Evaluation of possible role of fluoride in pathogenesis of oral submucous fibrosis: A pilot study

BACKGROUND

Oral submucous fibrosis (OSMF) is a potentially malignant disorder. Although areca nut chewing is an established risk factor, its low prevalence among nut chewers indicates additional factors likely facilitates pathogenesis. We recently demonstrated high fluoride levels in smokeless tobacco products and hypothesized a potential pathological role of fluoride in OSMF. Further exploring this novel role, this study compared fluoride levels in tissue, serum, and saliva samples from OSMF patients and healthy controls.

METHODS

The ethically approved study included 25 clinically confirmed OSMF patients and 25 healthy matched controls. OSMF cases underwent buccal mucosal incisional biopsy, while controls had buccal mucosa tissue sampling during third molar removal. Fasting venous blood and unstimulated saliva were collected. Fluoride levels were analysed using ion chromatography and expressed as median (IQR).

RESULTS

OSMF cases showed significantly higher fluoride concentrations compared with controls in tissue biopsies (30.1 vs. 0 mg/kg, p < 0.0001), serum (0.4 vs. 0 mg/L, p = 0.005) and saliva (1.3 vs. 0 mg/L, p < 0.0001). Majority (68%) of controls had undetectable fluoride levels across all samples. Tissue fluoride weakly correlated with OSMF severity (r = -0.158, p = 0.334).

CONCLUSION

The preliminary findings demonstrated increased tissue fluoride levels in OSMF patients compared with healthy controls. Along with a previous study showing high fluoride content in smokeless tobacco products, these findings provided early evidence suggesting fluoride could play a contributory role in OSMF pathogenesis. Further large-scale investigation is warranted to definitively establish whether the association between fluoride exposure and OSMF is indicative of causation.

The effect of particle size on oral bioavailability and bioaccessibility of soil Ni from different sources

The goal of the work was to contribute to a unified approach to assessing the risk to human health of soil ingestion, for contaminated sites with elevated [Ni]. Robust relationships between in vitro bioaccessibility and in vivo bioavailability of Ni in various soils, with mechanistic understanding, would enable site-specific assessments of human exposure through soil ingestion. Four soils (three ultramafic Brunisols with geogenic Ni and one Organic soil with anthropogenic Ni) were sieved into PS < 10 μm, 10-41 μm, 41-70 μm, 70-105 μm, 105-150 μm, and 150-250 μm, the [Ni]T for which ranged from 560 to 103000 mg/kg. Mass fraction-adjusted [Ni]IVBA (SBRC gastric) for each soil fraction was similar whether calculated for all particles <250 μm or <150 μm %NiIVBA ranged from 3% to 16% of [Ni]T and %NiABA (accumulated Ni in urine, kidneys, and small intestine of Sprague Dawley rats gavaged with a soil) ranged from 0% to 0.49%. The correlation between these two measurements was weak (R2 = 0.06). Multiple linear dose response relationships attributing variation in %NiABA to %NiIVBA plus soil physicochemical parameters known to influence trace element availability in soils were developed. As many soil properties measured in this study were highly correlated, ridge regression enabled a predictive relationship where the effect of each parameter was its true contribution to variation in %NiABA. Using a ridge constant (k) of 0.012, %NiABA could be predicted from %NiIVBA adjusted for soil absorptive entities (OrgC, and Fe oxides (negative coefficients)) and soil pH (positive coefficient). %NiABA predicted from this relationship was very close to 1:1 with the observed %NiABA except at the lowest observed values which were lower than predicted. This study shows that as the conditions increasingly favour soil Ni solubility, more of the Ni was bioavailable; this generalization was true regardless of particle size or soil origin.

Phytotoxicity effect concentrations (ECx) for Ce, Nd and Eu added to soil relative to total and bioaccessible soil REE concentrations, and tissue REE accumulations

Toxicity thresholds (EC_x) for radish, tomato, and durum wheat growth endpoints (shoot length, shoot mass, root length) to Ce, Nd or Eu added to a black organic soil were determined from 14-day dose-response growth assays. EC₁₀ expressed as total soil [REE] had a more than twenty-fold range, from 337 mg/kg to more than >8000 mg/kg. Averaged over all REEs and endpoints, durum wheat was more tolerant than radish and tomato; and averaged over all endpoints, Eu appeared to be the most phytotoxic of the three REEs. Bioaccessibility of each REE was determined by extraction with 0.01 M CaCl₂, which for all three REEs in this soil was quite low, <0.10% of total. However, bioaccessibility of Eu was five or six times greater than that for Ce and Nd, and thus could explain its apparently greater toxicity, namely that Eu was more likely to be accumulated at the site of toxic action in the plant. To discern inherent toxicity from enhanced bioaccumulation, concentration of each REE in root and shoot tissues was determined, for a tissue-residue approach to toxicity assessment. The EC₁₀ expressed as tissue concentration was lower for Nd than for Ce and Eu, thus the most toxic of the three REEs. As for many cationic inorganic elements, toxicity varies with the chemistry of the exposure medium due to its effects on bioaccessibility. Simple methods to harmonize toxicity thresholds from different media enables greater integration into regulatory standards. When EC₂₅ from this and other studies were normalized to CaCl₂-extractable REE in their respective media, the range in Ce EC₂₅ was reduced from 20-fold to 2.5-fold, and the range for Eu EC₂₅ was reduced from 25-fold to 3-fold. This novel and low-input approach to meta-analysis of toxicity thresholds demonstrates the value of considering soil physico-chemical properties as modifiers of soil REE toxicity.

Response addition is more protective of biogeochemical cycles of carbon and phosphorus compared to concentration addition

In soils, enzymes are crucial to catalyzing reactions and cycling elements such as carbon (C), nitrogen (N), and phosphorus (P). Although these soil enzymes are sensitive to metals, they are often disregarded in risk assessments, and regulatory laws governing their existence are unclear. Nevertheless, there is a need to develop regulatory standards for metal mixtures that protect biogeochemical cycles because soil serve as a sink for metals and exposures occur as mixtures. Using a fixed ratio ray design, we investigated the effects of 5 single metals and 10 quinary mixtures of Zn, Cu, Ni, Pb, and Co metal oxides on two soil enzymes (i.e., acid phosphatases [ACP] and beta glucosidases [BGD]) in two acidic Canadian soils (S1: acid sandy forest soil, and S2: acid sandy arable soil), closely matched to EU REACH standard soils. Compared to BGD, ACP was generally the more sensitive enzyme to both the single metals and the metal mixtures. The effective concentration inhibiting 50% enzyme activity (EC₅₀) estimates for single Cu (2.1-160.7 mmol kg^-1) and Ni (12-272 mmol kg^-1) showed that those were the most toxic to both enzymes in both soils. For metal mixtures, response addition (RA) was more conservative in predicting metal effects compared to concentration addition (CA). For both additivity models, antagonism was observed except at lower concentrations (≤10,000 mg/kg) where synergism was observed. At higher concentrations (>10,000 mg/kg), free and CaCl₂ extractable Cu protected both enzymes against the toxicity of other metals in the mixture. The results suggest that assuming CA at concentrations less than EC₅₀ does not protect biogeochemical cycling of C and P. And Cu in soil may protect soil enzymes from other toxic metals and thus may have an overall positive role.

Derivation of a Ni bioaccessibility value for screening-level risk assessment of Ni substances in ingested materials including soils

The objective of the present study was to derive a Ni bioaccessibility value for screening-level risk assessment of Ni substances in ingested materials including soils where multiple Ni substances are expected but not definitively identified. Broad ranges of Ni mass loading and dissolution time of a simple gastric assay were applied to pure Ni substances (removing the confounding factors of soil constituents on dissolution), thus broadening the applicability of the conclusions. The data were also used to support current knowledge of 'read across' for Ni substances. Release of Ni from pure manufactured Ni substances (Ni metal, NiO, NiSO₄, Ni₃S₂, and NiS) was determined relative to Ni mass and substance surface area loading. Mass loadings ranged from 0.33 to 20.0 g Ni per L of 0.15 M HCl, and dissolution time ranged from 1 to 168 h. Proton exhaustion was indicated only at the highest loading (20 g/L) of NiO and Ni-M. Dissolution of substances other than NiSO₄ was most likely limited by formation of intermediate products at the particle surface or particle agglomeration, impeding access to the principal Ni substance. The bioaccessibility of Ni for these substances was consistent with previously published data: substances other than NiSO₄ were < 48% bioaccessible for a variety of gastric assays, which is much lower than all data for NiSO₄, the usual reference substance. Thus, we suggest that Ni bioaccessibility data from gastric assays that are most relevant to human exposure can be relied upon to develop scientifically sound screening-level human health RA decisions for Ni contamination in soils and sediments in the absence of detailed Ni speciation.

Development of physical employment standards of specialist paramedic roles in the National Ambulance Resilience Unit (Naru)

AIM

To develop evidence-based role-specific physical employment standards and tests for National Ambulance Resilience Unit (NARU) specialist paramedics.

METHODS

Sixty-two (53 men, 9 women) paramedics performed an array of (1) realistic reconstructions of critical job-tasks (criterion job performance); (2) simplified, easily-replicable simulations of those reconstructions and; (3) fitness tests that are portable and/or practicable to administer with limited resources or specialist equipment. Pearson's correlations and ordinary least products regression were used to assess relationships between tasks and tests. Performance on reconstructions, subject-matter expert and participant ratings were combined to derive minimum acceptable job performance levels, which were used to determine cut-scores on appropriate correlated simulations and tests.

RESULTS

The majority of performance times were highly correlated with their respective simulations (range of r: 0.73-0.90), with the exception of those replicating water rescue (r range: 0.28-0.47). Regression compatibility intervals provided three cut-scores for each job-task on an appropriate simulation and fitness test.

CONCLUSION

This study provides a varied and easily-implementable physical capability assessment for NARU personnel, empirically linked to job performance, with flexible options depending on organisational requirements.

Injuries in youth football and the relationship to player maturation: An analysis of time-loss injuries during four seasons in an English elite male football academy

A better insight into injuries in elite-youth football may inform prevention strategies. The purpose of this prospective cohort study was to investigate the frequency, incidence, and pattern of time-loss injuries in an elite male football academy, exploring injuries in relation to age and maturation status. Across four consecutive playing seasons, playing exposure and injuries to all academy players (U'9 to U'21) were recorded by club medical staff. Maturation status at the time of injury was also calculated for players competing in U'13 to U'16 aged squads. Time-loss injury occurrence and maturation status at time of injury were the main outcome measures. A total of 603 time-loss injuries were recorded, from 190 different players. Playing exposure was 229 317 hours resulting in an overall injury rate of 2.4 p/1000 h, ranging from 0.7 p/1000 h (U'11) to 4.8 p/1000 h (U'21). Most injuries were traumatic in mechanism (73%). The most common injury location was the thigh (23%), and the most common injury type was muscle injury (29%) combining to provide the most common injury diagnosis; thigh muscle injury (17%). In U'13-U'16 players, a higher number of injuries to early-maturing players were observed in U'13-U'14 players, while more injuries to U'15-U'16 players occurred when classed as "on-time" in maturity status. Maturation status did not statistically relate to injury pattern; however, knee bone (not-fracture) injuries peaked in U'13 players while hip/groin muscle injuries peaked in U'15 players.

Introducing the Adverse Ecosystem Service Pathway as a Tool in Ecological Risk Assessment

Soils provide numerous ecosystem services (ESs) such as food production and water purification. These ESs result from soil organism interactions and activities, which are supported by the soil physicochemical properties. Risk assessment for this complex system requires understanding the relationships among its components, both in the presence and absence of stressors. To better understand the soil ecosystem and how exposure to potentially toxic elements impact ESs, we developed a quantitative technique, the adverse ecosystem service pathway (AESP) model. We sampled 47 soils across Canada and analyzed them for properties that included pH and cation exchange capacity. We spiked the soils with a metal mixture and measured 15 soil processes representing five ESs. Using a Pearson correlation, we confirmed that proxies of ESs are linked to soil properties. t test results showed that, apart from soil enzyme activities (p > 0.05), the processes underlying ES proxies are significantly reduced in metal-impacted soils. Using soil properties as predictors of ES proxies, we developed AESP models: one for spiked and another for control soils. These models showed adverse effects on ESs in spiked soils, depicted as changes in partial correlation coefficients. The AESP model, therefore, can be an important tool to understand complex ecosystems and improve risk assessment.

Metal oxides and annealed metals as alternatives to metal salts for fixed-ratio metal mixture ecotoxicity tests in soil

In soil metal ecotoxicology research, dosing is usually performed with metal salts, followed by leaching to remove excess salinity. This process also removes some metals, affecting metal mixture ratios as different metals are removed by leaching at different rates. Consequently, alternative dosing methods must be considered for fixed ratio metal mixture research. In this study three different metal mixture dosing methods (nitrate, oxide and annealed metal dosing) were examined for metal concentrations and toxicity. In the nitrate metal dosing method leaching reduced total metal retention and was affected by soil pH and cation exchange capacity (CEC). Acidic soils 3.22 (pH 3.4, CEC 8 meq/100g) and WTRS (pH 4.6, CEC 16 meq/100g) lost more than 75 and 64% of their total metals to leaching respectively while Elora (6.7 pH, CEC 21 meq/100g) and KUBC (pH 5.6, CEC 28 meq/100g) with higher pH and CEC only lost 13.6% and 12.2% total metals respectively. Metal losses were highest for Ni, Zn and Co (46.0%, 63.7% and 48.4% metal loss respectively) whereas Pb and Cu (5.6% and 20.0% metal loss respectively) were mostly retained, affecting mixture ratios. Comparatively, oxide and annealed metal dosing which do not require leaching had higher total metal concentrations, closer to nominal doses and maintained better mixture ratios (percent of nominal concentrations for the oxide metal dosing were Pb = 109.9%, Cu = 84.6%, Ni = 101.9%, Zn = 82.3% and Co = 97.8% and for the annealed metal dosing were Pb = 81.7%, Cu = 80.3%, Ni = 100.5%, Zn = 89.2% and Co = 101.3%). Relative to their total metal concentrations, nitrate metal dosing (lowest metal concentrations) was the most toxic followed by metal oxides dosing while the annealed dosing method was generally non-toxic. Due to the lack of toxicity of the annealed metals and their higher dosing effort, metal oxides, are the most appropriate of the tested dosing methods, for fixed-ratio metal mixtures studies with soil invertebrates.

Toxicity assessment of metal mixtures to soil enzymes is influenced by metal dosing method

Metals are present as mixtures in the environment, yet testing such complex mixture poses design and technical challenges. One possible solution is the use of fixed ratios, i.e. rays of increasing metal concentrations. But fixed ratios rays are compromised when soils dosed with metal salts are leached due to metal-soil selectivity rules. Two alternative metal forms, metal oxides and spinel minerals of quinary metal mixtures (Pb, Cu, Co, Ni, Zn), were evaluated for their toxicity to soil microorganisms measured by the activity of ammonia monooxygenases and acid-phosphatases in three soils. Leaching, a required step for salts, had a larger effect on ammonia monooxygenases than metals. Generally, metal salts were the most toxic form, while the spinel minerals were the least toxic form. Two extractants, CaCl2 and DTPA, were evaluated for their ability to link toxicity to metals across all three metal forms. Salt toxicity was closely linked to CaCl2 extractable concentrations but DTPA was the most appropriate for oxides. We strongly recommend combining fixed ratio rays with metal oxides for metal mixture studies, since soil ratios created using oxides were more precise and required less experimental effort compared to salts and spinel minerals. Furthermore, because DTPA and CaCl2 closely tracked the toxicity of more realistic metal forms (i.e. oxides), we recommend that field studies investigating metal mixtures use both DTPA and CaCl2.

Bioaccessibility estimates by gastric SBRC method to determine relationships to bioavailability of nickel in ultramafic soils

Frameworks for human health risk assessment often include the opportunity to correct the estimate of exposure for bioavailability, which could be predicted from bioaccessibility. Lead and As are the only metallic elements for which bioavailability and bioaccessibility have been correlated across a spectrum of mineralogy and particle types. The objective of the present study is to correlate in vivo bioavailability with ex vivo bioaccessibility for elevated Ni in soils of ultramafic origin and explore attribution of any variation in this correlation to mineralogical characterization of the Ni. Ultramafic soils were field collected in British Columbia, CA. Rietveld quantitative X-ray diffraction was used for the characterization and quantification of crystalline materials containing Ni. Bioaccessible Ni was determined using the in vitro method developed by the Solubility/Bioaccessibility Research Consortium. Bioavailable Ni was determined by gavage dose of the soils to Sprague-Dawley rats. Urine and feces were collected every 24 h. At the end of 72 h, the animals were humanely sacrificed using carbon dioxide as per the approved animal care protocol. All organs were harvested, washed and preserved. Fecal elimination of gavaged Ni ranged from 35 to 95% including positive control. Relative bioavailability (RBA) ranged from 5 to 18%. In vitro bioaccessibility (IVBA) of soil Ni ranged from 0 to 17%; IVBA explained 86% of the variation in RBA. Normalizing both axes to soil olivine accounted for an additional 10% of the variation in RBA. For risk assessment of Ni contaminated soils, IVBA would be a useful and cost effective tool in estimating exposure of mammals through ingestion of soil particles, with some additional benefit of considering Ni mineralogy.

A potential new oral mapping (OM) method in the clinical evaluation and documentation of oral submucous fibrosis-A prospective clinical crossover study

BACKGROUND

Despite much research, there is a lack of a definite protocol or method for documenting oral submucous fibrosis (OSMF) site presentation. In this study, we propose a new potential oral mapping (OM) method and evaluated its use in recording OSMF-affected mucosal sites.

METHODS

Fifty OSMF patients were evaluated by 15 primary care dental practitioners using both, a conventional subjective recording method and a new OM method, to document the degree of involvement of affected oral mucosa with a crossover study design. Mann-Whitney test (non-parametric test) was used to make comparison between groups to determine any significant differences between the two identification methods. Wilcoxon tests were used to evaluate any significant differences in the difficulty in identification of two methods.

RESULTS

There was a low agreement between the two methods used to detect OSMF in affected mucosal surfaces (P-value < 0.0001). More lesions were identified using the proposed OM method, and less discrepancy was found among dental practitioners. A difference in difficulty of OSMF documentation was found (Wilcoxon z = 3.615, P-value < 0.001), with the proposed OM method found to be easier.

CONCLUSION

The proposed OM method appears to be useful for documentation, can easily be adapted in clinical practice, and effectively administered in clinical research. Additionally, it could be a useful tool to helping to maintain an OSMF database.

1.5mile run time and body mass predict 8mile loaded march performance, irrespective of sex

OBJECTIVES

To develop a statistical model to predict 8mile Loaded March (LM) performance and quantify differences in physical characteristics for men and women British Army Personnel.

DESIGN

135 trained soldiers (87 men; 48 women) completed two sessions, seven days apart.

METHODS

Session 1: Participants' stature, body mass, Fat Free Mass (FFM) [by dual-energy X-ray absorptiometry], Single Lift (SL), Water Can Carry (WCC), and 1.5mile run performance were measured. Session 2: Participants completed an 8mile LM, carrying 25kg (4miles paced and 4miles individual best effort). Sex differences were compared using independent samples t-tests and 8mile LM performance time was predicted using various multiple linear regression analysis: hierarchical forced entry multiple ordinary least squares, principal component and ordinary least products.

RESULTS

A combination of 1.5mile run time and body mass were the strongest predictors of 8mile LM time (R²=0.71; SEE=4.17min; p<0.001). Including stature, FFM, sex, SL score, or WCC score did not further improve predictions (p>0.05). Compared to women, men had faster mean 1.5mile run and LM times, greater body mass and total FFM and higher SL and WCC scores (p<0.001), however some women outperformed men.

CONCLUSION

1.5mile run time and body mass predict 8mile LM performance with no further improvement gained in the model by including sex as a variable.

Validation of site-specific soil Ni toxicity thresholds with independent ecotoxicity and biogeochemistry data for elevated soil Ni

The Existing Substances Regulation Risk Assessments by the European Union (EU RA) generated new toxicity data for soil organisms exposed to Ni added to sixteen field-collected soils with low background concentration of metals and varying physico-chemical soil characteristics. Using only effective cation exchange capacity (eCEC) as a bioavailability correction, chronic toxicity of Ni in soils with a wide range of characteristics could be predicted within a factor of two. The objective of the present study was to determine whether this was also the case for three independent data sets of Ni toxicity thresholds. Two of the data sets were from Community Based Risk Assessments in Port Colborne ON, and Sudbury ON (Canada) for soils containing elevated concentrations of Ni, Co and Cu arising from many decades of Ni mining, smelting and refining. The third data set was the Metals in Asia study of soluble Ni added to field soils in China. These data yielded 72 leached and aged EC₁₀/NOEC values for soil Ni, for arthropods, higher plants and woodlot structure and function. These were reduced to nine most sensitive single or geometric mean species/function endpoints, none of which were lower than the HC₅ predicted for a soil with an eCEC of 20 cmol/kg. Most of these leached and aged EC₁₀/NOEC values were from soils co-contaminated with Cu, in some cases at its median HC₅ as predicted by the EU RA from soil characteristics. We conclude that the EU RA is protective of Ni toxicity to higher-tier ecological endpoints, including in mixture with Cu, before the assessment factor of 2 is applied. We suggest that for prospective risk assessment, the bioavailability based PNEC (HC₅/2) be used as a conservative screen, but for retrospective and site-specific risk assessment, the bioavailability based HC₅ is sufficient.

An Exploration Into Effectiveness of Existential–Phenomenological Therapy as a U.K. NHS Psychological Treatment Intervention

Counselling and psychotherapy are rooted in humanistic and phenomenological approaches that place emphasis on a choice of therapies being available to individuals. Practice-based evidence makes an important contribution to the field of evidence-based practice on which National Health Service (NHS) clinicians and patients base decisions about psychological treatment interventions that are most likely to be effective. This research aimed to explore the effectiveness of Existential–Phenomenological Therapy (EPT) as routinely used to treat NHS patients in a U.K. secondary care setting. Quantitative data were analyzed from all available NHS routine patients’ ( N = 143) Clinical Outcomes in Routine Evaluation Outcome Measures for all those who were treated with EPT ( n = 34) and Cognitive Behavioral Therapy ( n = 109) from January 2008 to September 2010. Differences were found between waiting list and posttherapy ( p = .016) and between pretherapy and posttherapy ( p = .03) for EPT research participants and mean results produced reliable and clinically significant change for some. A quarter of these participants moved from a clinical to nonclinical population from pretherapy to posttherapy. A similar pattern was found for the EPT and cognitive behavioral therapy NHS routine practice patients.

Effect of liming on nickel bioavailability and toxicity to oat and soybean grown in field soils containing aged emissions from a nickel refinery

Remediation of soils elevated in trace metals so that the soils may provide ecosystems services is typically achieved through pH adjustment or addition of sorbents. The present study aimed to generate higher-tier in situ toxicity data for elevated nickel (Ni) in soils with and without lime addition and to explore the effect of liming on soil chemistry and bioavailability of Ni to plants. A multiyear study of agronomic yield of field-grown oat and soybean occurred in 3 adjacent fields that had received air emissions from a Ni refinery for 66 yr. The soil Ni concentration in the plots ranged between 1300 mg/kg and 4900 mg/kg, and each field was amended with either 50 Mg/ha, 10 Mg/ha, or 0 Mg/ha (or tonnes/ha) of crushed dolomitic limestone. As expected, liming raised the pH of the soils and subsequently reduced the plant availability of Ni. Toxicity thresholds (effective concentrations causing 50% reduction in growth) for limed soils supported the hypothesis that liming reduces toxicity. Relationships were found between relative yield and soil cation exchange capacity and between relative yield and soil pH, corroborating findings of the European Union Risk Assessments and the Metals in Asia studies, respectively. Higher tier ecotoxicity data such as these are a valuable contribution to risk assessment for Ni in soils. Environ Toxicol Chem 2017;36:1110-1119. © 2016 SETAC.

Short message service (SMS) texting as a method of communication during on call: prevalence and experience of medical staff in a large acute NHS Trust in the UK

With the widespread use of smartphones, text messaging has become an accepted form of communication for both social and professional use in medicine. To our knowledge no published studies have assessed the prevalence and use of short message service (SMS) texting by doctors on call. We have used an online questionnaire to seek information from doctors in a large NHS Trust in the UK about their use of texting while on call, what they use it for, and whether they send images relevant to patients' care. We received 302 responses (43% response rate), of whom 166 (55%) used SMS while on call. There was a significant association between SMS and age group (p=0.005), with the 20-30-year-old group using it much more than the other age groups. Doctors in the surgical specialties used it significantly less than those in other speciality groups (p<0 .001). Texting while on call was deemed to be safe and reliable (p<0.001). Eighteen clinicians (11%) admitted to routinely sending images of patients by text, despite some being identifiable. Texting was mainly used to update colleagues on patients' progress and give information about times of ward rounds and meetings. With the increasing use of texting in healthcare, much of which seems to be unregulated, further work and detailed guidance is required on what information may be given to ensure confidentiality and that SMS is a safe and acceptable method of communication to use when on call.

Plant community and litter composition in temperate deciduous woodlots along two field gradients of soil Ni, Cu and Co concentrations

Perennial plant communities in the proximity of metal smelters and refineries may receive substantial inputs of base metal particulate as well as sulphate from the co-emission of sulphur dioxide. The Ni refinery at Port Colborne (Canada) operated by Inco (now Vale Canada Ltd.) emitted Ni, Co and Cu, along with sulphur dioxide, between 1918 and 1984. The objectives were to determine if vascular plant community composition, including standing litter, in twenty-one woodlots on clay or organic soil, were related to soil Ni concentration which decreased in concentration with distance from the Ni refinery. The soil Ni concentration in the clay woodlots ranged from 16 to 4130 mg Ni/kg, and in the organic woodlots, ranged from 98 to 22,700 mg Ni/kg. The concentrations of Co and Cu in the soils were also elevated, and highly correlated with soil Ni concentration. In consequence, each series of woodlots constituted a 'fixed ratio ray' of metal mixture exposure. For each of the woodlots, there were 16 independent measurements of 'woodlot status' which were correlated with elevated soil Ni concentration. Of the 32 combinations, there were eight linear correlations with soil Ni concentration, considerably more than would be expected by chance alone at a p-value of 0.05. With the exception of mean crown rating for shrubs at the clay sites, the correlations were consistent with the hypothesis that increased soil metal concentrations would be correlated with decreased diversity, plant community health or fitness, and increased accumulation of litter. Only five of the eight linear correlations were from the organic woodlots, suggesting that the observations were not confounded with soil type nor range in soil metal concentrations.

Do you mind if I vape? Immediate effects of electronic cigarettes on perfusion in buccal mucosal tissue--a pilot study

The association between smoking and postoperative complications is compounded in patients who have oral and maxillofacial operations by an additional local effect, and patients often continue to smoke after operation despite advice to stop. Recent studies have suggested that nicotine may reduce inflammation and improve angiogenesis, so topical application may be beneficial for smokers. The electronic cigarette is increasing in popularity and more patients ask whether they can vape after operation. We investigated the effect of electronic cigarettes (of which half contained nicotine and half did not) on blood flow in the buccal mucosa in 10 volunteers immediately after vaping. Smokers were excluded as this was considered an additional variable in a small pilot study and our Trust has a no-smoking policy. After vaping for 5 minutes, capillary blood flow was measured in the buccal mucosa at 5-minute intervals using a laser Doppler probe, and the results were expressed as arbitrary perfusion units. There was a wide variation in results and a small but significant rise (p=0.008) as a result of nicotine vaping, but these fell to the same levels as before within 30 minutes. Electronic cigarettes may have an effect on blood flow to the oral mucosa, although further studies are needed to show whether they improve healing time after operation. Additional work is also needed to compare them with cigarettes.

Low serum 25-hydroxyvitamin D is associated with increased risk of stress fracture during Royal Marine recruit training

The aim of this study was to investigate vitamin D status and stress fracture risk during Royal Marine military training. Poor vitamin D status was associated with an increased risk of stress fracture. Vitamin D supplementation may help to reduce stress fracture risk in male military recruits with low vitamin D status.

INTRODUCTION

Stress fracture is a common overuse injury in military recruits, including Royal Marine (RM) training in the UK. RM training is recognised as one of the most arduous basic training programmes in the world. Associations have been reported between serum 25-hydroxyvitamin D (25(OH)D) and risk of stress fracture, but the threshold of 25(OH)D for this effect remains unclear. We aimed to determine if serum 25(OH)D concentrations were associated with stress fracture risk during RM training.

METHODS

We prospectively followed 1082 RM recruits (males aged 16-32 years) through the 32-week RM training programme. Troops started training between September and July. Height, body weight and aerobic fitness were assessed at week 1. Venous blood samples were drawn at weeks 1, 15 and 32. Serum samples were analysed for 25(OH)D and parathyroid hormone (PTH).

RESULTS

Seventy-eight recruits (7.2 %) suffered a total of 92 stress fractures. Recruits with a baseline serum 25(OH)D concentration below 50 nmol L(-1) had a higher incidence of stress fracture than recruits with 25(OH)D concentration above this threshold (χ(2) (1) = 3.564, p = 0.042; odds ratio 1.6 (95 % confidence interval (CI) 1.0-2.6)). Baseline serum 25(OH)D varied from 47.0 ± 23.7 nmol L(-1) in February, to 97.3 ± 24.6 nmol L(-1) in July (overall mean 69.2 ± 29.2 nmol L(-1), n = 1016). There were weak inverse correlations between serum 25(OH)D and PTH concentrations at week 15 (r = -0.209, p < 0.001) and week 32 (r = -0.214, p < 0.001), but not at baseline.

CONCLUSION

Baseline serum 25(OH)D concentration below 50 nmol L(-1) was associated with an increased risk of stress fracture. Further studies into the effects of vitamin D supplementation on stress fracture risk are certainly warranted.

Angina at Low heart rate And Risk of imminent Myocardial infarction (the ALARM study): a prospective, observational proof-of-concept study

Background

Myocardial infarction (MI) is often preceded by unstable angina. Helping patients identify the onset of unstable angina rather than MI may result in earlier treatment and improve outcomes. Unstable angina is angina occurring at a lower-than-usual workload. Since heart rate (HR) is correlated with degree of exertion, we hypothesised that angina occurring at low HR is a warning signal for unstable angina and MI.

Methods

In this prospective study, 111 patients with acute coronary syndrome (ACS) or prognostically significant coronary disease were recruited. Each patient’s HR was measured using a portable electrocardiogram (ECG) recorder after regular class III exercise on the Canadian Cardiovascular Society Angina Grading Scale and the cumulative moving average and three-sigma (standard deviation) range were calculated for each new measurement. The HR was subsequently measured at the beginning of angina; a HR lower than the preceding three-sigma ranges for class III or anginal HR was regarded as a ‘warning signal’. The proportion of warning signals associated with ACS occurring in the following 2 weeks was compared with that for non-warning signals.

Results

Nine cases of ACS occurred in eight patients. Two cases were preceded by warning signals; a signal marked the onset of ACS in a third patient, and four patients failed to make anginal ECG recordings. There were 591 documented episodes of angina during the study and ECGs were available for 383 (64.8 %) of these of which 55 were warning signals. Of these warning signals, 4 occurred in the 2 weeks preceding ACS, compared with 4 of 328 non-warning signals (odds ratio, 6.4; 95 % confidence interval, 1.5–26.2; p = 0.01; positive predictive value, 7.3 %; negative predictive value, 98.8 %).

Conclusions

Low HR angina may identify unstable angina and serve as an early warning for MI. In addition, angina that does not occur at a low heart rate indicates that ACS is very unlikely.

Anesthetic management of super-morbidly obese parturients for cesarean delivery with a double neuraxial catheter technique: a case series

Parturients with super-morbid obesity, defined as body mass index greater than 50kg/m(2), represent a growing segment of patients who require anesthetic care for labor and delivery. Severe obesity and its comorbid conditions place the parturient and fetus at greater risk for pregnancy complications and cesarean delivery, as well as surgical and anesthetic complications. The surgical approach for cesarean delivery in these patients may require a supra-umbilical vertical midline incision due to a large pannus. The dense T4-level of spinal anesthesia can cause difficulties with ventilation for the obese patient during the procedure, which can be prolonged. Patients also may have respiratory complications in the postoperative period due to pain from the incision. We describe the anesthetic management of three parturients with body mass index ranging from 73 to 95kg/m(2) who had a cesarean delivery via a supra-umbilical vertical midline incision. Continuous lumbar spinal and low thoracic epidural catheters were placed in each patient for intraoperative anesthesia and postoperative analgesia, respectively. Continuous spinal catheters were dosed with incremental bupivacaine boluses to achieve surgical anesthesia. In one case, the patient required respiratory support with non-invasive positive pressure ventilation. Two cases were complicated by intraoperative hemorrhage. All patients had satisfactory postoperative analgesia with a thoracic epidural infusion. None suffered postoperative respiratory complications or postdural puncture headache. The use of a continuous lumbar spinal catheter and a low thoracic epidural provides several advantages in the anesthetic management of super-morbidly obese parturients for cesarean delivery.

Thallium and potassium uptake kinetics and competition differ between durum wheat and canola

Thallium (Tl) is very toxic to mammals but little is known about its accumulation by plants, and it would be useful if prediction of Tl accumulation could be done using potassium (K) accumulation models. The objectives of this study were to compare the uptake kinetics of Tl(+) and K(+), and to determine how readily K(+) can inhibit Tl(+) uptake. Durum wheat (Triticum turgidum L.) and spring canola (Brassica napus L.) were grown hydroponically and exposed to 0-75 μM Tl or 0-250 μM K for up to 150 min (kinetics experiment), or to 0.1 or 10 μM Tl with Tl to K ratios of 1:1 to 1:10,000 for up to 300 min (competition experiment). The rate of uptake of Tl(+) by canola was about three to five times faster than by wheat, while the rate of Tl(+) uptake in wheat was the same as the rate of K(+) uptake by either species. Uptake of Tl(+) was more readily suppressed by K(+) in wheat than in canola. When exposed to 0.1 uM Tl for 300 min with 100 or 1,000 uM K(+), Tl(+) uptake by wheat was reduced by 20 % and 50 %, respectively, while Tl(+) uptake by canola was not reduced. Our results suggest that predicting Tl accumulation using a K accumulation model with a correction factor may be possible for canola, but would be much more difficult for wheat, since uptake of Tl(+) is very sensitive to levels of K(.)

Sheehan syndrome: acute presentation with severe headache

Postpartum headache is a common occurrence with a broad differential diagnosis. Sheehan syndrome, or postpartum pituitary necrosis, is not typically recognized as a cause of postpartum headache. We present a case of Sheehan syndrome that initially presented as severe headache after vaginal delivery complicated by retained placenta and postpartum hemorrhage. The patient was discharged home on postpartum day three but continued to have headaches and returned to hospital on postpartum day six with severe headache, failure to lactate, edema, dizziness, fatigue, nausea and vomiting. Cranial magnetic resonance imaging revealed pituitary infarction consistent with Sheehan syndrome. We discuss the differential diagnosis for postpartum headache, the pathophysiological features of Sheehan syndrome and headache as an atypical acute presentation.

Does the great auricular nerve predict the size of the main trunk of the facial nerve? A clinical and cadaveric study

There seems to be only individual clinical experience and some anecdotal evidence about a relation between the width of the great auricular nerve (GAN) and the size of the main trunk of the facial nerve during parotidectomy. To our knowledge no anatomical studies have been published. In this cadaveric and clinical study we measured the widest point of the GAN as it crosses the sternomastoid muscle before it divides, and the main trunk of the facial nerve before it bifurcates. Measurements were obtained from 16 patients who required formal superficial parotidectomies with identification of the facial nerve, and from 21 cadavers (16 formalin-fixed and 5 fresh frozen) where both sides were dissected. We recorded the results and the side of dissection. The mean (SD) width of the GAN and facial nerve from all the dissections was 2.75 (0.53)mm and 2.83 (0.54)mm, respectively. There was a strong correlation between the width of the nerves from both sides (left: r=0.934, p<0.001; right: r=0.940, p<0.001). The nerves did not differ significantly in size in patients or cadavers (GAN: right, p=0.873; left, p=0.486; facial nerve: right, p=0.931; left, p=0.691). We have found that the GAN accurately predicts the width of the main trunk of the facial nerve. This is particularly useful surgically as a narrow GAN can alert the surgeon to expect a small facial nerve.

Effect of major cations (Ca2+, Mg2+, Na+, K+) and anions (SO4(2-), Cl- , NO3-) on Ni accumulation and toxicity in aquatic plant (Lemna minor L.): implications For Ni risk assessment

The effect of major cation activity (Ca(2+) , Mg(2+) , Na(+) , K(+) ) on Ni toxicity, with dose expressed as exposure (total dissolved Ni concentration NiTot ) or free Ni ion activity (in solution Ni(2+) ), or as tissue residue (Ni concentration in plant tissue NiTiss ) to the aquatic plant Lemna minor L. was examined. In addition, Ni accumulation kinetics was explored to provide mechanistic insight into current approaches of toxicity modeling, such as the tissue residue approach and the biotic ligand model (BLM), and the implications for plant Ni risk assessment. Major cations did not inhibit Ni accumulation via competitive inhibition as expected by the BLM framework. For example, Ca(2+) and Mg(2+) (sulfate as counter-anion) had an anticompetitive effect on Ni accumulation, suggesting that Ca or Mg forms a ternary complex with Ni-biotic ligand. The counter-anion of the added Ca (sulfate, chloride, or nitrate) affected plant response (percentage of root growth inhibition) to Ni. Generally, sulfate and chloride influenced plant response while nitrate did not, even when compared within the same range of Ca(2+) , which suggests that the anion dominated the observed plant response. Overall, although an effect of major cations on Ni toxicity to L. minor L. was observed at a physiological level, Ni(2+) or NiTot alone modeled plant response, generally within a span of twofold, over a wide range of water chemistry. Thus, consideration of major cation competition for improving Ni toxicity predictions in risk assessment for aquatic plants may not be necessary.

Arsenic bioaccessibility in a gold mining area: a health risk assessment for children

High concentrations of total arsenic (As) have been measured in soils of gold mining areas of Brazil. However, bioaccessibility tests have not yet been conducted on those materials, which is essential for better health risk estimates. This study aimed at evaluating As bioaccessibility in samples from a gold mining area located in Brazil and assessing children's exposure to As-contaminated materials. Samples were collected from different materials (a control and four As-contaminated soils/sediments) found in a gold mine area located in Paracatu (MG), Brazil. Total and bioaccessible As concentrations were determined for all samples. The control soil presented the lowest As concentrations, while all other materials contained high total As concentrations (up to 2,666 mg kg(-1)) and low bioaccessible As percentage (<4.2%), indicating a low risk from exposure of resident children next to this area. The calculated dose of exposure indicated that, except for the pond tailings, in all other areas, the exposure route considering soil ingestion contributed at most to 9.7% of the maximum As allowed ingestion per day (0.3 μg kg(-1) BW day(-1)).

Human health risks of Pb and As exposure via consumption of home garden vegetables and incidental soil and dust ingestion: a probabilistic screening tool

The consumption of home grown vegetables may represent a significant exposure pathway for arsenic (As) and lead (Pb) relative to direct incidental ingestion of soil, thus a probabilistic screening tool for estimating these exposures was developed using regression models relating co-located soil and home garden (HG) vegetable concentrations of Pb and As established from multiple independent studies and 2-dimensional Monte Carlo analyses. For high-quantity consumers of HG vegetables (i.e., the upper 95th percentile of consumers in the general population), the HG consumption pathway can be as significant as incidental soil and dust ingestion for inorganic As and, therefore, should be considered when developing generic health-based soil criteria in residential settings. Predicted Pb Hazard Quotient (HQ) estimates among young children resulting from HG consumption were 4- to 10-fold lower than exposures resulting from direct incidental soil and dust ingestion. The difference in soil/dust ingestion rates used to characterize young children (the 95th percentile of 202 mg/d) versus a lifetime residential receptor (the 95th percentile of 30 mg/d) was a primary factor contributing to the relative differences observed between HQ and incremental lifetime cancer risk (ILCR) resulting from these two exposure pathways for lead Pb and inorganic arsenic As, respectively.

Effects of cement or lime on Cd, Co, Cu, Ni, Pb, Sb and Zn mobility in field-contaminated and aged soils

Cement or lime can be used to treat trace element contaminated soils, reducing their mobility due to increased soil pH which enhances precipitation and adsorption, and also due to pozzolanic reactions and cementation. In the present work, an alkaline and an acidic soil both containing Cd, Co, Cu, Ni, Pb, Sb and Zn from either geogenic or geogenic and anthropogenic origin were treated with cement or calcium hydroxide. Soils were then extracted with dilute HNO(3) or NaOH solution of different concentrations to obtain extracts of different pH (pH 4-12). In untreated soils, Co, Cu, Ni and Pb in solutions were detected at alkaline pH. The addition of cement or Ca(OH)(2) reduced the mobility of every trace element at high pH, but enhanced the mobility of Cd, Co, Cu, Ni, Pb and Zn at low pH. Metal mobilisation at high pH was observed for Cu in the acidic soil due to the liberation of dissolved organic matter. Below pH 6, Sb mobility was lower in the cement-treated soil compared to the untreated soil, but the same in the Ca(OH)(2) treated soil as in the control soil. Comparison with theoretical trace element precipitates suggested that the mobility of trace elements is likely reduced at high pH by encapsulation and immobilisation within the cement matrix rather then precipitation.

In vitro estimates of bioaccessible nickel in field-contaminated soils, and comparison with in vivo measurement of bioavailability and identification of mineralogy

This study determined nickel (Ni) bioaccessibility in weathered smelter-contaminated soils, separately for particle-sized fractions using two in vitro methods: simulated gastrointestinal digestion (PBET) and PBET followed by absorption by Caco-2 cells. Relative bioavailability of Ni in soils was determined in vivo using rats, validating in vitro estimates; a mineralogical basis of variation in bioavailability/bioaccessibility among soils was explored. In vitro assays identified the same difference in bioaccessibility for Ni among particle size fractions. PBET estimates were more precise, thus likely to be more useful in discerning differences among soils. In vivo bioavailability for Ni was below limit of detection for the small soil particles, and 31% and 56% for the larger particles. The relative bioavailability calculated from this work suggests that risk from ingesting Ni-contaminated soils could be overestimated by between 2- and 50-fold if the estimates of exposure are not adjusted for the lower bioavailability of weathered Ni originating from smelter emissions. The overestimation that would occur by using total Ni is greatest for the particle size that is most likely to adhere to the hands of children, demonstrating the importance of particle-size separation of soils for bioavailability determination and risk assessment.

Metals in the Human Environment Strategic Network (MITHE-SN): the interface of risk assessment, public policy, and advocacy

A 5-year strategic research network with a diverse base of industry, government, and academic partners was approved for support by National Sciences and Engineering Research Council of Canada (NSERC) on January 3, 2005. This Metals in the Human Environment Strategic Network (MITHE-SN) builds on, and further extends, science knowledge developed by the NSERC-sponsored Metals in the Environment Research Network (MITE-RN, 1999-2004). In addition to the initial award, the MITHE-SN received an additional 2-year grant specifically targeted to (1) enhance training opportunities for internships with international organizations, (2) increase international networking and linkages, and (3) optimize knowledge dissemination and technology transfer. The research program is comprised of three themes and represents a cascade of effects along food webs, from the lowest trophic levels to the highest consumers. Each of the themes addresses issues related to distinguishing the magnitudes and roles of natural background and anthropogenic metal inputs in biotic exposure to metals; estimating the bioavailable fraction of metals in the exposure media, thus better quantifying the true exposure concentration; and determining the factors that influence bioavailability of metals in media, so that predictive models can be developed for use in the development of site-specific metals criteria.

Cd accumulation in roots and shoots of durum wheat: the roles of transpiration rate and apoplastic bypass

Cadmium is readily taken up from soils by plants, depending on soil chemistry, and variably among species and cultivars; altered transpiration and xylem transport and/or translocation in the phloem could cause this variation in Cd accumulation, some degree of which is heritable. Using Triticum turgidum var. durum cvs Kyle and Arcola (high and low grain Cd accumulating, respectively), the objectives of this study were to determine if low-concentration Cd exposure alters transpiration, to relate transpiration to accumulation of Cd in roots and shoots at several life stages, and to evaluate the role of apoplastic bypass in the accumulation of Cd in shoots. The low abundance isotope (106)Cd was used to probe Cd translocation in plants which had been exposed to elemental Cd or were Cd-naïve; apoplastic bypass was monitored using the fluorescent dye PTS (8-hydroxy-1,3,6-pyrenetrisulphonate). Differential accumulation of Cd by 'Kyle' and 'Arcola' could be partially attributed to the effect of Cd on transpiration, as exposure to low concentrations of Cd increased mass flow and concomitant Cd accumulation in 'Kyle'. Distinct from this, exposure of 'Arcola' to low concentrations of Cd reduced translocation of Cd from roots to shoots relative to root accumulation of Cd. It is possible, but not tested here, that sequestration mechanisms (such as phytochelatin production, as demonstrated by others) are the genetically controlled difference between these two cultivars that results in differential Cd accumulation. These results also suggest that apoplastic bypass was not a major pathway of Cd transport from the root to the shoot in these plants, and that most of the shoot Cd resulted from uptake into the stele of the root via the symplastic pathway.

Culpability and blame after pregnancy loss

The problem of feeling guilty about a pregnancy loss is suggested to be primarily a moral matter and not a medical or psychological one. Two standard approaches to women who blame themselves for a loss are first introduced, characterised as either psychologistic or deterministic. Both these approaches are shown to underdetermine the autonomy of the mother by depending on the notion that the mother is not culpable for the loss if she "could not have acted otherwise". The inability to act otherwise is explained as not being as strong a determinant of culpability as it may seem at first. Instead, people's culpability for a bad turn of events implies strongly that they have acted for the wrong reasons, which is probably not true in the case of women who have experienced a loss of pregnancy. The practical conclusion of this paper is that women who feel a sense of guilt in the wake of their loss have a good reason to reject both the psychologistic and the deterministic approaches to their guilt-that they are justified in feeling upset about what has gone wrong, even responsible for the life of the child, but are not culpable for the unfortunate turn of events.