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To characterize the traumatic brain injury (TBI) profile and its associated risk factors in homeless individuals in Santa Clara County, CA. Observational cohort study. Two homeless shelter health clinics in Santa Clara County, CA. Currently or recently homeless individuals seeking health care at 2 homeless shelter health clinics between August 2013 and May 2014. Not applicable. Demographics, TBI incidence and characteristics. The findings indicate that TBI history in the homeless population was higher (79.7%) than in the general population (12%). Almost half of the population (49.2%) reported that their TBI occurred before the age of 18. Of the participants, 68.2% reported sustaining a TBI with loss of consciousness. TBI caused by violence (60%) was lower in this cohort than other homeless cohorts but was the main cause of injury regardless of age. Alcoholism was a risk factor for having more TBIs. No differences in TBI profile were found between sexes. Our findings underscore the need for more research on the lifetime risk factors associated with TBI to prevent and reduce the number of brain injuries in homeless populations. [ABSTRACT FROM AUTHOR]

To examine the unique contribution of alexithymia at 1 year after traumatic brain injury (TBI) to the prospective prediction of emotional and social health outcomes at 2 years after injury. Multicenter, longitudinal cohort study. Data were collected during year 1 and year 2 postinjury follow-up interviews across 4 TBI Model System centers. Persons with TBI (N=175; 134 men and 41 women) who had English fluency and were capable of providing self-reported data. Not applicable. Primary independent variable was the Toronto Alexithymia Scale-20. Outcome measures included the Interpersonal Reactivity Index, National Institute of Health Toolbox Emotion Battery Anger, Difficulty with Emotion Regulation Scale, Connor-Davidson Resilience Scale, Posttraumatic Stress Disorder Checklist – Civilian, Satisfaction with Life Scale, General Anxiety Disorder-7, Patient Health Questionnaire 9, suicidal ideation, and problematic substance use. Simple adjusted models demonstrated that after controlling for the specific outcome at year 1, Toronto Alexithymia Scale-20 scores significantly predicted year 2 scores for perspective-taking, physical aggression, emotional dysregulation, resilience, anxiety, depression, and suicidal ideation. All of these predictive findings except for physical aggression were maintained in the fully adjusted models that also controlled for age, sex, education level, number of prior TBIs, and motor and cognitive functioning. Compared with those with lower alexithymia scores, persons with TBI who had higher alexithymia scores at 1 year after injury reported poorer emotional health at 2 years after TBI, even after controlling for year 1 outcome scores, sociodemographic characteristics, and injury-related factors. These results support the need to assess for elevated alexithymia and to provide interventions targeting alexithymia early in the TBI recovery process. [ABSTRACT FROM AUTHOR]

The aim of the current study was to investigate the impact of individualised versus standardised combined endurance and resistance training on the fitness–fatness index in physically inactive adults. Randomised controlled trial. Fifty-four participants aged 21–55 years were randomised into three groups; 1) non-exercise control (n = 18), 2) standardised moderate-intensity continuous training (n = 18), or 3) individualised moderate-intensity continuous training + high-intensity interval training (n = 18). The fitness–fatness index was calculated by dividing cardiorespiratory fitness (expressed as metabolic equivalents) by the waist-to-height ratio. Participants were classified as likely responders to the intervention if a change of ≥ 1 fitness–fatness index unit was achieved. The individualised group showed the greatest fitness–fatness index improvement (between group difference p < 0.001), with 100 % of this group classified as likely responders, compared to the standardised (68 %) and non-exercise control (0 %) groups. An individualised, threshold-based exercise programme may produce more favourable changes in the fitness–fatness index than a standardised exercise programme. [ABSTRACT FROM AUTHOR]

• A fourth dose of NVX-CoV2373 did not increase local/systemic reactogenicity. • A fourth dose of NVX-CoV2373 enhanced immune response to SARS-CoV-2 variants. • An NVX-CoV2373 fourth dose induced robust immunogenicity in those aged 18–84 years. • Correlates of protection imply post-boost efficacy of ≥ 82% for Omicron variants. The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants has significantly reduced the efficacy of some approved vaccines. A fourth dose of NVX-CoV2373 (5 µg SARS-CoV-2 recombinant spike [rS] protein + 50 µg Matrix-M™ adjuvant; Novavax, Gaithersburg, MD) was evaluated to determine induction of cross-reactive antibodies to variants of concern. A phase II randomized study (NCT04368988) recruited participants in Australia and the United States to assess a primary series of NVX-CoV2373 followed by two booster doses (third and fourth doses at 6-month intervals) in adults 18–84 years of age. The primary series was administered when the SARS-CoV-2 ancestral strain was prevalent and the third and fourth doses while the Alpha and Delta variants were prevalent in AUS and US. Local/systemic reactogenicity was assessed the day of vaccination and for 6 days thereafter. Unsolicited adverse events (AEs) were reported. Immunogenicity was measured before, and 14 days after, fourth dose administration, using anti-spike serum immunoglobulin G (IgG) and neutralization assays against ancestral SARS-CoV-2 strain and Omicron sublineages. Among 1283 enrolled participants, 258 were randomized to receive the two-dose primary series, of whom 104 received a third dose, and 45 received a fourth dose of NVX-CoV2373. The incidence of local/systemic reactogenicity events increased after the first three doses of NVX-CoV2373 and leveled off after dose 4. Unsolicited AEs were reported in 9 % of participants after dose 4 (none of which were severe or serious). Anti-rS IgG levels and neutralization antibody titers increased following booster doses to a level approximately four-fold higher than that observed after the primary series, with a progressively narrowed gap in response between the ancestral strain and Omicron BA.5. A fourth dose of NVX-CoV2373 enhanced immunogenicity for ancestral and variant SARS-CoV-2 strains without increasing reactogenicity, indicating that updates to the vaccine composition may not be currently warranted. [ABSTRACT FROM AUTHOR]

A 13 year old male was referred to the Department of Otorhinolaryngology due to unsuccessful decannulation. At 2 years of age, patient accidentally ingested a caustic liquid alkali and underwent emergency tracheostomy, exploratory laparotomy, and tube gastrectomy. 11 years after, patient was seen at the outpatient department for decannulation. On nasopharyngolaryngoscopy, a supraglottic stenosis with a central 1-mm opening was visualized. Patient underwent transoral carbon dioxide laser excision of supraglottic stenosis. Fused aryepiglottic folds were released from the epiglottis. Patient was discharged well with no immediate complications and was successfully decannulated 1 month post operation with good voice outcome. No recurrence of stenosis at one year post operation. Accidental caustic ingestion commonly occurs in the pediatric age group. A frequent complication of accidental caustic ingestion is strictures. The use of transoral carbon dioxide laser in the surgical treatment of supraglottic stenosis is a suitable option for pediatric patients as this offer several advantages such as less post operative edema, good intraoperative control of hemorrhage, few post-operative complications and is less invasive compared to open laryngeal procedures. This case exhibits the importance of close monitoring for pediatric patients after caustic ingestion in order to diagnose complications earlier. [ABSTRACT FROM AUTHOR]

The major risk factor for idiopathic pulmonary fibrosis (IPF), MUC5B rs35705950, was found to be associated with rheumatoid arthritis-associated interstitial lung disease (RA-ILD). Whilst the MUC5B rs35705950 T risk allele has been associated with better survival in IPF, its impact on RA-ILD prognosis remains to be determined. Our objective was to explore the influence of MUC5B rs35705950 on survival and progression in RA-ILD. Through an international retrospective observational study, patients with RA-ILD were genotyped for the MUC5B rs35705950 variant and consecutive pulmonary function tests (PFTs) findings were collected. Longitudinal data up to a 10-year follow-up were considered and analyzed using mixed regression models. Proportional hazards and joint proportional hazards models were used to analyze the association of baseline and longitudinal variables with lung transplant-free survival. Significant progression of RA-ILD was defined as at least an absolute or relative 10% decline of forced vital capacity at 2 years from baseline. Out of 321 registered patients, 261 were included in the study: 139 women (53.3%), median age at RA-ILD diagnosis 65 years (interquartile range [IQR] 57 to 71), 151 ever smokers (59.2%). Median follow-up was 3.5 years (IQR 1.3 to 6.6). Mortality rate was 32% (95%CI 19 to 42) at 10 years. The MUC5B rs35705950 variant did not impact lung transplant-free survival (HR for the T risk allele carriers=1.26; 95%CI 0.61 to 2.62; P=0.53). Decline in pulmonary function at 2 years was not influenced by MUC5B rs35705950 (OR=0.95; 95%CI 0.44 to 2.05; P=0.89), irrespective of the HRCT pattern. In this study, the MUC5B rs35705950 promoter variant did not influence transplant- free survival or decline in pulmonary function in patients with RA-ILD. [ABSTRACT FROM AUTHOR]

[Display omitted] • In agreement with recently published studies, repeated mRNA SARS-CoV-2 vaccination was associated with an increase in Spike-specific IgG4. • By contrast, IgG4 class switch was not observed following four doses of Novavax protein-based SARS-CoV-2 vaccine. • SARS-CoV-2 specific IgG3, an IgG subclass known to induce potent neutralization and Fc functions, was higher after Novavax (>10x vs. mRNA). • In contrast to the mRNA homologous regimens, Novavax homologous and heterologous vaccinations evoked stronger Fcγ effector activities. [ABSTRACT FROM AUTHOR]

This study investigates instances of elevated radiation dose on a radiation tracking system to determine their aetiologies. It aimed to investigate the impact of radiographer feedback on these alerts. Over two six-month periods 11,298 CT examinations were assessed using DoseWatch. Red alerts (dose length products twice the median) were identified and two independent reviewers established whether alerts were true (unjustifiable) or false (justifiable). During the second time period radiographers used a feedback tool to state the cause of the alert. A Chi–Square test was used to assess whether red alert incidence decreased following the implementation of radiographer feedback. There were 206 and 357 alerts during the first and second time periods, respectively. These occurred commonly with CT pulmonary angiography, brain, and body examinations. Procedural documentation errors and patient size accounted for 57% and 43% of false alerts, respectively. Radiographer feedback was provided for 17% of studies; this was not associated with a significant change in the number of alerts, but the number of true alerts declined (from 7 to 3) (χ2 = 4.14; p = 0.04). Procedural documentation errors as well as patient-related factors are associated with false alerts in DoseWatch. Implementation of a radiographer feedback tool reduced true alerts. The implementation of a radiographer feedback tool reduced the rate of true dose alerts. Low uptake with dose alert systems is an issue; the workflow needs to be considered to address this. [ABSTRACT FROM AUTHOR]

Increasing integration of computed tomography (CT) into routine patient care has escalated concerns regarding associated radiation exposure. Specific patient cohorts, particularly those with cystic fibrosis (CF) and Crohn's disease, have repeat exposures and thus have an increased risk of high lifetime cumulative effective dose exposures. Thoracic CT is the gold standard imaging method in the diagnosis, assessment and management of pulmonary disease. In the setting of CF, CT demonstrates increased sensitivity compared with pulmonary function tests and chest radiography. Furthermore, in specific cases of Crohn's disease, CT demonstrates diagnostic superiority over magnetic resonance imaging (MRI) for radiological evaluation. Low dose CT protocols have proven beneficial in the evaluation of CF, Crohn's disease and renal calculi, and in the follow up of testicular cancer patients. For individuals with chronic conditions warranting frequent radiological follow up, the focus must continue to be the incorporation of appropriate CT use into patient care. This is of particular importance for the paediatric population who are most susceptible to potential radiation induced malignancy. CT technological developments continue to focus on radiation dose optimisation. This article aims to highlight these advancements, which prioritise the acquisition of diagnostically satisfactory images with the least amount of radiation possible. [ABSTRACT FROM AUTHOR]

In patients with only one embryo on Day 3 post-IVF treatment, does transferring the embryo into the uterine environment achieve a higher pregnancy rate than growing the embryo on with a plan to transfer at Day 4–6? This was a retrospective cohort study conducted in patients with only one viable embryo on Day 3 post-IVF treatment. Data were extracted from a standardized IVF database and included 1384 women who fulfilled this study's selection criteria. Outcomes of these embryos were followed up and stratified into two groups: embryos transferred on Day 3 and those grown on to Day 4–6. Pregnancy rate (biochemical and clinical) and live birth rates were analysed with logistic regression and adjusted using a parsimonious model for baseline patient characteristics. Biochemical pregnancy (16.7% versus 9.5%, odds ratio [OR] 1.9, P = 0.001), clinical pregnancy (14.7% versus 6.8%, OR 2.35, P < 0.001) and live birth rates (9.7% versus 4.4%, OR 2.37, P = 0.002) were significantly higher in the Day 3 group than those in the group grown on to Day 4–6. These differences were still significant after adjusting for potential confounders (adjusted OR 2.60, 3.71, 4.08, respectively, P < 0.001). These findings support Day 3 cleavage-stage embryo transfer instead of growing on to Day 4–6 for blastocyst-stage transfer when only a single embryo is available. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to describe the 4-step process (consent, selection, protection, and abstraction) of acquiring a large sample of chiropractic patient records from multiple practices and subsequent data abstraction. From April 2017 to December 2017, RAND acquired patient records from 99 chiropractic practices across the United States. The records included patients enrolled in a survey e-study (prospective sample) and a random sample of all clinic patients (retrospective sample) with chronic back or neck pain. Clinic staff were trained to collect the sample, scan, and transfer the records. We designed an online data collection tool for abstraction. Protocols were instituted to protect patient confidentiality. Doctors of chiropractic were selected and trained as abstractors, and a system was established to monitor data collection. In compliance with data protection protocols, 3603 patient records were scanned, including 1475 in the prospective sample and 2128 in the random sample. A total of 1716 patients (prospective sample) consented to having their records scanned, but only 1475 could be retrieved. Of records scanned, 19% were unusable owing to illegibility, no care during the period of interest, or poor scanning. The abstractor interrater reliability for appropriateness of care decisions was fair to moderate (κ.38-.48). The acquisition, handling, and abstraction of a large sample of chiropractic records was a complex task with challenges that necessitated adapting planned approaches. Of the records abstracted, many revealed incomplete provider documentation regarding the details of and rationale for care. Better documentation and more standardized record keeping would facilitate future research using patient records. [ABSTRACT FROM AUTHOR]

Abstract The purpose of the present study was to develop a physiologically based pharmacokinetic model for dextromethorphan (DEX) and its metabolites in extensive and poor metabolizers. The model was used to study the influence of dissolution rates on the sensitivity of maximum plasma concentration and area under the concentration-time curve for immediate release formulations. Simulation of in vitro cellular transwell permeability was used to confirm lysosomal trapping. GastroPlus™ was used to build a mechanistic absorption and physiologically based pharmacokinetic model of DEX. The model simulations were conducted with and without lysosomal trapping. The simulated results matched well with observed data only when lysosomal trapping was included. The model shows that DEX is rapidly absorbed into the enterocytes, but DEX and its metabolites only appear slowly in the portal vein and plasma, presumably due to lysosomal trapping. For this class of drug, the rate of in vitro and in vivo dissolution is not a sensitive factor in determining bioequivalence. This study shows that dissolution and the rate of absorption into the enterocytes are clinically irrelevant for the performance of DEX immediate release product. An understanding of the entire underlying mechanistic processes of drug disposition is needed to define clinically relevant product specifications for DEX. [ABSTRACT FROM AUTHOR]

Electrospinning is a nano-fabrication technique that easily produces ceramic oxide nanofibres which can find numerous applications as energy storage materials, such as battery electrodes. Vanadium oxide is a viable alternative electrode material with tuneable oxidation states and a layered structure that can reversibly intercalate charge carriers. This review examines the use of vanadium oxide as an electrode material for metal ion batteries with focus on electrospun derivatives. Vanadium oxide-based electrodes are predominantly considered in lithium ion batteries given the amount of published literature in this context. The use of vanadium oxide in energy storage devices, while promising, is limited by its low structural stability and slow electrochemical kinetics associated with charge carrier intercalation resulting in poor cycle stability. Doping with other metallic element and incorporation of carbon derivatives in vanadium oxides can potentially improve its cycle stability and rate retention. Vanadium oxide-based electrodes for sodium ion and aluminium ion batteries are also discussed to highlight its versatility in alternative metal ion battery systems. [ABSTRACT FROM AUTHOR]

This study tests the influence of a diverse set of biochar properties on As(V), Se(IV), Cd(II), Cu(II), Ni(II), Pb(II), or Zn(II) removal from solution at pH 4.5. Six commercial biochars produced using different feedstock and pyrolysis conditions were extensively characterized using physical, chemical, and spectroscopic techniques, and their properties were correlated to anion and cation removal using multiple linear regression. H/total organic C (TOC) ratio and volatile matter were positively correlated to cation removal from solution, which indicate interactions between metals and non-aromatic C. Defining the correlation of ion removal with specific OC functional groups was hindered by the inherent limitations of the spectroscopic techniques, which was exacerbated by the heterogeneity of the biochars. Ash was negatively correlated to Se(IV) and positively correlated to Cd(II), Cu(II), and Ni(II) removal from solution. Interference from soluble P in biochars may partly explain the low Se(IV) removal from solution; and Ca-, P-, and Fe- containing compounds likely sorbed or precipitated Pb(II), Cd(II), Cu(II), Ni(II) and Zn(II). Furthermore, Ca-oxalate identified using X-ray diffraction in willow, may be responsible for willow's increased ability to remove Cd(II), Ni(II), and Zn(II) compared to the other 5 biochars. It was clear that both OC and inorganic biochar components influenced metal(loid) and Se(IV) removal from solution. The non-aromatic and volatile OC correlated to removal from solution may be readily available for microbial degradation, while Mg, N, P, and S are required for biological growth. Biological metabolism and uptake of these compounds may inhibit or destabilize their interaction with contaminants. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to propose and qualify a novel funding mechanism for international neurosurgical nonprofits. The article first identifies and explains neurosurgeons' means for practicing in the developing world through a literature review. After this examination of the current funding methods for surgical care in low-income regions, the work transitions to an explanation of the applications and limitations of a new resource: the internal wealth of a developing country. This wealth may be leveraged by way of a for-profit hospital to create sustainable and domestic funding for nonprofit neurosurgical training. The applicability of the proposed mechanism extends beyond the field of neurosurgery to nonprofits in any health-related discipline. Factors influencing the viability of this mechanism (including local disease burden, economic trajectory, and political stability) are examined to create a baseline set of conditions for success. [ABSTRACT FROM AUTHOR]

Objective To describe the ongoing Clinical Tracking Form (CTF) study of the Defense and Veterans Brain Injury Center (DVBIC). Design Prospective longitudinal study. Data at baseline and postinjury are collected on participants through interview and questionnaire, review of medical records, and periodic follow-ups throughout their lifetime. Setting A regional DVBIC site located at a Veterans Affairs Medical Center. Participants Participants (N=211; age range, 18–75y) were enrolled between January 1, 2005, and December 31, 2012, at a regional DVBIC site. Intervention Not applicable. Main Outcome Measures Injury information, functioning, and psychological health. Results Sixty percent of 211 participants were identified as having severe traumatic brain injuries (TBIs), 14% moderate TBIs, and 26% mild TBIs. Of these 211 participants, 79% sustained closed head injuries, 15% penetrating head injuries, and 6% were not reported. Comparing the severity of TBI in combat versus stateside situations, most of the mild injuries (71%) occurred in combat locations, while most of the severe injuries (62%) occurred in the United States. Among those injured in combat, blast-related TBIs (82%) greatly outnumbered non–blast-related TBIs, regardless of severity. Conclusions The CTF study serves as a significant resource of data to understand the effect and outcomes of TBI in the military population. The lifelong experience of military veterans across the full spectrum of TBI and recovery will be recorded through the CTF, and will translate into more informed clinical decisions and educational efforts to guide future research pathways. [ABSTRACT FROM AUTHOR]

Objectives: The vulnerability of individuals with the metabolic syndrome (MetS) to cardiovascular events (CVEs) is attenuated by increased cardiorespiratory fitness (CRF), despite the presence of obesity as a usual component of MetS. To better understand the importance of CRF and body fat in treating this condition, we investigated the relationship between fitness and fatness with pancreatic beta cell function (BCF) indices that are known independent predictors of CVEs.Design: Cross sectional study.Methods: This study included 84 individuals with MetS. BCF indices were derived from a fasted steady state (basal disposition index [DI], proinsulin, proinsulin:insulin, and proinsulin:C-peptide) and dynamic conditions via an oral glucose tolerance test (1st and 2nd phase DI). CRF and body fat percentage (BF%) were assessed via indirect calorimetry (during a maximal exercise test) and dual energy X-ray absorptiometry, respectively.Results: CRF was positively associated with basal DI (r=0.40, p<0.001), 1st phase DI (r=0.49, p<0.005), and 2nd phase DI (r=0.38, p=0.02). Hierarchical multiple regression analysis showed CRF was associated with basal DI (β=0.18, p=0.04), 1st phase DI (β=0.36, p=0.04), and 2nd phase DI (β=0.33, p=0.03), independent of BF% and other confounding factors including age, sex, diabetic status, anthropometric measures, lipid profile, and insulin sensitivity. No significant associations were found between CRF and proinsulin measures. BF% was not significantly correlated with BCF indices.Conclusions: Increased CRF was independently associated with enhanced BCF. This study provides evidence that equal, if not more attention should be dedicated to CRF improvement relative to fat-loss for favorable pancreatic BCF and thus possible reduction in CV risk in individuals with MetS. [ABSTRACT FROM AUTHOR]

Rationale and Objectives: The Association of Program Directors in Radiology regularly surveys its members regarding issues of importance to support radiology residency programs and their directors.Materials and Methods: This is an observational cross-sectional study using two Web-based surveys posed to the Association of Program Directors in Radiology membership in the fall of 2014 (49 items) and the spring of 2015 (46 items) on the subjects of importance to the members, including the Accreditation Council on Graduate Medical Education Milestones, the Non-Interpretative Skills Curriculum, the American Board of Radiology Core Examination, the effect of the new resident testing and program accreditation paradigms on training outcomes, the 2015 Residency Match, the Interventional Radiology/Diagnostic Radiology (IR/DR) Residency, and Program Director (PD)/Program Coordinator resources.Results: Responses were collected electronically, results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 63rd annual meeting of the Association of University Radiologists. The maximal response rate was 33% in the fall of 2014 and 36% in the spring of 2015.Conclusions: PDs believed that the radiology Milestones, now largely implemented, did not affect overall resident evaluation, was not reflective of resident experience, and actually made evaluation of residents more difficult. PDs also felt that although the American Board of Radiology oral examination had been a better test for clinical practice preparedness, their new residents knew at least as much as before. There was little evidence of recall reemergence. The radiology training community saw a drop in residency applicant quality as demonstrated by the United States Medical Licensing Examination scores and clinical rotation grades. Because the new IR/DR Residency positions were to be funded at the expense of the traditional DR positions, the majority of PDs expected a negative effect of the impending IR/DR match on their DR recruitment. PDs were in favor of a unified clinical radiology curriculum similar to the Radiological Society of North America online physics modules. [ABSTRACT FROM AUTHOR]

Risk assessments of arsenic have focused on skin, bladder, and lung cancers and skin lesions as the sensitive cancer and non-cancer health endpoints, respectively; however, an increasing number of epidemiologic studies that can inform risk assessment have examined neurodevelopmental effects in children. We conducted a systematic review and risk assessment based on the epidemiologic literature on possible neurodevelopmental effects at lower arsenic exposures. Twenty-four cross-sectional, case-control, and cohort studies were identified that report on the association between low-level arsenic exposure (i.e., largely <100 μg/L of arsenic in drinking water) and neurological outcomes in children. Although the overall evidence does not consistently show a causal dose-response relationship at low doses, the most rigorously conducted studies from Bangladesh indicate possible inverse associations with cognitive function, predominantly involving concurrent arsenic exposure as measured by biomarkers (i.e., arsenic in urine or blood) and raw verbal test scores at ages 5–11 years. Issues such as non-comparability of outcome measures across studies; inaccuracies of biomarkers and other measures of inorganic arsenic exposure; potential effect modification by cultural practices; insufficient adjustment for nutritional deficiencies, maternal IQ, and other important confounders; and presence of other neurotoxicants in foreign populations limit generalizability to U.S. populations. Of the few U.S. studies available, the most rigorously conducted study did not find a consistent dose-response relationship between arsenic concentrations in tap water or toenails and decrements in IQ scores. Assuming that the strongest dose-response relationship from the most rigorous evidence from Bangladesh is generalizable to U.S. populations, possible reference doses were estimated in the range of 0.0004–0.001 mg/kg-day. These doses are higher than the U.S. Environmental Protection Agency reference dose for chronic lifetime exposure, thus indicating protectiveness of the existing value for potential neurotoxicity in children. This reference dose is undergoing revision as EPA considers various health endpoints in the reassessment of inorganic arsenic health risks. [ABSTRACT FROM AUTHOR]

The U.S. Environmental Protection Agency (EPA) is developing an integrated assessment of non-cancer and cancer risk assessment of inorganic arsenic (iAs). Cardiovascular disease (CVD) in association with iAs exposure has been examined in a number of studies and provides a basis for evaluating a reference dose (RfD) for assessing potential non-cancer health risks of arsenic exposure. In this systematic review of low-level iAs exposure (i.e., <100-150 µg/L arsenic water concentration) and CVD in human populations, 13 cohort and case-control studies from the United States, Taiwan, Bangladesh, and China were identified and critically examined for evidence for derivation of a RfD. Eight cross-sectional and ecological studies from the United States were also examined for additional information. Prospective cohort data from Bangladesh provided the strongest evidence for determining the point of departure in establishing a candidate RfD based on a combined endpoint of mortality from "ischemic heart disease and other heart diseases." This study as well as the overall literature supported a no-observed-adverse-effect level of 100 µg/L for arsenic in water, which was equivalent to an iAs dose of 0.009 mg/kg-day (based on population-specific water consumption rates and dietary iAs intake). The study population was likely sensitive to arsenic toxicity because of nutritional deficiencies affecting arsenic methylation and one-carbon metabolism, as well as increasing CVD risk. Evidence is less clear on the interaction of CVD risk factors in the United States (e.g., diabetes, obesity, and hypertension) with arsenic at low doses. Potential uncertainty factors up to 3 resulted in a RfD for CVD in the range of 0.003-0.009 mg/kg-day. Although caution should be exercised in extrapolating these results to the U.S. general population, these doses allow a margin of exposure that is 10-30 times the current RfD derived by EPA (based on skin lesions in Southwest Taiwan). These findings suggest that the current EPA RfD is protective of CVD. [ABSTRACT FROM AUTHOR]

Adverse events secondary to opioid-induced advancing sedation and respiratory depression continue to occur during hospitalizations despite efforts to increase awareness and clinical practice guidelines to address prevention strategies. In 2009, ASPMN surveyed membership on current practices surrounding this topic. ASPMN clinical practice guidelines were then published in 2011. In winter of 2013, ASPMN membership was again surveyed to assess progress in preventing adverse events. This is a report of the follow-up membership survey. In general, monitoring practices are slowly improving over time, but there are many facilities that have not instituted best practices for avoiding adverse events. [ABSTRACT FROM AUTHOR]

Abstract: While exposures to high levels of arsenic in drinking water are associated with excess cancer risk (e.g., skin, bladder, and lung), exposures at lower levels (e.g., <100–200µg/L) generally are not. Lack of significant associations may result from methodological issues (e.g., inadequate statistical power, exposure misclassification), or a different dose–response relationship at low exposures, possibly associated with a toxicological mode of action that requires a sufficient dose for increased tumor formation. The extent to which bladder cancer risk for low-level arsenic exposure can be statistically measured by epidemiological studies was examined using an updated meta-analysis of bladder cancer risk with data from two new publications. The summary relative risk estimate (SRRE) for all nine studies was elevated slightly, but not significantly (1.07; 95% confidence interval [CI]: 0.95–1.21, p-Heterogeneity [p-H]=0.543). The SRRE among never smokers was 0.85 (95% CI: 0.66–1.08, p-H=0.915), whereas the SRRE was positive and more heterogeneous among ever smokers (1.18; 95% CI: 0.97–1.44, p-H=0.034). The SRRE was statistically significantly lower than relative risks predicted for never smokers in the United States based on linear extrapolation of risks from higher doses in southwest Taiwan to arsenic water exposures >10µg/L for more than one-third of a lifetime. By contrast, for all study subjects, relative risks predicted for one-half of lifetime exposure to 50µg/L were just above the upper 95% CI on the SRRE. Thus, results from low-exposure studies, particularly for never smokers, were statistically inconsistent with predicted risk based on high-dose extrapolation. Additional studies that better characterize tobacco use and stratify analyses of arsenic and bladder cancer by smoking status are necessary to further examine risks of arsenic exposure for smokers. [Copyright &y& Elsevier]