Associations of Serum Perfluoroalkyl Substances and Placental Human Chorionic Gonadotropin in Early Pregnancy, Measured in the UPSIDE Study in Rochester, New York

BACKGROUND

Per- and polyfluoroalkyl substances (PFAS) are widely detected in pregnant women and associated with adverse outcomes related to impaired placental function. Human chorionic gonadotropin (hCG) is a dimeric glycoprotein hormone that can indicate placental toxicity.

OBJECTIVES

Our aim was to quantify the association of serum PFAS with placental hCG, measured as an intact molecule (hCG), as free alpha-(hCG α ) and beta-subunits (hCG β ), and as a hyperglycosylated form (h-hCG), and evaluate effect measure modification by social determinants and by fetal sex.

METHODS

Data were collected from 326 pregnant women enrolled from 2015 to 2019 in the UPSIDE study in Rochester, New York. hCG forms were normalized for gestational age at the time of blood draw in the first trimester [multiple of the median (MoM)]. Seven PFAS were measured in second-trimester maternal serum. Multivariate imputation by chained equations and inverse probability weighting were used to evaluate robustness of linear associations. PFAS mixture effects were estimated by Bayesian kernel machine regression.

RESULTS

Perfluorohexane sulfonic acid (PFHxS) [hCG β : 0.29 log MoM units per log PFHxS; 95% confidence interval (CI): 0.08, 0.51] and perfluorodecanoic acid (PFDA) (hCG: - 0.09 ; 95% CI: - 0.16 , - 0.02 ) were associated with hCG in the single chemical and mixture analyses. The PFAS mixture was negatively associated with hCG α and positively with hCG β . Subgroup analyses revealed that PFAS associations with hCG differed by maternal race/ethnicity and education. Perfluoropentanoic acid (PFPeA) was associated with hCG β only in Black participants (- 0.23 ; 95% CI: - 0.37 , - 0.09 ) and in participants with high school education or less (- 0.14 ; 95% CI: - 0.26 , - 0.02 ); conversely, perfluorononanoic acid (PFNA) was negatively associated with hCG α only in White participants (- 0.15 ; 95% CI: - 0.27 , - 0.03 ) and with hCG β only in participants with a college education or greater (- 0.19 ; 95% CI: - 0.36 , - 0.01 ). These findings were robust to testing for selection bias, confounding bias, and left truncation bias where PFAS detection frequency was < 100 % . Two associations were negative in male (and null in female) pregnancies: Perfluoroundecanoic acid (PFUnDA) with hCG α , and PFNA with h-hCG.

CONCLUSIONS

Evidence was strongest for the association between PFHxS and PFDA with hCG in all participants and for PFPeA and PFNA within subgroups defined by social determinants and fetal sex. PFAS mixture associations with hCG α and hCG β differed, suggesting subunit-specific types of toxicity and/or regulation. Future studies will evaluate the biological, clinical and public health significance of these findings. https://doi.org/10.1289/EHP12950.

Evaluating contamination of seafood purchased from U.S. retail stores by persistent environmental pollutants, pesticides and veterinary drugs

Studies have reported health risks associated with seafood contamination, but few data exist on levels in commercially available seafood in the US. To better understand, the magnitude of foodborne exposure and identify vulnerable populations in the US, we measured concentrations of veterinary drugs, persistent organic pollutants (POPs) (polycyclic aromatic hydrocarbons [PAHs], polybrominated diphenyl ethers [PBDEs] and polychlorinated biphenyls [PCBs]), and legacy and current-use pesticides in 46 seafood samples purchased from retail outlets. Measured levels were used to estimate risk based on available maximum residue limits (MRLs) and toxic equivalence (TEQ) factors for analytes. Only seventeen of the 445 analytes were detected, at low substance frequencies. However, half of the samples tested positive for one or more analyte, with total concentrations ranging from below the limit of detection (LOD) to as high as 156 µg/kg wet weight. Based on the risk assessment for individual pesticides and veterinary drugs, the hazard quotients (HQ) were all <1, indicating no risk. However, for the sum of PCB126 and PCB167, two dioxin-like PCBs detected in our samples, the TEQ was nearly two orders of magnitude higher than the WHO limits in one catfish sample. Moreover, vulnerable groups with higher rates of consumption of specific fish types may face higher risks.

Mechanisms and Opportunities for Rational In Silico Design of Enzymes to Degrade Per- and Polyfluoroalkyl Substances (PFAS)

Per and polyfluoroalkyl substances (PFAS) present a unique challenge to remediation techniques because their strong carbon-fluorine bonds make them difficult to degrade. This review explores the use of in silico enzymatic design as a potential PFAS degradation technique. The scope of the enzymes included is based on currently known PFAS degradation techniques, including chemical redox systems that have been studied for perfluorooctanesulfonic acid (PFOS) and perfluorooctanoic acid (PFOA) defluorination, such as those that incorporate hydrated electrons, sulfate, peroxide, and metal catalysts. Bioremediation techniques are also discussed, namely the laccase and horseradish peroxidase systems. The redox potential of known reactants and enzymatic radicals/metal-complexes are then considered and compared to potential enzymes for degrading PFAS. The molecular structure and reaction cycle of prospective enzymes are explored. Current knowledge and techniques of enzyme design, particularly radical-generating enzymes, and application are also discussed. Finally, potential routes for bioengineering enzymes to enable or enhance PFAS remediation are considered as well as the future outlook for computational exploration of enzymatic in situ bioremediation routes for these highly persistent and globally distributed contaminants.

Per- and polyfluoroalkyl substances (PFAS) measured in seafood from a cross-section of retail stores in the United States

Seafood is a dominant source of human exposure to per- and polyfluoroalkyl substances (PFAS). Existing studies on foodborne PFAS exposure have focused on only a subset of these compounds. Here, we conducted a pilot study to screen 33 PFAS in 46 seafood samples from a cross-section of national and local stores in the US. Low levels of 8 PFAS were measured in 74% of the samples, predominated by PFHxS (59%). Total PFAS ranged between 0.12 and 20 ng/g; highest levels were measured in Estonia-sourced smelt. The highest median levels were of PFOA (0.84 ng/g) with elevated concentrations found in Chinese clams (2.4 ng/g), which exceeds the EU established maximum limits (MLs). Measured levels of PFHxS, PFOA, and PFNA also exceeded MLs in 24%, 7%, and 5% of the samples, respectively. For average consumption levels, exposures were below the EU established tolerable weekly intakes (TWIs). However, for more frequent consumption of flounder, catfish, and cod, exposures exceeded regulations, which warrants identifying vulnerable high seafood consuming populations. Accidental PFBS cross contamination from sample storage bags resulted in 100% detection in samples, highlighting the problem with post-purchase food handling practices such as storage and cooking that could also have a substantial impact on human exposure, potentially in larger amounts than the (sea)food itself.

Real-World Treatment Patterns of Older Adults with Locally Advanced SCCHN Using SEER-Medicare

PURPOSE/OBJECTIVE(S)

Roughly 50-67% of patients with squamous cell carcinomas of the head and neck (SCCHN) present with locally advanced (LA) disease and 65% of them relapse after initial therapy. The standard of care for LA SCCHN is definitive therapy (DT), a combination of surgery and or radiation therapy (RT), with or without platinum-based chemotherapy/cetuximab (chemo), that has been shown to optimize long term disease control. Few published analyses have characterized recent real-world treatment (Tx) patterns of older adults with LA SCCHN in the US.

MATERIALS/METHODS

We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, a linkage of cancer registry and claims data, to identify patients diagnosed with LA SCCHN (first and only cancer) from 2010 to 2017 who initiated a relevant Tx (Tx initiation date defined as index date) and were continuously enrolled in Medicare Parts A, B, and D from 12 months pre-index until death or 12 months post-index. We used clinical guidelines regarding timing and frequency of treatments to build an algorithm that used Medicare claims to categorize initial Tx as non-DT, non-surgical DT (concomitant chemo+RT (cCRT) or chemotherapy before RT/cCRT), or surgical DT (surgery then RT/cCRT ± prior chemo).

RESULTS

We identified 1052 older adults with LA SCCHN (median age 73 years, 37% female, and 81% non-Hispanic white) whose initial treatment was started a median of 26 days after initial diagnosis. Of the 610 patients who received a DT as their initial Tx, 23.3% of patients had a subsequent Tx: 3.8% received immunotherapy-containing regimens (IO), and the most common subsequent Tx were surgery only (7.7%), chemotherapy only (3.6%), and RT only (3.4%). The median time to next Tx (TTNT) differed by DT category and primary tumor site. (Table 1) CONCLUSION: In this descriptive analysis, we provided an update on the Tx patterns of older adults with LA SCCHN in the US, for whom there have been no novel FDA approvals in over a decade. We found that a large proportion (42%) of patients did not receive DT regimens in the real-world setting despite known benefits in LA SCCHN. Roughly a quarter of patients required subsequent Tx. Availability of IO was low due to approvals after 2017. These findings suggest a need for novel therapies that can improve outcomes in LA SCCHN.

Racial Disparities in Survival of Patients with High-Risk LA SCCHN in the U.S

PURPOSE/OBJECTIVE(S)

Approximately 50-67% of patients with squamous cell carcinomas of the head and neck (SCCHN) present with locally advanced (LA) disease. Human papillomavirus (HPV) associated SCCHN has improved survival compared to non-HPV SCCHN. Studies have analyzed racial disparities in LA SCCHN but few have adjusted for HPV status and socio-economic status (SES). Our objective was to characterize disparities in LA SCCHN.

MATERIALS/METHODS

We identified high-risk patients from 2010-2017 with AJCC v8 Stage IVA/IVB SCCHN of the oral cavity, oropharynx (OP), larynx or hypopharynx, or Stage III SCCHN of the OP in the Surveillance, Epidemiology, and End Results (SEER) with HPV Status and Census Tract-level SES/Rurality Combined Database. We excluded OP patients with missing HPV data. SEER-reported treatment was used to classify initial treatment as definitive therapy (DT) categories: surgical DT, non-surgical DT or non-DT. The Kaplan Meier method was used to estimate overall survival (OS) with 95% confidence intervals (CI). Multivariable cox proportional hazard models were used for associations between covariates and hazard ratio (HR) of death, adjusted for age, sex, race, ethnicity, DT category, marital status, rurality, tumor size, cancer stage, and HPV status. We explored the impact of additionally adjusting for Yost SES index quintiles.

RESULTS

We identified 17,818 eligible patients: 79.3% White, 14.4% Black, 5.8% Asian/Pacific Islander (A/PI), and 0.6% American Indian/Alaska Native (AI/AN). Primary tumor sites were oral cavity (36.8%), larynx (29.0%), OP (24.4%), and hypopharynx (9.9%). 10.4% were HPV-associated. Race and SES quintiles were related (chi-squared, p<0.001) and the majority (56.5%) of black patients were in the lowest SES quintile. mOS was shorter and risk of death was significantly higher for black vs white patients in both the all-site and OP-only cohorts. When we added SES to multivariable analyses, Black race was no longer associated with increased risk of death in the all-site or OP-only cohorts. (Table 1) CONCLUSION: We found that when adjusting for sociodemographic and clinical factors, Black race was independently associated with a higher risk of death compared to white patients. When we adjusted for SES in multivariable analysis the association between Black race and risk of death was no longer significant, consistent with previously published analyses and indicative of a complex relationship between race and SES. Further research is needed to identify and address the causative factors of disparities in LA HNSCC.

A State-of-the-Science Review of Interactions of Per- and Polyfluoroalkyl Substances (PFAS) with Renal Transporters in Health and Disease: Implications for Population Variability in PFAS Toxicokinetics

BACKGROUND

Per- and polyfluoroalkyl substances (PFAS) are ubiquitous in the environment and have been shown to cause various adverse health impacts. In animals, sex- and species-specific differences in PFAS elimination half-lives have been linked to the activity of kidney transporters. However, PFAS molecular interactions with kidney transporters are still not fully understood. Moreover, the impact of kidney disease on PFAS elimination remains unclear.

OBJECTIVES

This state-of-the-science review integrated current knowledge to assess how changes in kidney function and transporter expression from health to disease could affect PFAS toxicokinetics and identified priority research gaps that should be addressed to advance knowledge.

METHODS

We searched for studies that measured PFAS uptake by kidney transporters, quantified transporter-level changes associated with kidney disease status, and developed PFAS pharmacokinetic models. We then used two databases to identify untested kidney transporters that have the potential for PFAS transport based on their endogenous substrates. Finally, we used an existing pharmacokinetic model for perfluorooctanoic acid (PFOA) in male rats to explore the influence of transporter expression levels, glomerular filtration rate (GFR), and serum albumin on serum half-lives.

RESULTS

The literature search identified nine human and eight rat kidney transporters that were previously investigated for their ability to transport PFAS, as well as seven human and three rat transporters that were confirmed to transport specific PFAS. We proposed a candidate list of seven untested kidney transporters with the potential for PFAS transport. Model results indicated PFOA toxicokinetics were more influenced by changes in GFR than in transporter expression.

DISCUSSION

Studies on additional transporters, particularly efflux transporters, and on more PFAS, especially current-use PFAS, are needed to better cover the role of transporters across the PFAS class. Remaining research gaps in transporter expression changes in specific kidney disease states could limit the effectiveness of risk assessment and prevent identification of vulnerable populations. https://doi.org/10.1289/EHP11885.

Assessing per- and polyfluoroalkyl substances in globally sourced food packaging

The purpose of this study was to investigate the presence and levels of per- and polyfluoroalkyl substances (PFAS) in food packaging originating from different geographic locations. Food packaging samples were extracted and analyzed by targeted analysis with liquid chromatography-mass spectrometry (LC-MS/MS) before and after a total oxidizable precursor (TOP) assay. Additionally, full-scan high resolution MS (HRMS) was used to screen for PFAS not included in the targeted list. Of the 88 food packaging samples, 84% had detectable levels of at least one PFAS prior to oxidation with a TOP assay, with 6:2 fluorotelomer phosphate diester (6:2 diPAP) found most frequently and at the highest levels (224 ng/g). Other frequently detected substances (in 15-17% of samples) were PFHxS, PFHpA and PFDA. Shorter chain perfluorinated carboxylic acids PFHpA (C7), PFPeA (C5) and PFHxS (C6) were present at levels up to 51.3, 24.1 and 18.2 ng/g, respectively. Average ∑PFAS levels were 28.3 ng/g and 381.9 ng/g before and after oxidation with the TOP assay. The 25 samples with highest frequency of detection and amounts of measured PFAS were selected for migration experiments with food simulants to better understand potential dietary exposure. PFHxS, PFHpA, PFHxA and 6:2 diPAP were measured in the food simulants of five samples at concentrations ranging from 0.04 to 12.2 ng/g and at increasing concentrations over the 10-day migration period. To estimate potential exposure to PFAS that had migrated from food packaging samples, weekly intake was calculated and ranged from 0.0006 ng/kg body weight/week for PFHxA exposure in tomato packaging to 1.1200 ng/kg body weight/week for PFHxS exposure in cake paper. These values were below the established EFSA maximum tolerable weekly intake (TWI) of 4.4 ng/kg body weight/week for the sum of PFOA, PFNA, PFHxS and PFOS.

Understanding inter-individual variability in short-chain chlorinated paraffin concentrations in human blood

Chlorinated paraffins (CPs), particularly short-chain CPs (SCCPs), have been reported in human blood with high detection frequency and often high variation among individuals. However, factors associated with and their contributions to inter-individual variability in SCCP concentrations in human blood have not been assessed. In this study, we first measured SCCP concentrations in 57 human blood samples collected from individuals living in the same vicinity in China. We then used the PROduction-To-Exposure model to investigate the impacts of variations in sociodemographic data, biotransformation rates, dietary patterns, and indoor contamination on inter-individual variability in SCCP concentrations in human blood. Measured ∑SCCP concentrations varied by a factor of 10 among individuals with values ranging from 122 to 1230 ng/g, wet weight. Model results show that age, sex, body weight, and dietary composition played a minor role in causing variability in ∑SCCP concentrations in human blood given that modeled ∑SCCP concentrations ranged over a factor of 2 - 3 correlated to the variations of these factors. In contrast, variations in the modeled ΣSCCP concentrations increased to factors of 6 and 8 when variability in biotransformation rates and indoor contamination were considered, respectively, indicating these two factors could be the most influential on inter-individual variability in SCCP concentrations in human blood.

From Protein Sequence to Structure: The Next Frontier in Cross-Species Extrapolation for Chemical Safety Evaluations

Computational screening for potentially bioactive molecules using advanced molecular modeling approaches including molecular docking and molecular dynamic simulation is mainstream in certain fields like drug discovery. Significant advances in computationally predicting protein structures from sequence information have also expanded the availability of structures for nonmodel species. Therefore, the objective of the present study was to develop an analysis pipeline to harness the power of these bioinformatics approaches for cross-species extrapolation for evaluating chemical safety. The Sequence Alignment to Predict Across Species Susceptibility (SeqAPASS) tool compares protein-sequence similarity across species for conservation of known chemical targets, providing an initial line of evidence for extrapolation of toxicity knowledge. However, with the development of structural models from tools like the Iterative Threading ASSEmbly Refinement (ITASSER), analyses of protein structural conservation can be included to add further lines of evidence and generate protein models across species. Models generated through such a pipeline could then be used for advanced molecular modeling approaches in the context of species extrapolation. Two case examples illustrating this pipeline from SeqAPASS sequences to I-TASSER-generated protein structures were created for human liver fatty acid-binding protein (LFABP) and androgen receptor (AR). Ninety-nine LFABP and 268 AR protein models representing diverse species were generated and analyzed for conservation using template modeling (TM)-align. The results from the structural comparisons were in line with the sequence-based SeqAPASS workflow, adding further evidence of LFABL and AR conservation across vertebrate species. The present study lays the foundation for expanding the capabilities of the web-based SeqAPASS tool to include structural comparisons for species extrapolation, facilitating more rapid and efficient toxicological assessments among species with limited or no existing toxicity data. Environ Toxicol Chem 2023;42:463-474. © 2022 SETAC. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

Modeling the transplacental transfer of small molecules using machine learning: a case study on per- and polyfluorinated substances (PFAS)

BACKGROUND

Despite their large numbers and widespread use, very little is known about the extent to which per- and polyfluoroalkyl substances (PFAS) can cross the placenta and expose the developing fetus.

OBJECTIVE

The aim of our study is to develop a computational approach that can be used to evaluate the of extend to which small molecules, and in particular PFAS, can cross to cross the placenta and partition to cord blood.

METHODS

We collected experimental values of the concentration ratio between cord and maternal blood (R_CM) for 260 chemical compounds and calculated their physicochemical descriptors using the cheminformatics package Mordred. We used the compiled database to, train and test an artificial neural network (ANN). And then applied the best performing model to predict R_CM for a large dataset of PFAS chemicals (n = 7982). We, finally, examined the calculated physicochemical descriptors of the chemicals to identify which properties correlated significantly with R_CM.

RESULTS

We determined that 7855 compounds were within the applicability domain and 127 compounds are outside the applicability domain of our model. Our predictions of R_CM for PFAS suggested that 3623 compounds had a log R_CM > 0 indicating preferable partitioning to cord blood. Some examples of these compounds were bisphenol AF, 2,2-bis(4-aminophenyl)hexafluoropropane, and nonafluoro-tert-butyl 3-methylbutyrate.

SIGNIFICANCE

These observations have important public health implications as many PFAS have been shown to interfere with fetal development. In addition, as these compounds are highly persistent and many of them can readily cross the placenta, they are expected to remain in the population for a long time as they are being passed from parent to offspring.

IMPACT

Understanding the behavior of chemicals in the human body during pregnancy is critical in preventing harmful exposures during critical periods of development. Many chemicals can cross the placenta and expose the fetus, however, the mechanism by which this transport occurs is not well understood. In our study, we developed a machine learning model that describes the transplacental transfer of chemicals as a function of their physicochemical properties. The model was then used to make predictions for a set of 7982 per- and polyfluorinated alkyl substances that are listed on EPA's CompTox Chemicals Dashboard. The model can be applied to make predictions for other chemical categories of interest, such as plasticizers and pesticides. Accurate predictions of R_CM can help scientists and regulators to prioritize chemicals that have the potential to cause harm by exposing the fetus.

759 RELATIONSHIP BETWEEN G8 AND CFS IN A COHORT OF LUNG CANCER PATIENTS REFERRED TO A SPECIALISED ONCO-GERIATRIC CLINIC

Introduction

The International Society of Geriatric Oncology recommends using screening tools to identify cancer patients who would benefit from a comprehensive geriatric assessment. G8, a tool specifically designed for oncology, has been well validated in this setting (1). Rockwood Clinical frailty score (CFS) is a widely used tool to assess frailty, and has been adopted into standard assessments at many sites (2). However, this tool is less well validated in patients with cancer.

Methods

In this single site observational study we recorded CFS and G8 in 89 patients with lung cancer referred to a local onco-geriatrics clinic between 21/10/20 and 5/2/21. Both scores were available for 82 patients. We aimed to measure the correlation between G8 and CFS in this cohort.

Results

G8 score ≤ 14 is a referral criteria for the clinic, therefore 100% (82/82) of patients were classified as ‘frail’ using G8. Of these, only 23.2% (19/82) were classified as ‘mildly frail’ or worse using CFS (scores ≥5). Using Spearman’s rank correlation we found a very weak/negligible negative correlation between CFS and G8 (−0.2519, p = 0.0224).

Conclusion

The small proportion of patients (23.2%) classified as frail by CFS suggests that a G8 cut off of 14 may overestimate frailty. Previous work by our group has found that using a cut off of 13 is better able to predict chemotherapy outcomes(3). However, considering the lack of evidence for CFS in oncology, this poor correlation between G8 and CFS may question the usefulness of CFS in this context. (1) Decoster L, Puyvelde K, Mohile S, et al. Ann Oncol. 2015 Feb; 26(2): 288–300 (2) NHS Elect. [Online].; 2018 [cited 16/2/21] (3) A. Tivey, M. Ullah, A. Beech, et al. J Geriatr Oncol. 2020 Mar; 11(7).

A repeating fast radio burst source in a globular cluster

Fast radio bursts (FRBs) are flashes of unknown physical origin¹. The majority of FRBs have been seen only once, although some are known to generate multiple flashes^2,3. Many models invoke magnetically powered neutron stars (magnetars) as the source of the emission^4,5. Recently, the discovery⁶ of another repeater (FRB 20200120E) was announced, in the direction of the nearby galaxy M81, with four potential counterparts at other wavelengths⁶. Here we report observations that localized the FRB to a globular cluster associated with M81, where it is 2 parsecs away from the optical centre of the cluster. Globular clusters host old stellar populations, challenging FRB models that invoke young magnetars formed in a core-collapse supernova. We propose instead that FRB 20200120E originates from a highly magnetized neutron star formed either through the accretion-induced collapse of a white dwarf, or the merger of compact stars in a binary system⁷. Compact binaries are efficiently formed inside globular clusters, so a model invoking them could also be responsible for the observed bursts.

Understanding the dynamics of physiological changes, protein expression, and PFAS in wildlife

Per- and polyfluoroalkyl substances (PFAS) accumulation and elimination in both wildlife and humans is largely attributed to PFAS interactions with proteins, including but not limited to organic anion transporters (OATs), fatty acid binding proteins (FABPs), and serum proteins such as albumin. In wildlife, changes in the biotic and abiotic environment (e.g. salinity, temperature, reproductive stage, and health status) often lead to dynamic and responsive physiological changes that alter the prevalence and location of many proteins, including PFAS-related proteins. Therefore, we hypothesize that if key PFAS-related proteins are impacted as a result of environmentally induced as well as biologically programmed physiological changes (e.g. reproduction), then PFAS that associate with those proteins will also be impacted. Changes in tissue distribution across tissues of PFAS due to these dynamics may have implications for wildlife studies where these chemicals are measured in biological matrices (e.g., serum, feathers, eggs). For example, failure to account for factors contributing to PFAS variability in a tissue may result in exposure misclassification as measured concentrations may not reflect average exposure levels. The goal of this review is to share general information with the PFAS research community on what biotic and abiotic changes might be important to consider when designing and interpreting a biomonitoring or an ecotoxicity based wildlife study. This review will also draw on parallels from the epidemiological discipline to improve study design in wildlife research. Overall, understanding these connections between biotic and abiotic environments, dynamic protein levels, PFAS levels measured in wildlife, and epidemiology serves to strengthen study design and study interpretation and thus strengthen conclusions derived from wildlife studies for years to come.

Pharmacological and clinical implications of local anaesthetic mixtures: a narrative review

Various techniques have been explored to prolong the duration and improve the efficacy of local anaesthetic nerve blocks. Some of these involve mixing local anaesthetics or adding adjuncts. We did a literature review of studies published between 01 May 2011 and 01 May 2021 that studied specific combinations of local anaesthetics and adjuncts. The rationale behind mixing long- and short-acting local anaesthetics to hasten onset and extend duration is flawed on pharmacokinetic principles. Most local anaesthetic adjuncts are not licensed for use in this manner and the consequences of untested admixtures and adjuncts range from making the solution ineffective to potential harm. Pharmaceutical compatibility needs to be established before administration. The compatibility of drugs from the same class cannot be inferred and each admixture requires individual review. Precipitation on mixing (steroids, non-steroidal anti-inflammatory drugs) and subsequent embolisation can lead to serious adverse events, although these are rare. The additive itself or its preservative can have neurotoxic (adrenaline, midazolam) and/or chondrotoxic properties (non-steroidal anti-inflammatory drugs). The prolongation of block may occur at the expense of motor block quality (ketamine) or block onset (magnesium). Adverse effects for some adjuncts appear to be dose-dependent and recommendations concerning optimal dosing are lacking. An important confounding factor is whether studies used systemic administration of the adjunct as a control to accurately identify an additional benefit of perineural administration. The challenge of how best to prolong block duration while minimising adverse events remains a topic of interest with further research required.

Absorption, distribution, and toxicity of per- and polyfluoroalkyl substances (PFAS) in the brain: a review

Per- and polyfluoroalkyl substances (PFAS) are a class of synthetic chemicals colloquially known as "forever chemicals" because of their high persistence. PFAS have been detected in the blood, liver, kidney, heart, muscle and brain of various species. Although brain is not a dominant tissue for PFAS accumulation compared to blood and liver, adverse effects of PFAS on brain functions have been identified. Here, we review studies related to the absorption, accumulation, distribution and toxicity of PFAS in the brain. We summarize evidence on two potential mechanisms of PFAS entering the brain: initiating blood-brain barrier (BBB) disassembly through disrupting tight junctions and relying on transporters located at the BBB. PFAS with diverse structures and properties enter and accumulate in the brain with varying efficiencies. Compared to long-chain PFAS, short-chain PFAS may not cross cerebral barriers effectively. According to biomonitoring studies and PFAS exposure experiments, PFAS can accumulate in the brain of humans and wildlife species. With respect to the distribution of PFAS in specific brain regions, the brain stem, hippocampus, hypothalamus, pons/medulla and thalamus are dominant for PFAS accumulation. The accumulation and distribution of PFAS in the brain may lead to toxic effects in the central nervous system (CNS), including PFAS-induced behavioral and cognitive disorders. The specific mechanisms underlying such PFAS-induced neurotoxicity remain to be explored, but two major potential mechanisms based on current understanding are PFAS effects on calcium homeostasis and neurotransmitter alterations in neurons. Based on the information available about PFAS uptake, accumulation, distribution and impacts on the brain, PFAS have the potential to enter and accumulate in the brain at varying levels. The balance of existing studies shows there is some indication of risk in animals, while the human evidence is mixed and warrants further scrutiny.

Addressing Urgent Questions for PFAS in the 21st Century

Despite decades of research on per- and polyfluoroalkyl substances (PFAS), fundamental obstacles remain to addressing worldwide contamination by these chemicals and their associated impacts on environmental quality and health. Here, we propose six urgent questions relevant to science, technology, and policy that must be tackled to address the "PFAS problem": (1) What are the global production volumes of PFAS, and where are PFAS used? (2) Where are the unknown PFAS hotspots in the environment? (3) How can we make measuring PFAS globally accessible? (4) How can we safely manage PFAS-containing waste? (5) How do we understand and describe the health effects of PFAS exposure? (6) Who pays the costs of PFAS contamination? The importance of each question and barriers to progress are briefly described, and several potential paths forward are proposed. Given the diversity of PFAS and their uses, the extreme persistence of most PFAS, the striking ongoing lack of fundamental information, and the inequity of the health and environmental impacts from PFAS contamination, there is a need for scientific and regulatory communities to work together, with cooperation from PFAS-related industries, to fill in critical data gaps and protect human health and the environment.

Pulse-shape discrimination against low-energy Ar-39 beta decays in liquid argon with 4.5 tonne-years of DEAP-3600 data

The DEAP-3600 detector searches for the scintillation signal from dark matter particles scattering on a 3.3 tonne liquid argon target. The largest background comes from 39 Ar beta decays and is suppressed using pulse-shape discrimination (PSD). We use two types of PSD estimator: the prompt-fraction, which considers the fraction of the scintillation signal in a narrow and a wide time window around the event peak, and the log-likelihood-ratio, which compares the observed photon arrival times to a signal and a background model. We furthermore use two algorithms to determine the number of photons detected at a given time: (1) simply dividing the charge of each PMT pulse by the mean single-photoelectron charge, and (2) a likelihood analysis that considers the probability to detect a certain number of photons at a given time, based on a model for the scintillation pulse shape and for afterpulsing in the light detectors. The prompt-fraction performs approximately as well as the log-likelihood-ratio PSD algorithm if the photon detection times are not biased by detector effects. We explain this result using a model for the information carried by scintillation photons as a function of the time when they are detected.

Integrative Computational Approaches to Inform Relative Bioaccumulation Potential of Per- and Polyfluoroalkyl Substances Across Species

Predictive toxicology is increasingly reliant on innovative computational methods to address pressing questions in chemicals assessment. Of importance is the evaluation of contaminant impact differences across species to inform ecosystem protection and identify appropriate model species for human toxicity studies. Here we evaluated 2 complementary tools to predict cross-species differences in binding affinity between per- and polyfluoroalkyl substances (PFAS) and the liver fatty acid-binding protein (LFABP): the Sequence Alignment to Predict Across Species Susceptibility (SeqAPASS) tool and molecular dynamics (MD). SeqAPASS determined that the structure of human LFABP, a key determinant of PFAS bioaccumulation, was conserved in the majority of vertebrate species, indicating these species would have similar PFAS bioaccumulation potentials. Level 3 SeqAPASS evaluation identified several potentially destabilizing amino acid differences across species, which were generally supported by DUET stability change predictions. Nine single-residue mutations and 7 whole species sequences were selected for MD evaluation. One mutation (F50V for PFNA) showed a statistically significant difference with stronger affinity than wild-type human LFABP. Predicted binding affinities for 9 different PFAS across 7 species showed human, rat, chicken, and rainbow trout had similar binding affinities to one another for each PFAS, whereas Japanese medaka and fathead minnow had significantly weaker LFABP-binding affinity for some PFAS. Based on these analyses, the combined use of SeqAPASS and MD provides rapid screening for potential species differences with deeper structural insight. This approach can be easily extended to other important biological receptors and potential ligands.

Quantitative Chemical Proteomics Reveals Interspecies Variations on Binding Schemes of L-FABP with Perfluorooctanesulfonate

Evaluating interspecies toxicity variation is a long-standing challenge for chemical hazard assessment. This study developed a quantitative interspecies thermal shift assay (QITSA) for in situ, quantitative, and modest-throughput investigation of chemical-protein interactions in cell and tissue samples across species. By using liver fatty acid binding protein (L-FABP) as a case study, the QITSA method was benchmarked with six per- and polyfluoroalkyl substances, and thermal shifts (ΔT_m) were inversely related to their dissociation constants (R² = 0.98). The QITSA can also distinguish binding modes of chemicals exemplified by palmitic acid. The QITSA was applied to determine the interactions between perfluorooctanesulfonate (PFOS) and L-FABP in liver cells or tissues from humans, mice, rats, and zebrafish. The largest thermal stability enhancement by PFOS was observed for human L-FABP followed by the mouse, rat, and zebrafish. While endogenous ligands were revealed to partially contribute to the large interspecies variation, recombinant proteins were employed to confirm the high binding affinity of PFOS to human L-FABP, compared to the rat and mouse. This study implemented an experimental strategy to characterize chemical-protein interactions across species, and future application of QITSA to other chemical contaminants is of great interest.

668 The Consequences to Emergency Surgery During COVID19 Pandemic in a UK District General Hospital in The North East of England

Aim

COVID19 pandemic has significantly affected surgical services. We aim to review its effects on our theatre output and risk of encountering COVID 19 cases.

Method

Serial record of operations performed locally were reviewed from start of UK COVID19 pandemic lockdown on 23rd March 2020 to 13th July 2020 after it was lifted. A weekly average by month of operations and the percentage of COVID19 cases diagnosed within 30 days of the procedure were noted.

Results

733 operations performed through this period. In March, 33 operations/week performed, 88.4% emergency and 7% diagnosed with COVID19. April, 31 operations /week performed, 95.9% emergency and 10.6% diagnosed with COVID19. May 46 operations /week performed, 94.5% emergency and 3.3% diagnosed with COVID19. June 56 operations /week, 80.9% emergency and less than 0.01% diagnosed with COVID19. By July 80 operations/week, 59.4% emergency and none diagnosed with COVID 19. Since testing capacity increased, only 6 of the 27 operated were diagnosed with COVID19.

Conclusions

There was initial reduction to non-emergency workload. However, this has gradually shifted as protocols are in place improve public confidence to return for surgical treatment. Mandatory admission testing allows early identification and remains essential for planning of services and protecting the workforce.

PFAS Exposure Pathways for Humans and Wildlife: A Synthesis of Current Knowledge and Key Gaps in Understanding

We synthesize current understanding of the magnitudes and methods for assessing human and wildlife exposures to poly- and perfluoroalkyl substances (PFAS). Most human exposure assessments have focused on 2 to 5 legacy PFAS, and wildlife assessments are typically limited to targeted PFAS (up to ~30 substances). However, shifts in chemical production are occurring rapidly, and targeted methods for detecting PFAS have not kept pace with these changes. Total fluorine measurements complemented by suspect screening using high-resolution mass spectrometry are thus emerging as essential tools for PFAS exposure assessment. Such methods enable researchers to better understand contributions from precursor compounds that degrade into terminal perfluoroalkyl acids. Available data suggest that diet is the major human exposure pathway for some PFAS, but there is large variability across populations and PFAS compounds. Additional data on total fluorine in exposure media and the fraction of unidentified organofluorine are needed. Drinking water has been established as the major exposure source in contaminated communities. As water supplies are remediated, for the general population, exposures from dust, personal care products, indoor environments, and other sources may be more important. A major challenge for exposure assessments is the lack of statistically representative population surveys. For wildlife, bioaccumulation processes differ substantially between PFAS and neutral lipophilic organic compounds, prompting a reevaluation of traditional bioaccumulation metrics. There is evidence that both phospholipids and proteins are important for the tissue partitioning and accumulation of PFAS. New mechanistic models for PFAS bioaccumulation are being developed that will assist in wildlife risk evaluations. Environ Toxicol Chem 2021;40:631-657. © 2020 SETAC.

Per- and Polyfluoroalkyl Substance Toxicity and Human Health Review: Current State of Knowledge and Strategies for Informing Future Research

Reports of environmental and human health impacts of per- and polyfluoroalkyl substances (PFAS) have greatly increased in the peer-reviewed literature. The goals of the present review are to assess the state of the science regarding toxicological effects of PFAS and to develop strategies for advancing knowledge on the health effects of this large family of chemicals. Currently, much of the toxicity data available for PFAS are for a handful of chemicals, primarily legacy PFAS such as perfluorooctanoic acid and perfluorooctane sulfonate. Epidemiological studies have revealed associations between exposure to specific PFAS and a variety of health effects, including altered immune and thyroid function, liver disease, lipid and insulin dysregulation, kidney disease, adverse reproductive and developmental outcomes, and cancer. Concordance with experimental animal data exists for many of these effects. However, information on modes of action and adverse outcome pathways must be expanded, and profound differences in PFAS toxicokinetic properties must be considered in understanding differences in responses between the sexes and among species and life stages. With many health effects noted for a relatively few example compounds and hundreds of other PFAS in commerce lacking toxicity data, more contemporary and high-throughput approaches such as read-across, molecular dynamics, and protein modeling are proposed to accelerate the development of toxicity information on emerging and legacy PFAS, individually and as mixtures. In addition, an appropriate degree of precaution, given what is already known from the PFAS examples noted, may be needed to protect human health. Environ Toxicol Chem 2021;40:606-630. © 2020 SETAC.

Perfluoroalkyl Acid Binding with Peroxisome Proliferator-Activated Receptors α, γ, and δ, and Fatty Acid Binding Proteins by Equilibrium Dialysis with a Comparison of Methods

The biological impacts of per- and polyfluorinated alkyl substances (PFAS) are linked to their protein interactions. Existing research has largely focused on serum albumin and liver fatty acid binding protein, and binding affinities determined with a variety of methods show high variability. Moreover, few data exist for short-chain PFAS, though their prevalence in the environment is increasing. We used molecular dynamics (MD) to screen PFAS binding to liver and intestinal fatty acid binding proteins (L- and I-FABPs) and peroxisome proliferator activated nuclear receptors (PPAR-α, -δ and -γ) with six perfluoroalkyl carboxylates (PFCAs) and three perfluoroalkyl sulfonates (PFSAs). Equilibrium dissociation constants, KDs, were experimentally determined via equilibrium dialysis (EqD) with liquid chromatography tandem mass spectrometry for protein-PFAS pairs. A comparison was made between KDs derived from EqD, both here and in literature, and other in vitro approaches (e.g., fluorescence) from literature. EqD indicated strong binding between PPAR-δ and perfluorobutanoate (0.044 ± 0.013 µM) and perfluorohexane sulfonate (0.035 ± 0.0020 µM), and between PPAR-α and perfluorohexanoate (0.097 ± 0.070 µM). Unlike binding affinities for L-FABP, which increase with chain length, KDs for PPARs showed little chain length dependence by either MD simulation or EqD. Compared with other in vitro approaches, EqD-based KDs consistently indicated higher affinity across different proteins. This is the first study to report PPARs binding with short-chain PFAS with KDs in the sub-micromolar range.

Behavioral testing in animal models of spinal cord injury

This review is based on a lecture presented at the Craig H. Neilsen Foundation sponsored Spinal Cord Injury Training Program at Ohio State University. We discuss the advantages and challenges of injury models in rodents and theory relation to various behavioral outcome measures. We offer strategies and advice on experimental design, behavioral testing, and on the challenges, one will encounter with animal testing. This review is designed to guide those entering the field of spinal cord injury and/or involved with in vivo animal testing.

The effect of Imatinib Mesylate in diffuse-type Tenosynovial Giant Cell Tumours on MR imaging and PET-CT

INTRODUCTION

Recurrence rates remain high after surgical treatment of diffuse-type Tenosynovial Giant Cell Tumour (TGCT). Imatinib Mesylate (IM) blocks Colony Stimulating Factor1 Receptor (CSF1R), the driver mechanism in TGCT. The aim of this study was to determine if IM reduces the tumour metabolic activity evaluated by PET-CT and to compare this response with the response seen on MR imaging.

MATERIALS AND METHODS

25 Consecutive patients treated with IM (off label use) for locally advanced (N = 12) or recurrent (N = 13) diffuse-type TGCT were included, 15 male and median age at diagnosis 39 (IQR 31-47) years. The knee was most frequently affected (n = 16; 64%). The effect of IM was assessed pre- and post-IM treatment by comparing MR scans and PET-CT. MR scans were assessed by Tumour Volume Score (TVS), an estimation of the tumour volume as a percentage of the total synovial cavity. PET-CT scans were evaluated based on maximum standardized uptake value (SUV-max). Partial response was defined as more than 50% tumour reduction with TVS and a decrease of at least 30% on SUV-max.

RESULTS

Median duration of IM treatment was 7.0 (IQR 4.2-11.5) months. Twenty patients (80%) discontinued IM treatment for poor response or intended surgery. Twenty patients experienced an adverse event grade 1-2, three patients grade 3 (creatinine increment, neutropenic sepsis, liver dysfunction). MR assessment of all joints showed 32% (6/19) partial response and 63% (12/19) stable disease, with a mean difference of 12% (P = 0.467; CI -22.4-46.0) TVS between pre- and post-IM and a significant mean difference of 23% (P = 0.021; CI 4.2-21.6) in all knee lesions. PET-CT, all joints, showed a significantly decreased mean difference of 5.3 (P = 0.004; CI 1.9-8.7) SUV-max between pre- and post-IM treatment (58% (11/19) partial response, 37% (7/19) stable disease). No correlation between MR imaging and PET-CT could be appreciated in 15 patients with complete radiological data.

CONCLUSION

This study confirms the moderate radiological response of IM in diffuse-type TGCT. PET-CT is a valuable additional diagnostic tool to quantify response to tyrosine kinase inhibitor treatment. Its value should be assessed further to validate its efficacy in the objective measurement of biological response in targeted systemic treatment of TGCT.

Acceptance of antiviral treatment and enhanced service model for pregnant patients carrying hepatitis B

INTRODUCTION

A service model was established for pregnant women with positive screening results for hepatitis B surface antigen (HBsAg) at Queen Mary Hospital in Hong Kong. All women were offered a blood test for hepatitis B virus (HBV) DNA level during the first antenatal visit. Women with HBV DNA levels of ≥200 000 IU/mL received counselling from hepatologists regarding treatment with antenatal tenofovir disoproxil fumarate (TDF) 300 mg daily.

METHODS

This retrospective review included women attending our antenatal clinic who exhibited positive HBsAg screening results from 15 May 2017 to 31 December 2019. The proportions of women with positive HBsAg, DNA test acceptance, hepatological review, and TDF acceptance during pregnancy were reviewed.

RESULTS

In total, 375 (2.9%) of 13 082 pregnant women had positive HBsAg screening results. Blood tests for HBV DNA and hepatological reviews were offered to 273 women who had not undergone hepatological review prior to pregnancy; the acceptance rate was 97.8%. Sixty (22.6%) pregnant women were hepatitis B carriers with high viral loads of ≥200 000 IU/mL. Among 58 women with high viral loads, 57 received antenatal counselling regarding TDF and 56 (96.6%) agreed to take the drug; 92.9% of these 56 women had commenced TDF at or before 32 weeks of gestation.

CONCLUSIONS

This study indicated broad acceptance of HBV DNA tests by pregnant women. Triage allowed early review and commencement of antiviral medication. This service model serves as a framework for enhanced antenatal service to prevent mother-to-child-transmission in public maternity units.

Estimating polybrominated diphenyl ether (PBDE) exposure through seafood consumption in Switzerland using international food trade data

Seafood is a major source of human exposure to polybrominated diphenyl ethers (PBDEs). The intake of these globally distributed and bioaccumulative contaminants depends on both consumption patterns (which seafoods are consumed) and on their origins. Here, we investigate exposure to PBDEs through seafood consumption as a function of species, origins and consumption levels. We estimate the contribution of seafood consumption to PBDE exposures in the Swiss population using two approaches. The first approach estimates exposures by estimating the composition of the Swiss seafood diet using trade data and national statistics on total seafood consumption. This naïve approach could be used for any country for which no individually reported consumption data are available for a population. The second approach uses dietary survey data provided by the Swiss Federal Statistical Office as part of the menuCH study for exposure estimates. To support region- and species-specific estimates of exposures for both approaches, we built a database of PBDE concentrations in seafood by analysis of published PBDE levels in fish from food markets or freshwater resources from various countries. We find estimated PBDE exposures ranging from 0.15 to 0.65 ng/kg bw/day for the trade data-based diet. These were close to the median exposures of 0.68 ng/kg bw/day for the Swiss population based on the menuCH survey, indicating that the composition and consumption rate derived from trade data are appropriate for calculating exposures in the average adult population. However, it could not account for PBDE exposures of more vulnerable (high seafood consuming) populations captured only by the survey data. All estimates were lower than the PBDE Chronic Oral Reference Doses (RfD's) suggested by the EPA, but could increase substantially to a value of 7 ng/kg bw/day if fish are sourced from the most contaminated origins, as in the case of Vietnamese shrimp/prawn, Norwegian salmon, and Swiss whitefish. Exposures as high as 8.50 ng/kg bw/day are estimated for the survey-based diet, which better captures the variability in consumption by individuals, including extreme high and low values. In general, the most frequently consumed species reported by Swiss consumers are consistent with those predicted using trade data.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.