCDFs, Pb, Cd, As and Cr(VI) concentrations at the closest residential points of exposure for 4 landfill sites accepting, in total, 75% w/w of the APC residues disposed of in 2000-2001 (UK). Inhalation risks, assessed by reference to air quality standards at residential exposure points, were assessed as insignificant. Preliminary modeling suggested that indirect exposures from PCDDs/PCDFs at the 95th percentile level for the site where APC deposition rates were highest could potentially exceed the tolerable daily soil intake (TDSI) but this warrants further study given the model limitations. These results offer an initial screen of the significance of potential risks from APC disposal, which is of value in addressing concerns about the uncertainty of potential risks to human health from bulk APC disposal at strategic locations.

Producer responsibility, waste minimisation and the WEEE Directive: case studies in eco-design from the European lighting sector

The EU Directive on Waste Electrical and Electrical Equipment (WEEE) (2002/96/EC), to be implemented in stages from August 2004, attempts to tackle the growing quantity WEEE by making producers responsible for the costs of the collection and recycling of their products at the end of usable life. This is considered to give producers a financial incentive to reduce waste at source through eco-design. This link is, however, under-researched and little is known generally about the effectiveness of extended producer responsibility (EPR) and policies to promote it. This paper presents the findings of an exploratory study to address these important gaps in knowledge. Literature review was used to develop an analytical framework to explain the relationships between the drivers for eco-design and the role of policies to promote EPR. This was applied to eight case studies of firms from the European lighting sector. While quantitative data to confirm the link between EPR and eco-design were difficult to obtain, the case studies showed that EPR has had little effect on product development so far. Within the sector studied, most producers have been able to pass on incremental costs associated with EPR to customers with negligible effects on sales. This reflects perceptions in the lighting sector that, because demand for products is relatively price inelastic and the regulation affects all producers equally, EPR is unlikely to drive eco-design at least in the short run. The cases also showed that choice between individual and centrally provided waste recovery schemes rested on perceptions of relative costs and practicability. It was evident that other drivers, such as bans on hazardous substances, product declarations and supply chain pressures, were often more effective promoters of eco-design. Thus it seems a mix of policy measures is required rather than reliance on economic instruments alone.

Prostate Specific Antigen Isoforms and Human Glandular Kallikrein 2—Which Offers the Best Screening Performance in a Predominantly Black Population?

PURPOSE

Free prostate specific antigen, complexed PSA and human glandular kallikrein 2 have independently been tested against the gold standard of total PSA for prostate cancer screening in largely white populations. With the incidence of prostate cancer much higher in black men, we sought to evaluate these markers simultaneously in a predominantly black population.

MATERIALS AND METHODS

A total of 138 men, of whom 108 were black, underwent ultrasound guided biopsy of the prostate for tPSA levels greater than 2.5 ng/ml or an abnormal digital rectal examination. Sera were drawn before biopsy and analyzed for tPSA, fPSA, cPSA and hK2 concentrations using standard methods (hK2 assay is for research use only, not for use in diagnostic procedures). The areas under the receiver operator characteristic curves were determined for each marker as well as biomarker combinations. Additionally, each parameter's specificity, positive and negative predictive values, and theoretical screening efficiency were assessed at or above the 95% sensitivity level.

RESULTS

A total of 43 (31.1%) men had prostate cancer by biopsy. While the AUC for %fPSA was statistically the highest (0.822, p <0.001), cPSA offered the highest specificity (31.6%) and positive predictive power (31.7%) of any of the tested biomarkers at comparable sensitivity (greater than 95%). The calculated efficiency of cPSA (51.4%) was also higher than the other markers. Nearly 20% of biopsies would be avoided using cPSA vs standard tPSA screening methods.

CONCLUSIONS

Comparing the major PSA isoforms and hK2, cPSA alone appears to offer superior diagnostic discrimination for cancer detection in a predominantly black population.

The ATAC (‘Arimidex’, Tamoxifen, Alone or in Combination) adjuvant breast cancer trial: first results of the endometrial sub-protocol following 2 years of treatment

BACKGROUND

Tamoxifen treatment results in a doubling of the risk of endometrial cancer after 1-2 years of treatment and a quadrupling after 5 years. Anastrozole, a third-generation aromatase inhibitor, with superior efficacy to tamoxifen, may also offer tolerability benefits in terms of effects on the endometrium.

METHODS AND RESULTS

A sub-protocol of the ATAC trial compared the incidence/type of intrauterine changes following treatment with these agents in a subgroup of patients (n = 285) from the main trial. After 2 years anastrozole treatment, endometrial thickness remained </= 5 mm (baseline: 3.0 mm); in patients receiving tamoxifen, endometrial thickness increased by 3.2 mm to 7.0 mm, with a similar trend in the combination group. At baseline, 26/285 patients (9.1%) had endometrial abnormalities, most commonly polyps. After 2 years the number of endometrial abnormalities appeared lower with anastrozole treatment compared with tamoxifen although these differences were not statistically significant (odds ratio: 0.44; 95% confidence interval 0.146, 1.314; P = 0.14). Most abnormalities occurred within the first year of treatment (anastrozole: 4/6; tamoxifen: 7/10; combination: 10/16; total: 21/32). Fewer patients in the anastrozole group (1.4%) required medical intervention (tamoxifen 12.5%; combination 13.6%).

CONCLUSIONS

Fewer endometrial abnormalities occurred during 2 years treatment with anastrozole compared with tamoxifen although statistical significance was not reached in this sub-protocol analysis.

Assessment of municipal waste compost as a daily cover material for odour control at landfill sites

The ability of municipal waste compost as a daily cover material to reduce the odorous emissions associated with landfill surfaces was investigated. Trials were carried out using landfill gas, a certified sulphurous gas mix and ambient air as a control. Odorous gas was passed through portable test column filled with compost at different densities (590 kg/m3 and 740 kg/m3). Gas samples were taken from the inlet, outlet and at varying column depths and examined using a combination of sensory analysis (olfactometry) and a novel analytical method (Transportable Selected Ion Flow Tube--TSIFT). Results for the trials using landfill gas showed a 69% odour reduction (OU/m3) through the column for compost with a bulk density of 590 kg/m3, and a reduction of 97% using compost with a bulk density of 740 kg/m3. TSIFT analysis showed an overall decrease in the concentration of terpenes, and sulphurous compounds in the outlet gas from the column for both bulk densities. No significant trend could be identified for the concentrations at different depths within the column. Results show the ability of compost to reduce landfill odours under differing conditions. The inconclusive data provided by TSIFT analysis may be due to the analysis of compounds that are not contributing to odour, and thus highlights the potential for synergetic effects and the importance of sensory measurement when examining odorous emissions.

The ATAC (‘Arimidex’, Tamoxifen, Alone or in Combination) adjuvant breast cancer trial: baseline endometrial sub-protocol data on the effectiveness of transvaginal ultrasonography and diagnostic hysteroscopy

BACKGROUND

The 'Arimidex', Tamoxifen, Alone or in Combination (ATAC) trial is a randomized, double-blind trial comparing anastrozole ('Arimidex'), alone or in combination with tamoxifen, relative to tamoxifen alone as 5 year adjuvant treatment for post-menopausal women with early breast cancer. Since tamoxifen is associated with endometrial pathology, the ATAC endometrial sub-protocol was initiated to establish the background prevalence of intrauterine pathology, and to assess prospectively the incidence and nature of intrauterine changes following endocrine therapy. Another aim was to provide data from which advice could be generated on the best endometrium screening method for patients receiving tamoxifen.

METHODS

Patients underwent endometrial assessments at entry to the sub-protocol. The baseline investigations comprised transvaginal ultrasound scanning (TVUS), a hysteroscopy and an endometrial biopsy.

RESULTS

A total of 285 gynaecologically asymptomatic women from 31 centres in 10 countries entered the endometrial sub-protocol. The mean uterine volume was 47.7 cm3. The median endometrial thickness overall was 3 mm. Twenty-four histologically confirmed, pathological changes were observed. Twenty-three pathologies were confirmed by TVUS, and 21 were identified by hysteroscopy and confirmed by histopathology. Women with or without intrauterine pathology had median endometrial thickness of 5 and 3 mm respectively.

CONCLUSIONS

The presence of pathology was associated with increased endometrial thickness. The relative sensitivity and specificity of hysteroscopy and endometrial thickness for the diagnosis of endometrial pathology was comparable to other studies. If screening of the endometrium prior to treatment is appropriate, this study supports the use of an endometrial thickness of 3 mm, as assessed by TVUS, as a threshold for needing further investigation. This study demonstrates that if the endometrial thickness is >3 mm, hysteroscopy and biopsy is the optimal method of detecting intrauterine pathology in women with breast cancer who are about to commence endocrine treatment.

The ATAC adjuvant breast cancer trial in postmenopausal women: baseline endometrial subprotocol data

OBJECTIVE

The ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial is a randomised, double-blind trial comparing 'Arimidex' (anastrozole), alone or in combination with tamoxifen, relative to tamoxifen alone as a five year adjuvant treatment for postmenopausal women with early breast cancer. Because tamoxifen is associated with endometrial pathology, the ATAC endometrial subprotocol was initiated to establish the background prevalence of pathology, and to assess prospectively the incidence and nature of intrauterine changes before and following endocrine therapy.

SETTING

International. POPULATION AND STUDY DESIGN: Two hundred and eighty-five women entered the subprotocol: the mean age was 60 years (range 44-80 years); 113 women (40%) had taken hormone replacement therapy prior to randomisation, and 238 women were parous (84%). The age at onset of the menopause was 32-58 years, with the majority becoming menopausal between 46 and 55 years of age. Two hundred and seventy-two women had a hysteroscopy before they commenced trial medication. Hysteroscopy was performed successfully in 265 women. In six women, failure of hysteroscopy at baseline led to withdrawal from the study. Three of the women who withdrew had a pipelle biopsy taken. Therefore, the total number of endometrial biopsies at baseline was 268.

MAIN OUTCOME MEASURES

To assess the demographic characteristics of women entering the endometrial subprotocol and their hysteroscopic and histological findings before commencing trial medication.

RESULTS

At hysteroscopy, there was a diagnosis of endometrial polyps in 34 women (13%), fibroids in 16 women (6%) and one case of suspicious endometrium, which was confirmed as a polyp on histology. Only 21 of the 34 polyps seen hysteroscopically were proven histologically (62% accuracy of hysteroscopy). Final histology found the prevalence of endometrial diagnostic categories as follows: 123 inactive endometrium (46%), 20 benign polyps (7%), 17 secretory endometrium (6%), 7 proliferative endometrium (3%), 3 atypical hyperplasia (2 in a polyp), 1 simple hyperplasia (in a polyp) and 1 fibroid. The remaining women had pipelle samples with insufficient tissue obtained, indicating a normal endometrial cavity.

CONCLUSION

This is the first study of such size in gynaecologically asymptomatic breast cancer patients. This paper describes the findings in individual patients before any trial treatment was given. In this baseline group, 82% (219/268) of women had a normal endometrial cavity; 18% (49/268) had endometrial activity (proliferative or secretory endometrium in 9%) or an intracavity abnormality (hyperplasia, polyps and a fibroid in 9%). In total, 36% of biopsies had insufficient tissue for diagnosis, which in combination with a normal hysteroscopy was classed as normal. The appearance of a polyp hysteroscopically in this group was not proven histologically in approximately 40% of cases. The development of uterine pathology over time in the ATAC study will subsequently be assessed against the findings of this baseline paper.

Complexed PSA performance for prostate cancer detection in an African-American population

OBJECTIVES

Complexed prostate-specific antigen (cPSA) has been shown to improve the differentiation of benign and malignant disease compared with total PSA (tPSA) in studies evaluating predominantly white populations of men. We sought to evaluate the diagnostic performance of cPSA relative to tPSA in a population of African-American men.

METHODS

Consecutive African-American men scheduled for prostate biopsy were enrolled prospectively at the Louisiana State University Medical Center, New Orleans. Serum was collected before the biopsy procedure and tested with the Immuno 1 tPSA and cPSA methods. Receiver operating characteristic curve analysis was performed and the area under the curve was calculated for tPSA and cPSA.

RESULTS

A total of 156 patients were evaluated, 51 (32.7%) of whom were diagnosed with prostate cancer. The median PSA value for men with prostate cancer was 4.96 ng/mL and for those with benign disease was 3.93 ng/mL. The receiver operating characteristic analysis indicated that the area under the curve for cPSA (0.679) was statistically greater than that achieved for tPSA (0.642, P = 0.004). Using cutoff values for cPSA of 2.3 ng/mL and for tPSA of 2.85 ng/mL provided a specificity of 31.4% and 26.7%, respectively, at a sensitivity for prostate cancer detection of 95%. This was not statistically significant (P = 0.18).

CONCLUSIONS

cPSA offers modest improvement in prostate cancer detection compared with tPSA in African-American men, but not at the clinically relevant 95% sensitivity level. Additional work is needed to improve prostate cancer detection in this high-risk cohort of patients.

Adult small intestinal transplantation in England and Wales

BACKGROUND

In 1996 two transplantation centres in the UK were commissioned by the National Specialist Commissioning Advisory Group for England and Wales to assess small intestinal transplantation in adults. The joint experience of the two centres is presented.

METHODS

Patients with irreversible small intestinal failure and complications of parenteral nutrition, and those with abdominal disease requiring extensive visceral resection, were assessed as candidates and where appropriate listed for surgery.

RESULTS

Thirty-six patients were assessed for small intestinal transplantation and, of these, 14 underwent surgery. Twelve patients survived the transplantation procedure. Of these, seven patients were alive at 1 year, five at 3 years and three at 5 years. Three patients remain alive. Patient and graft survival improved with experience; the 1-year survival rate improved in the last 4 years of this experience from 43 to 57 per cent, and the 3-year survival rate from 29 to 43 per cent.

CONCLUSION

Small intestinal transplantation is associated with a high mortality rate but may benefit carefully selected patients in whom conservative management is likely to carry a greater mortality rate.

The GABA(A) receptor complex in the chicken brain: immunocytochemical distribution of alpha 1- and gamma 2-subunits and autoradiographic distribution of BZ1 and BZ2 binding sites

Two antibodies, raised against the rat GABA(A) receptor alpha1- and gamma2-subunits, were used for an immunocytochemical study of the distribution of these proteins in the chicken brain. The immunoreactive bands obtained by Western blotting and the similar labelling distribution found in the rat and chicken brain support the suitability of these antibodies for the labelling of GABA(A) receptors in birds. We found abundant alpha1 and gamma2 immunoreactivity throughout the chicken brain, mainly in the paleostriata and lobus paraolfactorius, dorsal thalamus and some nuclei of the brainstem. The alpha1-subunit was more abundant in the telencephalon, thalamus and cerebellum, while the presence of the gamma2-subunit was stronger in the optic tectum and brainstem. We also report the autoradiographic distribution of the BZ1 and BZ2 benzodiazepine receptor subtypes in the chicken brain using [3H]flunitrazepam. Benzodiazepine binding was unevenly distributed throughout the chicken brain, and the anatomical distribution of the BZ1 and BZ2 subtypes was similar to that described in mammals. The highest binding values were found in the olfactory bulb, paleostriatum primitivum, optic tectum, nucleus mesencephalicus lateralis pars dorsalis and nucleus isthmi pars parvocellularis, the BZ2 subtype being predominant in the paleostriatum primitivum and optic tectum. A general agreement in the distribution of BZ1 and alpha1 immunoreactivity was observed in structures such as the olfactory bulb, paleostriata, lobus parolfactorius and dorsal thalamus, although some discrepancies were observed in areas such as the optic tectum or nucleus isthmi pars parvocellularis, with high BZ1 binding and low or no alpha1 immunolabelling.