Environmental poisoning: Presentation and management

Environmental poisoning is most commonly associated with chronic longterm exposure to toxins rather than to acute exposure. Such repeated exposure to sublethal doses of compounds and elements presents problems in risk assessment. This is primarily because the data are unavailable to describe relationships between dose and effect at lower levels of exposure to toxins. Bioavailability of toxins also presents a problem because the data on bioavailability are sparse and seldom as high as the default of 100% bioavailability commonly used in risk assessment. Examples are presented of two toxins: arsenic as an elemental anthropogenic and geologic poison and ciguatoxin, a polyether ladder compound, as a toxin produced naturally by dinoflagellates. Bioavailability drives the toxicity of arsenic from contaminated sites, whereas tissue accumulation drives the toxicity of ciguatoxin. Considerable benefit is derived from the harmonization of regulatory processes where there is linkage of health and environmental factors in the derivation of credible risk assessment.

Predictors of local recurrence after treatment of ductal carcinoma in situ - A meta-analysis

lBACKGROUND. Management of patients with ductal carcinoma in situ (DCIS) is a dilemma, as mastectomy provides nearly a 100% cure rate but at the expense of physical and psychologic morbidity. It would be helpful if we could predict which patients with DCIS are at sufficiently high risk of local recurrence after conservative surgery (CS) alone to warrant postoperative radiotherapy (RT) and which patients are at sufficient risk of local recurrence after CS + RT to warrant mastectomy. The authors reviewed the published studies and identified the factors that may be predictive of local recurrence after management by mastectomy, CS alone, or CS + RT. METHODS. The authors examined patient, tumor, and treatment factors as potential predictors for local recurrence and estimated the risks of recurrence based on a review of published studies. They examined the effects of patient factors (age at diagnosis and family history), tumor factors (sub-type of DCIS, grade, tumor size, necrosis, and margins), and treatment (mastectomy, CS alone, and CS + RT). The 95% confidence intervals (CI) of the recurrence rates for each of the studies were calculated for subtype, grade, and necrosis, using the exact binomial; the summary recurrence rate and 95% CI for each treatment category were calculated by quantitative meta-analysis using the fixed and random effects models applied to proportions. RESULTS, Meta-analysis yielded a summary recurrence rate of 22.5% (95% CI = 16.9-28.2) for studies employing CS alone, 8.9% (95% CI = 6.8-11.0) for CS + RT, and 1.4% (95% CI = 0.7-2.1) for studies involving mastectomy alone. These summary figures indicate a clear and statistically significant separation, and therefore outcome, between the recurrence rates of each treatment category, despite the likelihood that the patients who underwent CS alone were likely to have had smaller, possibly low grade lesions with clear margins. The patients with risk factors of presence of necrosis, high grade cytologic features, or comedo subtype were found to derive the greatest improvement in local control with the addition of RT to CS. Local recurrence among patients treated by CS alone is approximately 20%, and one-half of the recurrences are invasive cancers. For most patients, RT reduces the risk of recurrence after CS alone by at least 50%. The differences in local recurrence between CS alone and CS + RT are most apparent for those patients with high grade tumors or DCIS with necrosis, or of the comedo subtype, or DCIS with close or positive surgical margins. CONCLUSIONS, The authors recommend that radiation be added to CS if patients with DCIS who also have the risk factors for local recurrence choose breast conservation over mastectomy. The patients who may be suitable for CS alone outside of a clinical trial may be those who have low grade lesions with little or no necrosis, and with clear surgical margins. Use of the summary statistics when discussing outcomes with patients may help the patient make treatment decisions. Cancer 1999;85:616-28. (C) 1999 American Cancer Society.

An evaluation of the time dependence of the anisotropy of the water diffusion tensor in acute human ischemia

We have performed MRI examinations to determine the water diffusion tensor in the brain of six patients who were admitted to the hospital within 12 h after the onset of cerebral ischemic symptoms. The examinations have been carried out immediately after admission, and thereafter at varying intervals up to 90 days post admission. Maps of the trace of the diffusion tensor, the fractional anisotropy and the lattice index, as well as maps of cerebral blood perfusion parameters, were generated to quantitatively assess the character of the water diffusion tensor in the infarcted area. In patients with significant perfusion deficits and substantial lesion volume changes, four of six cases, our measurements show a monotonic and significant decrease in the diffusion anisotropy within the ischemic lesion as a function of time. We propose that retrospective analysis of this quantity, in combination with brain tissue segmentation and cerebral perfusion maps, may be used in future studies to assess the severity of the ischemic event. (C) 1999 Elsevier Science Inc.

Opioid overdose mortality in Australia, 1964-1997: birth-cohort trends

Objective: To examine trends in rates of opioid overdose deaths from 1964 to 1997 in different birth cohorts. Design: Age-period-cohort analysis of national data from the Australian Bureau of Statistics. Main outcome measures: Annual population rates of death attributed to opioid dependence or accidental opioid poisoning in people aged 15-44 years, by sex and birth cohort tin five-year intervals, 1940-1944 to 1975-1979). Results: The rate of opioid overdose deaths increased 55-fold between 1964 and 1997, from 1.3 to 71.5 per million population aged 15-44 years. The rate of opioid overdose deaths also increased substantially over the eight birth cohorts, with an incidence rate ratio of 20.70 (95% confidence interval, 13.60-31.46) in the 1975-1979 cohort compared with the 1940-1944 cohort. The age at which the cumulative rate of opioid overdose deaths reached 300 per million fell in successive cohorts (for men, from 28 years among those born 1955-1959 to 22 years among those born 1965-1974; for women, from 33 years among those born 1955-1959 to 27 years among those born 1965-1969). Conclusions: Heroin use in Australia largely began in the early 1970s and rates of heroin use have markedly increased in birth cohorts born since 1950.

The crack tip strain field of AISI 4340 - Part I - Measurement technique

This is the first paper in a study on the influence of the environment on the crack tip strain field for AISI 4340. A stressing stage for the environmental scanning electron microscope (ESEM) was constructed which was capable of applying loads up to 60 kN to fracture-mechanics samples. The measurement of the crack tip strain field required preparation (by electron lithography or chemical etching) of a system of reference points spaced at similar to 5 mu m intervals on the sample surface, loading the sample inside an electron microscope, image processing procedures to measure the displacement at each reference point and calculation of the strain field. Two algorithms to calculate strain were evaluated. Possible sources of errors were calculation errors due to the algorithm, errors inherent in the image processing procedure and errors due to the limited precision of the displacement measurements. Estimation of the contribution of each source of error was performed. The technique allows measurement of the crack tip strain field over an area of 50 x 40 mu m with a strain precision better than +/- 0.02 at distances larger than 5 mu m from the crack tip. (C) 1999 Kluwer Academic Publishers.

Increased ovulation rate in Merino ewes immunized against small synthetic peptide fragments of the inhibin alpha subunit

Four experiments were carried out in Merino ewes during a period of 4 years to determine the long-term effects of immunization against different synthetic peptides mimicking the amine terminal of the or subunit of porcine inhibin. Peptides were conjugated to human serum albumin and 100-200 mu g emulsified in Freund's complete adjuvant for the primary immunization. Usually two booster injections were given at monthly intervals with 50-100 mu g conjugated peptide using either incomplete Freund's adjuvant or Montanide : Marcel. In some experiments a further immunization was carried in the next year. Blood samples were taken 10 days after each immunization, during the luteal phase, for estimation of gonadotrophin concentrations and determination of inhibin antibody titres. One day after blood sampling cloprostenol was used to induce luteolysis and laparoscopy was performed in the subsequent oestrous cycle. Immunization of ewes with synthetic peptides 1-32, 1-26, 7-26 and 8-30 resulted in large increases in the ovulation rate (OR). An approximately two-fold increase in OR was observed following the first booster immunization with these peptides and a three- to five-fold increase after the second booster immunization. Immunization with these large peptides resulted in a sustained increase in OR for a period of at least 1 year after the second booster immunization. Of the shorter peptides, peptides 10-26 and 13-26 gave a reasonable ovulatory response, although it was more difficult to obtain a response with peptides 1-16, 8-22, 13-25, 8-19 and 10-19; peptides 7-13 and 1-6 gave no response (but were examined for one breeding season only). The smaller peptides led to lower inhibin antibody titres that were not necessarily associated with increased follicle-stimulating hormone (FSH) or OR. More intensive blood sampling in one experiment showed that following primary immunization against peptide 1-32 there was a transient increase in plasma FSH which did not lead to an increased OR. Moreover, a prolonged period of raised FSH after the first booster was significantly correlated with increased OR. In these animals antibody titres were only slightly increased after primary immunization, but after the first booster immunization higher titres were observed that were significantly correlated with trough FSH values and the subsequent OR. These results are interpreted as showing that (1) to obtain an increase in OR peptides 1-32, 1-26 and 7-26 are suitable as immunogens; (2) smaller peptides are less reliable, often require multiple injections, and the response may be delayed; and (3) an extended period of raised plasma FSH is needed to give a large ovulatory response.

Is there change over time in the season-of-birth effect for schizophrenia? Data from the southern hemisphere

The aim of this paper is to examine distributions of schizophrenia and general population births over time in order to determine whether (a) the pattern has changed over time, (b) any pattern was similar for both males and females, and (c) whether there is any indication that there is any relationship between the changes in pattern between schizophrenia and general population births. Birth month and year for 7807 individuals with ICD8/9 schizophrenia were gained from the Queensland Mental Health Statistical System for 1914-1975. Monthly births for the general population in Queensland for the same period were obtained from the Australian Bureau of Statistics. For each decade we obtained two comparisons, (1) between two 'seasons' (summer-autumn/winter-spring), and (2) between the third (coldest) quarter and the remaining quarters. Based on expected contrasts from general population proportions, odds ratios and their confidence intervals were used to analyse these comparisons for all subjects, and for males and females separately. The seasonality found in our previous studies was again evident (OR 1.09; 95% CI= 1.01-1.17). However there was no significant change in its pattern over time either for the total group or for males and females separately. When the general population births alone were examined using the same contrasts, seasonality was also observed, but here there were fluctuations over time. These results suggest that exposures linked to changes in general population births over time should be examined in disorders such as schizophrenia which demonstrate seasonality in births. The Stanley Foundation supported this project.

Effects of preferred hand and sex on the perception of tactile simultaneity

The effects of handedness, sex and the influence of hand placement in extrapersonal space on temporal information processing was investigated by measuring thresholds for perceiving the simultaneity of pairs of tactile stimuli. Simultaneity thresholds of preferred right handed and left handed university students with left hemisphere speech representation were compared using unimanual and bimanual stimulation at three hand placements (midline, lateral and crossed). In unimanual conditions two fingers of one hand were stimulated (single hemisphere), whereas in the bimanual conditions one finger of each hand was stimulated (cross hemispheres). Bimanual minus unimanual thresholds provided an estimate of interhemisphere transmission time (IHTT) regardless of hand placement. The effects of hemispace varied with the type of stimulation. With unimanual stimulation, overall thresholds were longer at the midline placement, however, with bimanual stimulation, thresholds were longer when the hands were spatially separated (crossed and/or uncrossed). Left handers' IHTTs were 8 ms faster than those of right handers. IHTTs in males were faster than females with hands placed in lateral (by 10.8 ms) or crossed (by 9.8 ms) but not midline positions. It was concluded that the cerebral hemispheres are equally capable of discriminating temporal intervals, but that the left hemisphere predominates when there is uncertainty about location of stimulation.

Early diagnosis of lymphedema in postsurgery breast cancer patients

Lymphedema is an accumulation of lymph fluid in the limb resulting from an insufficiency of the lymphatic system. It is commonly associated with surgical or radiotherapy treatment for breast cancer. As with many progressively debilitating disorders, the effectiveness of treatment is significantly improved by earlier intervention. Multiple frequency bioelectrical impedance analysis (MFBIA) previously was shown to provide accurate relative measures of lymphedema in the upper limb in patients after treatment for breast cancer, This presentation reports progress to date on a three-year prospective study to evaluate the efficacy of MFBIA to predict the early onset of lymphedema in breast cancer patients following treatment. Bioelectrical impedance measurements of each upper limb were recorded in a group of healthy control subjects (n = 50) to determine the ratio of extracellular limb-fluid volumes. From this population, the expected normal range of asymmetry (99.7% confidence) between the limbs was determined, Patients undergoing surgery to treat breast cancer were recruited into the study, and MFBIA measurements were recorded presurgery, at one month and three months after surgery, and then at two-month intervals for up to 24 months postsurgery, When patients had an MFBIA measure outside the 99.7% range of the control group, they were referred to their physician for clinical assessment. Results to date: Over 100 patients were recruited into the study over the past two years; at present, 19 have developed lymphedema and, of these, 12 are receiving treatment. In each of these 19 cases, MFBIA predicted the onset of the condition up to four months before it could be clinically diagnosed. The false-negative rate currently is zero, The study will continue to monitor patients over the remaining year to accurately ascertain estimates of specificity and sensitivity of the procedure.

Investigation of threat-related attentional bias in anxious children using the startle eyeblink modification paradigm

We used the startle eyeblink modification paradigm to investigate whether clinically anxious children, like high trait-anxious adults, display a bias in favour of threat words compared to neutral words. The present study included 16 clinically anxious children whose diagnostic status was determined using the parent version of a semistructured diagnostic interview as part of a larger childhood anxiety study. The children were presented with threat and neutral words fur 6 s each. A startle-eliciting auditory stimulus - a 100 dBA burst of white noise of 50 ms duration - was presented during the words at lead intervals of 60, 120, 240, or 3500 ms and during intertrial intervals. The overall pattern of startle eyeblink modification indicated inhibition at the 120 and 240 ms lead intervals and facilitation at the 3500 ms lead interval. startle-latency shortening during threat words at the :60 ms lead interval was larger than at other intervals, whereas there was no difference during neutral words. This result reflects an anxiety-related bias in favour of threat words occurring at a very early - and possibly preattentive stage - of information processing.

Projecting mammographic screens

Objective-The purpose of mammographic screening is to reduce mortality from breast cancer. This study describes a method for projecting the number of screens to be performed by a mammographic screening programme, and applies this method in the context of New South Wales, Australia. Method-The total number of mammographic screens was projected as the sum of initial screens and re-screens, and is based on projections of the population, rates of new recruitment, rates of attrition within the programme, and the mix of screening intervals. The baseline scenario involved: 70% participation of women aged 50-69 years, 90% return rate for the second and subsequent re-screens, 5% annual screens (95% biennial screens), and a specified population projection. The results were assessed with respect to variations in these assumptions. Results-The projections were strongly influenced by: the rate of screening of the target age group; the proportion of women re-screened annually; and the rates of attrition within the programme. Although demographic change had a notable effect, there was little difference between different population projections. Standard assumptions about attrition within the programme suggest that the current target participation rates in NSW may not be achieved in the long term. Conclusions-A practical model for projecting mammographic screens for populations is described which is capable of forecasting the number of screens under different scenarios. Implications-Projections of mammographic screens provide important information for the planning and financing of equipment and personnel, and for testing the effects of variations in important operational parameters. Re-screening attrition is an important contributor to screening viability.

Residues of zeta-cypermethrin in bovine tissues and milk following pour-on and spray application

The depletion of zeta-cypermethrin residues in bovine tissues and milk was studied. Beef cattle were treated three times at 3-week intervals with 1 ml 10 kg(-1) body weight of a 25 g litre(-1) or 50 g litre(-1) pour-on formulation (2.5 and 5.0 mg zeta-cypermethrin kg(-1) body weight) or 100 mg kg(-1) spray to simulate a likely worst-case treatment regime. Friesian and Jersey dairy cows were treated once with 2.5 mg zeta-cypermethrin kg(-1) in a pour-on formulation. Muscle, liver and kidney residue concentrations were generally less than the limit of detection (LOD = 0.01 mg kg(-1)). Residues in renal-fat and back-fat samples from animals treated with 2.5 mg kg(-1) all exceeded the limit of quantitation (LOQ = 0.05 mg kg(-1)), peaking at 10 days after treatment. Only two of five kidney fat samples were above the LOQ after 34 days, but none of the back-fat samples exceeded the LOQ at 28 days after treatment. Following spray treatments, fat residues were detectable in some animals but were below the LOQ at all sampling intervals. Zeta-cypermethrin was quantifiable (LOQ = 0.01 mg kg(-1)) in only one whole-milk sample from the Friesian cows (0.015 mg kg(-1), 2 days after treatment). In whole milk from Jersey cows, the mean concentration of zeta-cypermethrin peaked 1 day after treatment, at 0.015 mg kg(-1), and the highest individual sample concentration was 0.025 mg kg(-1) at 3 days after treatment. Residues in milk were not quantifiable beginning 4 days after treatment. The mean concentrations of zeta-cypermethrin in milk fat from Friesian and Jersey cows peaked two days after treatment at 0.197 mg kg(-1) and 0.377 mg kg(-1), respectively, and the highest individual sample concentrations were 2 days after treatment at 0.47 mg kg(-1) and 0.98 mg kg(-1), respectively. (C) 2001 Society of Chemical Industry.

The preparation and execution of self-initiated and externally-triggered movement: A study of event-related fMRI

Studies of functional brain imaging in humans and single cell recordings in monkeys have generally shown preferential involvement of the medially located supplementary motor area (SMA) in self-initiated movement and the lateral premotor cortex in externally cued movement. Studies of event-related cortical potentials recorded during movement preparation, however, generally show increased cortical activity prior to self-initiated movements but little activity at early stages prior to movements that are externally cued at unpredictable times. In this study, the spatial location and relative timing of activation for self-initiated and externally triggered movements were examined using rapid event-related functional MRI. Twelve healthy right-handed subjects were imaged while performing a brief finger sequence movement (three rapid alternating button presses: index-middle-index finger) made either in response to an unpredictably timed auditory cue (between 8 to 24 s after the previous movement) or at self-paced irregular intervals. Both movement conditions involved similar strong activation of medial motor areas including the pre-SMA, SMA proper, and rostral cingulate cortex, as well as activation within contralateral primary motor, superior parietal, and insula cortex. Activation within the basal ganglia was found for self-initiated movements only, while externally triggered movements involved additional bilateral activation of primary auditory cortex. Although the level of SMA and cingulate cortex activation did not differ significantly between movement conditions, the timing of the hemodynamic response within the pre-SMA was significantly earlier for self-initiated compared with externally triggered movements. This clearly reflects involvement of the pre-SMA in early processes associated with the preparation for voluntary movement. (C) 2002 Elsevier Science.

Nonoxynol-9 spermicide for prevention of vaginally acquired HIV and other sexually transmitted infections: systematic review and meta-analysis of randomised controlled trials including more than 5000 women

We aimed to determine the effectiveness of the vaginally administered spermicide nonoxynol-9 (N-9) among women for the prevention of HIV and other sexually transmitted infections (STIs), We did a systematic review of randomised controlled trials, Nine such trials including 5096 women, predominantly sex workers, comparing N-9 with placebo or no treatment, were included. Primary outcomes were new HIV infection, new episodes of various STIs, and genital lesions. Five trials included HIV and nine included STI outcomes, and all but one (2% of the data) contributed to the meta-analysis. Overall, relative risks of HIV infection (1.12, 95% confidence interval 0.88-1.42), gonorrhoea (0.91, 0.67-1.24), chlamyclia (0.88, 0.77-1.01), cervical infection (1.01, 0.84-1-22), trichomoniasis (0.84, 0.69-1.02), bacterial vaginosis (0.88, 0.74-1.04) and candidiasis (0.97, 0.84-1.12) were not significantly different in the N-9 and placebo or no treatment groups. Genital lesions were more common in the N-9 group (1.18, 1.02-1.36). Our review has found no statistically significant reduction in risk of HIV and STIs, and the confidence intervals indicate that any protection that may exist is likely to be very small. There is some evidence of harm through genital lesions. N-9 cannot be recommended for HIV and STI prevention.

Outcome research in psychodynamic psychotherapy: Psychological, social and neuropsychological factors

While many studies have demonstrated positive outcomes from psychotherapy when it is practiced in a controlled research environment with carefully selected (or excluded) patient groups and rigid manualised therapy sessions there is a paucity of research regarding effective outcomes from psychotherapy as it is practiced in actual clinical conditions. The aim of this series of studies was to investigate outcomes, using an effectiveness approach, from psychodynamic psychotherapy as it is practiced by private psychiatrists. Three studies were planned. The aim of Study 1 was to provide standardized baseline measures on the following dimensions • Personal Demographic Information (PDI), • Target Symptoms and Disorders (TSD) including a neuropsychological profile • Inter and Intra Personal (IIP) factors, and, • General Functioning and Quality of Life (GFQoL) factors. Study 2 aimed to examine changes in patient characteristics during the course of treatment. Thus, baseline assessments were repeated at sixmonthly intervals to determine if therapy had been effective for individual patients. A third study was planned to assess the extent to which the results of significant outcome predictors could be replicated in different patient samples. Twenty-nine psychiatrists consented to refer patients with 20 patients having completed pre therapy assessments and six and 18-month follow-up questionnaires. The presentation of this research will focus on the interesting research methodology utilized, patient demographic characteristics and on the patient changes occurring over time on the dimensions of Defence Style (DSQ), Quality of Life (WHOQOL- Bref) and the severity of depression (BDI). The patient sample included 10 male and 10 female patients, whose ages ranged from 19 years to 66 years (mean = 43 years). While seven of the patients did not meet SCID-IV criteria for a current DSM-IV Axis 1 disorder, six patients met criteria for a current mood disorder, three for panic disorder, one patient each for PTSD, alcohol abuse and dependence, and 2 patients met current criteria for multiple Axis 1 disorders. The research is ongoing.