Evolution of surgical approach to rectal cancer resection: A multinational registry assessment.

PURPOSE: Surgical approach to rectal cancer has evolved in recent decades, with introduction of minimally invasive surgery (MIS) techniques and local excision. Since implementation might differ internationally, this study is aimed at evaluating trends in surgical approach to rectal cancer across different countries over the last 10 years and to gain insight into patient, tumour and treatment characteristics. METHODS: Pseudo-anonymised data of patients undergoing resection for rectal cancer between 2010 and 2019 were extracted from clinical audits in the Netherlands (NL), Sweden (SE), England-Wales (EW) and Australia-New Zealand (AZ). RESULTS: Ninety-nine thousand five hundred ninety-seven patients were included (38,413 open, 55,155 MIS and 5416 local excision). An overall increase in MIS was observed from 29.9% in 2010 to 72.1% in 2019, with decreasing conversion rates (17.5-9.0%). The MIS proportion was highly variable between countries in the period 2010-2014 (54.4% NL, 45.3% EW, 39.8% AZ, 14.1% SE, P < 0.001), but variation reduced over time (2015-2019 78.8% NL, 66.3% EW, 64.3% AZ, 53.2% SE, P < 0.001). The proportion of local excision for the two periods was highly variable between countries: 4.7% and 11.8% in NL, 3.9% and 7.4% in EW, 4.7% and 4.6% in AZ, 6.0% and 2.9% in SE. CONCLUSIONS: Application and speed of implementation of MIS were highly variable between countries, but each registry demonstrated a significant increase over time. Local excision revealed inconsistent trends over time.

CRCBaSe: a Swedish register-based resource for colorectal adenocarcinoma research.

OBJECTIVES: To facilitate high-quality register-based research on colorectal cancer (CRC) in Sweden by constructing a database consisting of CRC patients, matched comparators, and relatives. MATERIAL AND METHODS: Patients with adenocarcinoma in the colon and/or rectum were identified in the Swedish Colorectal Cancer Register, a nationwide quality-of-care register. For each patient, six comparators from the general population were matched on birth year, sex, year of CRC diagnosis, and county. Comparators were free from CRC at the time of matching, but could later become cases. For both patients and comparators, first-degree relatives (parents, siblings, and children) were identified. Information from nationwide population-based registers was retrieved and linked to each individual in the database using the personal identification number unique to all Swedish residents. RESULTS: A total of 76,831 CRC patients diagnosed between 1995 and 2016 were identified (51% colon, 49% rectal; before 2007 only rectal cancer patients were included). Among all patients, 37% were stage I-II, 22% stage III, and 22% stage IV. The median follow-up time was 11.9 years (inter-quartile range, IQR: 8.6-15.3). Together with comparators and relatives, the database contains 2,413,139 individuals with information on demographics, dates and causes of death, in- and outpatient healthcare records, cancer diagnoses, prescribed and dispensed drugs, childbirths (among women), and social security information (such as sick leave and early retirement). CONCLUSION: The Colorectal Cancer Database Sweden (CRCBaSe) is a large and unique register-based data research platform, which opens up for clinically important, large epidemiological studies with innovative design in the field of colorectal adenocarcinoma.

A Horizon Scan to Support Chemical Pollution-Related Policymaking for Sustainable and Climate-Resilient Economies.

While chemicals are vital to modern society through materials, agriculture, textiles, new technology, medicines, and consumer goods, their use is not without risks. Unfortunately, our resources seem inadequate to address the breadth of chemical challenges to the environment and human health. Therefore, it is important we use our intelligence and knowledge wisely to prepare for what lies ahead. The present study used a Delphi-style approach to horizon-scan future chemical threats that need to be considered in the setting of chemicals and environmental policy, which involved a multidisciplinary, multisectoral, and multinational panel of 25 scientists and practitioners (mainly from the United Kingdom, Europe, and other industrialized nations) in a three-stage process. Fifteen issues were shortlisted (from a nominated list of 48), considered by the panel to hold global relevance. The issues span from the need for new chemical manufacturing (including transitioning to non-fossil-fuel feedstocks); challenges from novel materials, food imports, landfills, and tire wear; and opportunities from artificial intelligence, greater data transparency, and the weight-of-evidence approach. The 15 issues can be divided into three classes: new perspectives on historic but insufficiently appreciated chemicals/issues, new or relatively new products and their associated industries, and thinking through approaches we can use to meet these challenges. Chemicals are one threat among many that influence the environment and human health, and interlinkages with wider issues such as climate change and how we mitigate these were clear in this exercise. The horizon scan highlights the value of thinking broadly and consulting widely, considering systems approaches to ensure that interventions appreciate synergies and avoid harmful trade-offs in other areas. We recommend further collaboration between researchers, industry, regulators, and policymakers to perform horizon scanning to inform policymaking, to develop our ability to meet these challenges, and especially to extend the approach to consider also concerns from countries with developing economies. Environ Toxicol Chem 2023;42:1212-1228. © 2023 Crown copyright and The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC. This article is published with the permission of the Controller of HMSO and the King's Printer for Scotland.

Discrepancy between surgeon and radiological assessment of ligation level of the inferior mesenteric artery in patients operated for rectal cancer-impacting registry-based research and surgical practice.

BACKGROUND: The reliability of the registered ligation level of the inferior mesenteric artery (IMA) in the Swedish Colorectal Cancer Registry has been questioned. The primary aim of this study was to evaluate this parameter in the registry by comparing the registered ligation levels with a postoperative computed tomography angiography (CT-angiography) in patients operated for rectal cancer. METHODS: Patients operated for rectal cancer at two Swedish university hospitals were prospectively included between December 2016 and December 2019. At the 1-year postoperative follow-up, an additional CT-angiography was performed and independently examined by two radiologists. The radiological assessment of the ligation level was compared to registry data, using different measures of agreement. RESULTS: A total of 94 patients were included, 55 (59%) were men and 39 (41%) women. All patients underwent abdominal resection: conventional or robot-assisted laparoscopic surgery, n=56 (60%), or open resection, n=38 (40%). The ligation level as assessed on CT-angiography was high in 29 (31%) patients and low in 65 (69%). The registered level of ligation of the IMA and the radiological assessment of the CT-angiographies were consistent in 77/94 cases, demonstrating an 82% agreement and a sensitivity and specificity of 86% and 72%, respectively. The estimated Kappa value was 0.58, reaching 0.64 after prevalence bias adjustment. CONCLUSION: This study showed that CT-angiography can be used to evaluate the reliability of the registered ligation level in the Swedish Colorectal Cancer Registry. The demonstrated agreement between the registry and postoperative CT-angiography was moderate to good. This discrepancy impacts registry-based research using IMA ligation data and may ultimately influence surgical practice. TRIAL REGISTRATION: Clinical Trials identifier NCT03875612.

Development and validation of an OECD reproductive toxicity test guideline with the mudsnail Potamopyrgus antipodarum (Mollusca, Gastropoda).

Mollusks are known to be uniquely sensitive to a number of reproductive toxicants including some vertebrate endocrine disrupting chemicals. However, they have widely been ignored in environmental risk assessment procedures for chemicals. This study describes the validation of the Potamopyrgus antipodarum reproduction test within the OECD Conceptual Framework for Endocrine Disrupters Testing and Assessment. The number of embryos in the brood pouch and adult mortality serve as main endpoints. The experiments are conducted as static systems in beakers filled with artificial medium, which is aerated trough glass pipettes. The test chemical is dispersed into the medium, and adult snails are subsequently introduced into the beakers. After 28 days the reproductive success is determined by opening the brood pouch and embryo counting. This study presents the results of two validation studies of the reproduction test with eleven laboratories and the chemicals tributyltin (TBT) with nominal concentrations ranging from 10 to 1000 ng TBT-Sn/L and cadmium with concentrations from 1.56 to 25 µg/L. The test design could be implemented by all laboratories resulting in comparable effect concentrations for the endpoint number of embryos in the brood pouch. After TBT exposure mean EC10, EC50, NOEC and LOEC were 35.6, 127, 39.2 and 75.7 ng Sn/L, respectively. Mean effect concentrations in cadmium exposed snails were, respectively, 6.53, 14.2, 6.45 and 12.6 µg/L. The effect concentrations are in good accordance with already published data. Both validation studies show that the reproduction test with P. antipodarum is a well-suited tool to assess reproductive effects of chemicals.

Validation of the OECD reproduction test guideline with the New Zealand mudsnail Potamopyrgus antipodarum using trenbolone and prochloraz.

The Organisation for Economic Cooperation and Development (OECD) provides several standard test methods for the environmental hazard assessment of chemicals, mainly based on primary producers, arthropods, and fish. In April 2016, two new test guidelines with two mollusc species representing different reproductive strategies were approved by OECD member countries. One test guideline describes a 28-day reproduction test with the parthenogenetic New Zealand mudsnail Potamopyrgus antipodarum. The main endpoint of the test is reproduction, reflected by the embryo number in the brood pouch per female. The development of a new OECD test guideline involves several phases including inter-laboratory validation studies to demonstrate the robustness of the proposed test design and the reproducibility of the test results. Therefore, a ring test of the reproduction test with P. antipodarum was conducted including eight laboratories with the test substances trenbolone and prochloraz and results are presented here. Most laboratories could meet test validity criteria, thus demonstrating the robustness of the proposed test protocol. Trenbolone did not have an effect on the reproduction of the snails at the tested concentration range (nominal: 10-1000 ng/L). For prochloraz, laboratories produced similar EC10 and NOEC values, showing the inter-laboratory reproducibility of results. The average EC10 and NOEC values for reproduction (with coefficient of variation) were 26.2 µg/L (61.7%) and 29.7 µg/L (32.9%), respectively. This ring test shows that the mudsnail reproduction test is a well-suited tool for use in the chronic aquatic hazard and risk assessment of chemicals.

Ecotoxicological hazard and risk assessment of endocrine active substances.

This collection of papers provides state-of-the-art science on a complex topic that has been challenging for scientists and regulators for a long time. The papers emanated from the Society of Environmental Toxicology and Chemistry (SETAC) Pellston Workshop® Environmental Hazard and Risk Assessment Approaches for Endocrine-Active Substances (EHRA). Forty-eight international experts met in early February 2016 to discuss whether the environmental risks posed by endocrine-disrupting substances (EDS) can be reliably assessed. The primary conclusion of the workshop was that if data on environmental exposure, effects on sensitive species and life-stages, delayed effects, and effects at low concentrations are robust, initiating environmental risk assessment of EDS is scientifically sound and reliable. Integr Environ Assess Manag 2017;13:264-266. © 2016 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals, Inc. on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

A comparison of two methods for the assessment of stress axis activity in wild fish in relation to wastewater effluent exposure.

Riverine fish are particularly vulnerable to chemical exposure - rivers receive chemicals of anthropogenic origin from a variety of sources, one of the most significant being the chemically complex effluents discharged by wastewater treatment works (WWTWs). The extent to which non-reproductive components of the endocrine system in fish may be vulnerable to interference by contaminants associated with WWTW effluent is not well understood, but a significant body of evidence does suggest that contaminants present in the aquatic environment may interfere with the normal function of the neuroendocrine stress axis in fish. Field investigations of stress axis function in free-living populations of fish by measurement of hormone concentrations in blood can be confounded by the remoteness of sampling locations and the size of target species. Two methods for assessing stress axis reactivity in situations where blood samples are unavailable were compared in three-spined sticklebacks in relation to their exposure to WWTWs effluent. Sticklebacks were sampled in two successive years at fifteen sites in north-west England impacted by WWTW effluent and the response of each fish to the combined stressor of capture and a brief period of confinement was evaluated using both whole-body immunoreactive cortisol concentrations (WBIC) and the rate of release of cortisol to water (CRTW). A positive relationship between the magnitude of stress-induced CRTW in sticklebacks of both sexes and WWTW effluent concentration at site of capture was observed in both years. However, the relationship between stress-induced WBIC and WWTW effluent concentration was not consistent. These results suggest that components of WWTW effluent can modulate the magnitude of the neuroendocrine stress response in sticklebacks, and by inference in other fish species, but they raise questions about the measurement and interpretation of stress axis responses in fish via endpoints other than blood hormone concentrations. Possible factors underlying the disparity between the CRTW and WBIC results are discussed.

[Potential Use of Healthcare Professions by Privately Insured Considering Complementary Medical Benefits]. / Potenzielle Inanspruchnahme von Gesundheitsprofessionen durch privat Versicherte unter Berücksichtigung komplementärmedizinischer Versorgungsleistungen.

BACKGOUND: Patient preferences are becoming more and more important in healthcare and research. The aim of this study was to gain information about potential consultation of health professionals among a population of clients of a private insurer, considering complementary health care services of the insurer. METHODS: Based on 7 hypothetical afflictions (pain in chest, allergy, digestive complaints, depressive mood, knee swelling, reducing addictive substance, child with febrile infect) the surveyed were asked to indicate who they would turn to in the first and second place. The options were: a general practitioner, a conventionally-oriented specialist, a complementary-oriented specialist, an alternative practitioner, a pharmacist, and others. RESULTS: 1,960 insurants (74.1% male; 62.4 ± 10.2 years) completed the questionnaire. In all potential afflictions the surveyed would prefer to consult a general practitioner in the first place, followed by a specialist. Only in case of allergy (12.5%) and depression (11.8%) or reduction of addictive substances (18.6%) they would also consider a complementary-oriented specialist as first choice. In case of depressive mood, allergy, digestive complaints, and angina pectoris the compliance was high, with Kappa >0.5. Moreover, a sensitivity analysis regarding gender and education showed a markedly higher compliance when the population was homogenized. DISCUSSION: Irrespective of the affliction, for the majority of the surveyed the general practitioner and specialist seem to be the first choice when it comes to health problems. Complementary-oriented specialists seem to be relevant only in specific disorders.

Development and validation of an OECD reproductive toxicity test guideline with the pond snail Lymnaea stagnalis (Mollusca, Gastropoda).

The OECD test guideline development program has been extended in 2011 to establish a partial life-cycle protocol for assessing the reproductive toxicity of chemicals to several mollusk species, including the great pond snail Lymnaea stagnalis. In this paper, we summarize the standard draft protocol for a reproduction test with this species, and present inter-comparison results obtained in a 56-day prevalidation ring-test using this protocol. Seven European laboratories performed semi-static tests with cultured snails of the strain Renilys® exposed to nominal concentrations of cadmium chloride (from 53 to 608µgCdL(-1)). Cd concentrations in test solutions were analytically determined to confirm accuracy in the metal exposure concentrations in all laboratories. Physico-chemical and biological validity criteria (namely dissolved oxygen content >60% ASV, water temperature 20±1°C, control snail survival >80% and control snail fecundity >8 egg-masses per snail over the test period) were met in all laboratories which consistently demonstrated the reproductive toxicity of Cd in snails using the proposed draft protocol. Effect concentrations for fecundity after 56days were reproducible between laboratories (68

[Complementary medicine and scientific pluralism--from governmental research funding to the dialogue forum of pluralism in medicine]. / Komplementärmedizin und Wissenschaftspluralismus--von der staatlichen Forschungsförderung zum Dialogforum Pluralismus in der Medizin.

Medicine is based on a pluralism of different ways of thinking and practical approaches. Given this assumption, the history and experiences of the 2 German governmental research funding programs 'Unconventional Methods of Cancer' (UMK) and 'Unconventional Medicine Directions' (UMR) are described from the perspective of the project supporter of 2 working groups that were based at the University of Witten/Herdecke, Germany, on behalf of the federal government. The results of a nationwide inventory analysis conducted under my direction in the years 1989­1992 showed a distinct lack of human and infrastructural resources for competitive research for complementary medicine at that time. The field of complementary medicine was found to be very heterogeneous and was divided into procedures without any visible research interest, but also contained approaches nourishing mainstream medicine by its different paradigm. The representatives of complementary medicine were and still are recognizably interested in evaluative, empirical research. The following contains our funding recommendations made for the relevant ministries, the advertised funding issues, and the research activities carried out. Although this governmental research funding was limited, a signal function can be awarded, retrospectively. For the subsequent period, there has been a significant improvement in infrastructural, staff, and research conditions. This development led to a significant increase in the level of quality and the acceptability of research results. As a result of an increased willingness for cooperations, the foundations, concerns, and activities of the 'dialogue forum pluralism in medicine' set up in 2000 are presented and compared with the situation at the time of research funding by government. 'Integrative Medicine' is currently being favored and welcomed as a sign of better mutual acceptance. Nevertheless, complementary medicine is still seen as being creative, enriching medical and health care, improving the patient-centeredness, and thus as an educational (unrest) element (of agitation).

Multi-criteria decision analysis of test endpoints for detecting the effects of endocrine active substances in fish full life cycle tests.

Fish full life cycle (FFLC) tests are increasingly required in the ecotoxicological assessment of endocrine active substances. However, FFLC tests have not been internationally standardized or validated, and it is currently unclear how such tests should best be designed to provide statistically sound and ecologically relevant results. This study describes how the technique of multi-criteria decision analysis (MCDA) was used to elicit the views of fish ecologists, aquatic ecotoxicologists and statisticians on optimal experimental designs for assessing the effects of endocrine active chemicals on fish. In MCDA qualitative criteria (that can be valued, but not quantified) and quantitative criteria can be used in a structured decision-making process. The aim of the present application of MCDA is to present a logical means of collating both data and expert opinions on the best way to focus FFLC tests on endocrine active substances. The analyses are presented to demonstrate how MCDA can be used in this context. Each of 3 workgroups focused on 1 of 3 species: fathead minnow (Pimephales promelas), Japanese medaka (Oryzias latipes), and zebrafish (Danio rerio). Test endpoints (e.g., fecundity, growth, gonadal histopathology) were scored for each species for various desirable features such as statistical power and ecological relevance, with the importance of these features determined by assigning weights to them, using a swing weighting procedure. The endpoint F1 fertilization success consistently emerged as a preferred option for all species. In addition, some endpoints scored highly in particular species, such as development of secondary sexual characteristics (fathead minnow) and sex ratio (zebrafish). Other endpoints such as hatching success ranked relatively highly and should be considered as useful endpoints to measure in tests with any of the fish species. MCDA also indicated relatively less preferred endpoints in fish life cycle tests. For example, intensive histopathology consistently ranked low, as did measurement of diagnostic biomarkers, such as vitellogenin, most likely due to the high costs of these methods or their limited ecological relevance. Life cycle tests typically do not focus on identifying toxic modes and/or mechanisms of action, but rather, single chemical concentration-response relationships for endpoints (e.g., survival, growth, reproduction) that can be translated into evaluation of risk. It is, therefore, likely to be an inefficient use of limited resources to measure these mechanism-specific endpoints in life cycle tests, unless the value of such endpoints for answering particular questions justifies their integration in specific case studies.

An assessment of endocrine disruption in mollusks and the potential for developing internationally standardized mollusk life cycle test guidelines.

This paper summarizes what is known about the endocrine systems of mollusks and how they can be disrupted by exogenous substances. It then examines the various possibilities for using mollusk-based toxicity tests to detect and assess the environmental risks of endocrine-disrupting chemicals (EDCs). It is concluded that there are no internationally standardized tests with mollusks available at present that are suitable for assessing the risks of long-term exposure to EDCs but that several published methods show potential. At the present state of knowledge, the most promising mollusk species for use in partial life cycle testing is probably the fresh- and brackish-water mesogastropod, Potamopyrgus antipodarum, which is known to be responsive to both direct and indirect androgens and to estrogens (and their mimics). Less experience of full life cycle testing exists with mollusks, but the freshwater pulmonate gastropod Lymnaea stagnalis at present offers the best possibility for a practical procedure. In both cases, there is a need for substantial test optimization and validation before these procedures could form the basis of international guidelines.

Implications of research on endocrine disruption for the environmental risk assessment, regulation and monitoring of chemicals in the European Union.

We assess the implications which research on endocrine disrupting chemicals (EDCs) has for the regulation of synthetic substances and for the protection of the environment, particularly under the forthcoming European Union (EU) REACH legislation. EDCs present regulatory problems inter alia because they can act additively at concentrations which are individually harmless, and they may have non-classical dose (concentration)-response relationships at low exposure levels. Furthermore, current in vivo testing routines were not specifically designed to assess the endocrine disrupting properties of chemicals, whilst in silico and in vitro methods have only limited applicability and availability for this purpose. We need to ensure that the assessment approaches specified in the draft REACH legislation and Technical Guidance are able to evaluate EDCs efficiently. However, it must also be recognised that environmental monitoring procedures in Europe will need to be improved to detect EDCs that have evaded identification, and where appropriate, control, under REACH.

Use of complementary medicine in Switzerland.

OBJECTIVE: Within the framework of the Swiss governmental Program of Evaluation of Complementary Medicine (PEK) we assessed the prevalence, use, perceived effectiveness and appreciation of complementary medicine (CAM) in Switzerland, according to published surveys. MATERIALS AND METHODS: Search was performed through electronic databases, by hand-searching and by contacting experts at universities, hospitals, health insurances, patient organizations and pharmaceutical companies. RESULTS: Surveys were carried out among the general population (40%), physicians (20%), hospitalized patients (30%) and obstetric institutions (5%). The number of publications increased strongly between 1981 and 2004. The mean +/- SD prevalence (use) of CAM is 49 +/- 22% and varies depending on the survey's topic and the population group interviewed. The acceptance, appreciation or demand for CAM among individuals specifically interviewed on CAM is 91 +/- 6%. When asked about favored general improvements in healthcare, 6.5% of the individuals spontaneously mentioned CAM. CAM therapies are considered to be effective by the majority of CAM users and by about 40% of cancer patients using CAM. Approximately 50% of the population stated a preference for hospitals that also provide CAM. 85% of the population wishes the costs for CAM to be covered by the basic health insurance. CONCLUSION: Approximately half of the Swiss population has used CAM. CAM treatment is considered to be effective by the majority of CAM users. About 50% of the population would prefer hospitals that also provide CAM therapies and the majority of the population wishes the cost for CAM therapies to be covered by basic health insurance.

Effectiveness, safety and cost-effectiveness of homeopathy in general practice - summarized health technology assessment.

INTRODUCTION: The Health Technology Assessment report on effectiveness, cost-effectiveness and appropriateness of homeopathy was compiled on behalf of the Swiss Federal Office for Public Health (BAG) within the framework of the 'Program of Evaluation of Complementary Medicine (PEK)'. MATERIALS AND METHODS: Databases accessible by Internet were systematically searched, complemented by manual search and contacts with experts, and evaluated according to internal and external validity criteria. RESULTS: Many high-quality investigations of pre-clinical basic research proved homeopathic high-potencies inducing regulative and specific changes in cells or living organisms. 20 of 22 systematic reviews detected at least a trend in favor of homeopathy. In our estimation 5 studies yielded results indicating clear evidence for homeopathic therapy. The evaluation of 29 studies in the domain 'Upper Respiratory Tract Infections/Allergic Reactions' showed a positive overall result in favor of homeopathy. 6 out of 7 controlled studies were at least equivalent to conventional medical interventions. 8 out of 16 placebo-controlled studies were significant in favor of homeopathy. Swiss regulations grant a high degree of safety due to product and training requirements for homeopathic physicians. Applied properly, classical homeopathy has few side-effects and the use of high-potencies is free of toxic effects. A general health-economic statement about homeopathy cannot be made from the available data. CONCLUSION: Taking internal and external validity criteria into account, effectiveness of homeopathy can be supported by clinical evidence and professional and adequate application be regarded as safe. Reliable statements of cost-effectiveness are not available at the moment. External and model validity will have to be taken more strongly into consideration in future studies.

Traditional Chinese medicine (phytotherapy): Health Technology Assessment report - selected aspects.

OBJECTIVE: A summary of main aspects from a Health Technology Assessment report on Traditional Chinese Medicine (TCM) in Switzerland concerning effectiveness and safety is given. MATERIALS AND METHODS: Literature search was performed through 13 databases, by scanning reference lists of articles and by contacting experts. Assessed were quality of documentation, internal and external validity. RESULTS: Effectiveness: 43 articles concerning 'gastrointestinal tract and liver' were assessed. The studies covering 7,436 patients were undertaken in China (35), Japan (3), USA (2) and Australia (3); 33/43 being controlled studies. 34/40 show significantly better results in the TCM-treated group. A comparison of studies on results of treatment based on a diagnosis according to TCM criteria and studies on results of treatment according to Western diagnosis shows that treatment based on TCM diagnosis improves the result. The comparison of treatment by individual medication and standard medication showed a trend in favor of individual medication. SAFETY: TCM training and practice for physicians in Switzerland are officially regulated. Side effects occur, but no severe effects have been registered up to now in Switzerland. TCM medicinals are imported; admission regulations are being installed. Problems due to production abroad, Internet trade, self-medication or admixtures are possible. CONCLUSION: The evaluation of the literature search provides evidence for a basic clinical effectiveness of TCM therapy. Severe side effects were not observed in Switzerland. Regulations for trading and use of medicinals prevent treatment risks. Further clinical studies in a Western context are required.

Complementary and alternative medicine costs - a systematic literature review.

OBJECTIVE: The aim of this literature review, performed within the framework of the Swiss governmental Program of Evaluation of Complementary Medicine (PEK), was to investigate costs of complementary and alternative medicine (CAM). MATERIALS AND METHODS: A systematic literature search was conducted in 11 electronic databases. All retrieved titles and reference lists were also hand-searched. RESULTS: 38 publications were found: 23 on CAM of various definitions (medical and non-medical practitioners, over-the-counter products), 13 on homeopathy, 2 on phytotherapy. Studies investigated different kinds of costs (direct or indirect) and used different methods (prospective or retrospective questionnaires, data analyses, cost-effectiveness models). Most studies report 'out of pocket' costs, because CAM is usually not covered by health insurance. Costs per CAM-treatment / patient / month were AUD 7-66, CAD 250 and GBP 13.62 +/- 1.61. Costs per treatment were EUR 205 (range: 15-1,278), USD 414 +/- 269 and USD 1,127. In two analyses phytotherapy proved to be cost-effective. One study revealed a reduction of 1.5 days of absenteeism from work in the CAM group compared to conventionally treated patients. Another study, performed by a health insurance company reported a slight increase in direct costs for CAM. Costs for CAM covered by insurance companies amounted to approximately 0.2-0.5% of the total healthcare budget (Switzerland, 2003). Publications had several limitations, e.g. efficacy of therapies was rarely reported. As compared to conventional patients, CAM patients tend to cause lower costs. CONCLUSION: Results suggest lower costs for CAM than for conventional patients, but the limited methodological quality lowers the significance of the available data. Further well-designed studies and models are required.

An assessment of in vitro androgenic activity and the identification of environmental androgens in United Kingdom estuaries.

Environmental androgens are a group of compounds that to date have received very little attention. In this study, a yeast-based androgen screen (YAS) was used to determine the level of in vitro androgenic activity in seven United Kingdom estuaries. Surface water, sediment pore water, and sediment particulate material solvent extracts collected from Southampton Water, the Thames, Mersey, Tees, Tyne, Clyde, and Forth were tested for in vitro androgenic activity. Eleven of the 41 surface water samples collected displayed androgenic activity >2 ng dihydrotestosterone (DHT) equivalents/L (3-9 ng DHT/L), while eight of the 39 sediment pore waters collected showed activity >45 ng DHT/L (51-187 ng DHT/L). High levels of androgenic activity were determined in the solvent extracts of sediments, with 10 of 39 samples exhibiting a level of androgenic activity >454 ng DHT/kg (1,020-15,300 ng DHT/kg). In vitro YAS testing of five selected sewage treatment works (STW) effluents entering these estuaries showed that measurable levels (34-635 ng DHT/L) of androgenic activity were observed in those receiving only primary treatment (Howdon STW and Irvine Valley Sewer) at the time of the survey. A toxicity identification evaluation (TIE) study of Irvine Valley Sewer effluent using the YAS assay was used to identify the natural steroids/steroid metabolites dehydrotestosterone, androstenedione, androstanedione, 5beta-androstane-3alpha,11beta-diol-17-one, androsterone, and epi-androsterone as responsible for 99% of the in vitro activity determined in the effluent.