Fracture liaison services in Ireland-how do we compare to international standards?

In this first na tional survey of public hospitals in The Republic of Ireland, we found fracture liaison services (FLS) to be heterogeneous, limited in many cases and poorly supported. A national strategy is urgently needed to support the implementation and operation of an FLS, and thus help reduce the burden of fragility fractures for patients and the healthcare system. INTRODUCTION: Fragility/low-trauma fractures are a global concern, whose incidence is rising as the population ages. Many are preventable, and people with a prior fragility fracture are at particularly high risk of further fractures. This patient group is the target of the International Osteoporosis Foundation (IOF) Capture the Fracture campaign, advocating global adoption of fracture liaison services (FLS), with the aim of preventing secondary fragility fractures. We wished to determine the current availability and standards of an FLS in Ireland, ahead of the launch of a National FLS database. METHODS: We devised a questionnaire encompassing the thirteen IOF standards for an FLS and asked all 16 public hospitals with an orthopaedic trauma unit in Ireland, to complete for the calendar year 2019 in patients aged ≥ 50 years. RESULTS: All sites returned the questionnaire, i.e. 100% response rate. Nine hospitals stated that they have an FLS, additionally one non-trauma hospital running a FLS responded, and were included. These 10 FLS had identified and managed 3444 non-hip fractures in the year 2019. This figure represents 19% of the expected non-hip fragility fracture numbers occurring annually in Ireland. Implementation of the IOF standards was very variable. All sites reported being inadequately resourced to provide a high-quality service necessary to be effective. CONCLUSION: The existence and functioning of FLS in Ireland are heterogeneous and suboptimal. A national policy to support the implementation of this programme in line with international standards of patient care is urgently needed.

Consumption of freshwater fish: A variable but significant risk factor for PFOS exposure.

PFOS, PFOA, PFNA and PFHxS are the PFAS substances that currently contribute most to human exposure, and in 2020 the European Food Safety Authority (EFSA) presented a draft opinion on a tolerable intake of 8 ng/kg/week for the sum of these four substances (equaling 0.42 µg/kg if expressed as an annual dose). Diet is usually the dominating exposure pathway, and in particular the intake of PFOS has been shown to be strongly related to the consumption of fish and seafood. Those who eat freshwater fish may be especially at risk since freshwater and its biota typically display higher PFOS concentrations than marine systems. In this study, we estimated the range in PFOS intake among average Swedish "normal" and "high" consumers of freshwater fish. By average we mean persons of average weight who eat average-sized portions. The "normal consumers" were assumed to eat freshwater fish 3 times per year, and the "high consumers" once a week. Under these assumptions, the yearly tolerable intake for "normal" and "high" consumers is reached when the PFOS concentrations in fish equals 59 and 3.4 µg per kg fish meat. For this study, PFOS concentrations in the muscle tissue of edible-sized perch, pike and pikeperch were retrieved from three different Swedish datasets, covering both rural and urban regions and a total of 78 different inland waters. Mean PFOS concentrations in fish from these sites varied from 0.3 to 750 µg/kg. From the available data, the annual min-max dietary PFOS intake for male "normal consumers" was found to be in the range 0.0021-5.4 µg/kg/yr for the evaluated scenarios, with median values of 0.02-0.16 µg/kg/yr. For male "high consumers", the total intake range was estimated to be 0.04-93 µg/kg/yr, with median values being 0.27-1.6 µg/kg/yr. For women, the exposure estimates were slightly lower, about 79% of the exposure in men. Despite highly variable PFOS concentrations in fish from different sites, we conclude that the three most commonly consumed freshwater species in Sweden constitute an important source for the total annual intake even for people who eat this kind of fish only a few times per year. The analyses of PFOA, PFNA and PFHxS showed values which were all below detection limit, and their contribution to the total PFAS intake via freshwater fish consumption is negligible in comparison to PFOS.

Cardiovascular and cancer mortality in relation to dietary polychlorinated biphenyls and marine polyunsaturated fatty acids: a nutritional-toxicological aspect of fish consumption.

BACKGROUND: Co-exposure to environmental contaminants present in fish could mitigate the beneficial effects of fish consumption and possibly explain the lack of association observed for mortality in some geographical regions. OBJECTIVE: To assess the independent associations of dietary exposure to polychlorinated biphenyls (PCBs) and long-chain omega-3 fish fatty acids intake with cardiovascular and cancer mortality. METHODS: We used the prospective population-based Swedish Mammography Cohort and the Cohort of Swedish Men comprising 32 952 women and 36 545 men, free from cancer, cardiovascular disease and diabetes at baseline in 1998. Validated estimates of dietary PCBs and long-chain omega-3 fish fatty acids [i.e. eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)] intake were obtained via a food frequency questionnaire at baseline. Information on death was ascertained through register linkage. RESULTS: During a mean follow-up of 15.5 years, we ascertained 16 776 deaths. We observed for cardiovascular mortality, comparing extreme quintiles in multivariable models mutually adjusted for PCBs and EPA-DHA, dose-dependent associations for dietary PCB exposure, hazard ratio (HR) 1.31 (CI 95%: 1.08 to 1.57; P-trend 0.005) and for dietary EPA-DHA intake, HR 0.79 (CI 95%: 0.66 to 0.95; P-trend 0.041). For cancer mortality, no clear associations were discerned. CONCLUSION: The beneficial effect of fish consumption on the cardiovascular system seems compromised by co-exposure to PCBs - one likely explanation for the inconsistent associations observed between fish consumption and mortality.

A Review of the Parenteral Nutrition Supply Service in an Irish Neonatal Unit

Background Neonatal Intensive Care (NICU) patients have individual nutritional requirements often requiring Patient Specific Parenteral Nutrition (PSPN). From October 2015, the national PSPN compounding service availability changed from 7 days per week service to 5 days per week (i.e. no weekend and limited bank holiday ordering available). The aim of this study was to examine the introduction of a 5 day only PSPN supply on neonatal patient parenteral nutrition availability in a tertiary NICU. Methods We performed a prospective assessment of the provision of a 5 day rather than 7 day ordering of PSPN over a one month period (June 2017). Results Fifteen neonatal patients received a cumulative 89 days of PN during June 2017. 10 (66%) patients received PSPN during this time period. There was same day availability of PSPN in 62 of 89 days of PN (69%). Conclusion Thorough education and training will help prescribers to make appropriate PSPN ordering decisions. Improvements to available stock bags may reduce the amount of PSPN that is required but a 7 day PSPN ordering service would improve efficient provision of clinically indicated PSPN to premature infants in NICU in Ireland.

Dietary exposure to polychlorinated biphenyls is associated with increased risk of stroke in women.

OBJECTIVE: The potentially beneficial effects of fish consumption on stroke may be modified by major food contaminants in fish. Polychlorinated biphenyls (PCBs) in particular are proposed to play a role in the aetiology of stroke. The aim of this study was to assess the association between dietary PCB exposure and stroke risk with the intake of long-chain omega-3 fish fatty acids and fish consumption. DESIGN: The prospective population-based Swedish Mammography Cohort was examined. It was comprised of 34,591 women free of cardiovascular diseases and cancer at baseline in 1997 and followed up for 12 years. Validated estimates of dietary PCB exposure were obtained via a food frequency questionnaire at baseline. Incident cases of stroke were ascertained through register linkage. RESULTS: During 12 years of follow-up (397,309 person-years), there were 2015 incident cases of total stroke (1532 ischaemic strokes, 216 intracerebral haemorrhages, 94 subarachnoid haemorrhages and 173 unspecified strokes). Multivariable-adjusted relative risks (RR), controlled for known stroke risk factors and fish consumption, were 1.67 [95% confidence interval (CI), 1.29-2.17] for total stroke, 1.61 (95% CI, 1.19-2.17) for ischaemic stroke and 2.80 (95% CI, 1.42-5.55) for haemorrhagic stroke for women in the highest quartile of dietary PCB exposure (median 288 ng day(-1) ) compared with women in the lowest quartile (median 101 ng day(-1) ). CONCLUSION: Dietary exposure to PCBs was associated with an increased stroke risk in women, especially haemorrhagic stroke. The results provide important information regarding the risk-benefit analysis of fish consumption, particularly for cerebrovascular disease prevention.

Leveraging physiological data from literature into a pharmacokinetic model to support informative clinical study design in pregnant women.

PURPOSE: Physiological changes during pregnancy can effect pharmacokinetic (PK) parameters, which may lead to altered dose requirements. We aimed to leverage literature-based physiological changes during pregnancy into a PK model and compare its performance to a published reference model in pregnant women and to use the literature-based model to determine informative PK sampling times for a clinical study that aims to quantify the PK of enoxaparin throughout pregnancy. METHODS: Changes in total body water (BW) and creatinine clearance (CRCL) during pregnancy were described using regression models. BW and CRCL were linked to a PK model of enoxaparin in non-pregnant women. Performance of the literature-based PK model was compared to a previously published empirical reference model. D-optimal sampling times were determined and evaluated for literature-based and reference models. RESULTS: The literature-based model adequately predicted anti-Xa plasma concentrations when compared to reference model predictions. An informative sampling design was successfully developed, with parameters expected with good precision (RSE < 36.4%). CONCLUSION: A literature-based model describing enoxaparin PK during pregnancy was developed and evaluated. The modelling framework could be used to support development of informative designs in pregnancy when prior models are unavailable.

Investigation of hypomagnesaemia prevalence and underlying aetiology in a hospitalised cohort of dogs with ionised hypocalcaemia.

OBJECTIVES: Calcium is the most abundant mineral in the body and plays a critical role in a wide range of physiological processes. Low concentrations of ionised calcium, the most metabolically available form of calcium, have been linked to an increased risk of adverse clinical outcomes in dogs. Magnesium plays an important role in parathyroid hormone function. The objective of this study was to define the prevalence and aetiology of hypomagnesaemia in a hospitalised cohort of dogs with ionised hypocalcaemia (IHC). METHODS: A total magnesium reference interval was established using serum biochemistry results from 346 clinically healthy dogs. The clinical records of dogs with IHC were reviewed, and concurrent serum magnesium concentrations were recorded alongside clinical signs and underlying aetiology. The prevalence, clinical presentation and aetiology of hypomagnesaemia were examined in the IHC population. RESULTS: Two hundred and ninety-five IHC dogs were identified. Hypomagnesaemia was identified in 22%. Total magnesium concentration was significantly higher in dogs with renal disease. The most common cause of concurrent hypomagnesaemia and IHC was gastrointestinal diseases. CONCLUSION: Low concentrations of serum magnesium occur in approximately one fifth of all dogs with IHC. Further studies are required to clarify the link between magnesium status, IHC and clinical outcome.

Cutaneous Vasculopathy and Pulmonary Thromboembolism in an Unstable Diabetic Cat.

A 6-year-old, male-neutered, domestic short-haired cat was referred for further management of a 3-month history of uncontrolled diabetes mellitus. The cat visited the hospital on 3 occasions during a 3-week time period. Hyperglycemia was documented at all visits. The cat initially presented with evidence of hypovolemia, cranial abdominal pain, and dehydration. Moderate hyperglycemia, mild ketonemia, and severe hypokalemia were documented. A 3 × 2 cm skin lesion with associated alopecia and erythema was first noticed at a routine follow-up examination (visit 2) 1 week later. A diagnosis of diabetic ketoacidosis was made 6 days later. The previously identified skin lesion now measured 6 × 2.5 cm. Two episodes of respiratory distress were identified at this visit, with no evidence of cardiac or pulmonary pathology. The cat developed a moderate anemia (packed cell volume 16 %, total solids 7.9 g/dL) on the fifth day of hospitalization. Fluid therapy, electrolyte supplementation, regular insulin, anti-emetic, and analgesia medications were administered during visits 1 and 3. Due to development of anemia, suspected pulmonary thromboembolism events and progression of skin lesions, euthanasia was elected. A diagnosis of cutaneous vasculopathy with secondary ischemic necrosis was made postmortem and pulmonary thromboembolism was confirmed. To the authors' knowledge, this is the first report of cutaneous vasculopathy and pulmonary thromboembolism in a cat with confirmed diabetes mellitus, warranting further research to assess if hypercoagulability is common in this patient population, as routine thromboprophylaxis and anticoagulation may be potentially indicated.

Aerosol exposure to the angola strain of marburg virus causes lethal viral hemorrhagic Fever in cynomolgus macaques.

Cynomolgus macaques were exposed to the Angola strain of Lake Victoria Marburg virus (MARV) by aerosol to examine disease course and lethality. Macaques became febrile 4 to 7 days postexposure; the peak febrile response was delayed 1 to 2 days in animals that received a lower dose; viremia coincided with the onset of fever. All 6 macaques succumbed to the infection, with the 3 macaques in the low-dose group becoming moribund on day 9, a day later than the macaques in the high-dose group. Gross pathologic lesions included maculopapular cutaneous rash; pulmonary congestion and edema; pericardial effusion; enlarged, congested, and/or hemorrhagic lymphoid tissues; enlarged friable fatty liver; and pyloric and duodenal congestion and/or hemorrhage. Fibrinous interstitial pneumonia was the most consistent pulmonary change. Lymphocytolysis and lymphoid depletion, as confirmed by TUNEL (terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling), were observed in the mediastinal lymph nodes and spleen. MARV antigen was detected in the lungs, mediastinal lymph nodes, spleen, and liver of all animals examined. In infected macaques, nuclear expression of interleukin-33 was lost in pulmonary arteriolar and mediastinal lymph node high endothelial venule endothelial cells; interleukin-33-positive fibroblastic reticular cells in the mediastinal lymph node were consistently negative for MARV antigen. These macaques exhibited a number of features similar to those of human filovirus infections; as such, this model of aerosolized MARV-Angola might be useful in developing medical countermeasures under the Animal Rule.

Encouraging the move towards predictive population models for the obese using propofol as a motivating example.

PURPOSE: To develop a predictive pharmacokinetic model for propofol that could inform development of a dosing strategy for the obese population. METHODS: A prior model that included a nonlinear relationship between clearance (CL) and Total Body Weight (TBW) was re-parameterized with a linear relationship between CL and Lean Body Weight (LBW). The predictive performance of both models was compared and the LBW model used to explore propofol exposure from normal to obese patients. A dosing strategy was evaluated that normalized awakening time across a range of patient weights. RESULTS: The predictive performance of the LBW model was similar to the nonlinear TBW model for normal weighted subjects. Simulations in 70-160 kg subjects indicated that dosing linearly on TBW (label recommendation), in contrast to LBW, resulted in increased plasma concentrations in the larger weight groups. This result might explain why obese subjects take longer to awaken from anesthesia compared to normal weighted subjects. Dosing by LBW normalized patient awakening times across this weight range. CONCLUSIONS: LBW as a covariate provides a plausible mechanistic explanation for an observed nonlinear increase in drug CL with TBW and may be suitable for developing dosing strategies that are appropriate for use in the obese population.

Obstacles to reduction in infantile developmental dysplasia of the hip.

PURPOSE: Identification of anatomical structures that block -reduction in developmental dysplasia of the hip (DDH) is -important for the management of this challenging condition. Obstacles to reduction seen on arthrogram are well-known. However, despite the increasing use of MRI in the assessment of adequacy of reduction in DDH, the interpretation of MRI patho-anatomy is ill-defined with a lack of relevant literature to guide clinicians. METHOD: This is a retrospective analysis of the MRI of patients with DDH treated by closed reduction over a five-year period (between 2009 and 2014). Neuromuscular and genetic disorders were excluded. Each MRI was analysed by two orthopaedic surgeons and a paediatric musculoskeletal radiologist to identify the ligamentum teres, pulvinar, transverse acetabular ligament (TAL), capsule, labrum and acetabular roof cartilage hypertrophy. Inter- and intraobserver reliability was calculated. The minimum follow-up was 12 months. RESULTS: A total of 29 patients (38 hips) underwent closed reduction for treatment of DDH. Eight hips showed persistent subluxation on post-operative MRI. Only three of these eight hips showed an abnormality on arthrogram. The pulvinar was frequently interpreted as 'abnormal' on MRI. The main obstacles identified on MRI were the ligamentum teres (15.8%), labrum (13.1%) and acetabular roof cartilage hypertrophy (13.2%). The inter-rater reliability was good for TAL, capsule and pulvinar; moderate for ligamentum teres and labrum; and poor for hypertrophied cartilage. CONCLUSION: The labrum, ligamentum teres and acetabular roof cartilage hypertrophy are the most important structures seen on MRI preventing complete reduction of DDH. Focused interpretation of these structures may assist in the management of DDH.

Dietary intake estimations of organohalogen contaminants (dioxins, PCB, PBDE and chlorinated pesticides, e.g. DDT) based on Swedish market basket data.

By use of a Swedish Market basket study from 1999, in which foods were sampled from four regions, the dietary intake of persistent organic pollutants (POPs) was assessed. Based on earlier data, six food groups (fish, meat, dairy products, egg, fats/oils, and pastries; comprising 52 food items) were selected for POP analyses. Homogenates from these six groups were subjected to POP analyses and levels presented on dioxins (PCDD/PCDFs), dioxin-like PCBs, PCB-153, summation operatorPCBs, BDE-47, summation operatorPBDEs, DDE, summation operatorDDTs, HCB, summation operatorHCHs, and summation operatorchlordanes, after adjusting non-quantified levels to 1/2 LOQ. For all compounds, the fish homogenate contained the comparatively highest levels, on a fresh weight basis. Intake calculations based on the six food groups showed that summation operatorPCBs and summation operatorDDTs gave per capita intakes of 615 and 523 ng/day, respectively, that the estimated summation operatorPBDE intake was 51 ng/day and that of dioxins and dioxin-like PCBs was 96 pg WHO-TEQ/day. The estimated mean intakes were below (total-TEQ: 1.3 pg/kgbw/day) or well below (summation operatorDDTs: 8.9 ng/kgbw/day) internationally agreed intake limits (total-TEQ: 2 pg/kgbw/day; summation operatorDDTs: 10,000 ng/kgbw/day). A number of uncertainty factors, including analytical limitations due to low POP levels in food, give reason for caution in the use of the presented intake data. However, the intake estimations of dioxins, summation operatorPCBs and summation operatorPBDEs are well in accordance to calculations of POP intakes in Sweden made by alternate methods.

Five Years Later: An Update on the Status of Collections of Endemic Gulf of Mexico Fishes Put at Risk by the 2010 Oil Spill.

BACKGROUND: The 2010 Gulf of Mexico Oil Spill took place over 180,000 square kilometers during a 12-week period over five years ago; however, this event continues to influence the development and distribution of organisms in and around the region of the disaster. Here we examine fish species that may have been most affected by noting their past distribution in the region of the spill and examining data of known collecting events over the last 10 years (five years prior to the spill, five years post spill). NEW INFORMATION: We found that more than half of the endemic fish species of the Gulf (45 of 77).

Carpal tunnel release using local anaesthetic and a forearm tourniquet.

Carpal tunnel release can be performed under general or local anaesthetic. However, many surgeons believe the upper arm tourniquet is not tolerated by the patient when awake. We use a forearm tourniquet for carpal tunnel decompression under local anaesthesia. The aim of this study is to assess patient tolerance of the technique. Between January 1st 1996 and December 31st 2000, 74 patients had carpal tunnel release performed using local anaesthesia. We sent a postal questionnaire to each, asking the patient to rate different aspects of the procedure. Fifty-eight patients replied (78% response). Forty-four of the respondents (76%) tolerated the tourniquet well, finding it to be 'no problem' or only 'mildly painful'. The same number reported they would prefer to have local anaesthesia again in the event of their requiring a similar operation on their hand. We believe carpal tunnel release using local anaesthetic and a forearm tourniquet is well tolerated by the patient.

Use of the automatic interaction detector method to identify patient characteristics related to methotrexate clearance.

Systemic methotrexate (MTX) clearance was determined in 108 children who received 15 courses of MTX, 1000 mg/m2 iv over 24 hours, as a component of therapy for acute lymphocytic leukemia. The median MTX clearance was used as the representative value for each patient, and these values ranged from 44.7 to 132.1 ml/min/m2 (X = 78.4 ml/min/m2). The automatic interaction detector approach was used to determine the patient characteristics that correlated with MTX clearance. Characteristics examined were sex, age, estimated creatinine clearance, SGPT, and body surface area. The initial splits were based on creatinine clearance, and mean MTX clearances in three subgroups (50 to 100, 100 to 150, and greater than 150 ml/min/m2) were 73.1, 78.3, and 90.5 ml/min/m2, respectively. For patients with the slowest creatinine clearance, abnormal SGPT concentrations (greater than 35 IU/L) were associated with slower MTX clearance (77.6 vs. 67.8 ml/min/m2). In the latter subgroup, boys had faster clearance than girls (77.4 vs. 60.9 ml/min/m2). These results demonstrate that for children with normal serum creatinine concentrations, interpatient variability in MTX clearance can partly be explained by measures of renal and hepatic function, which indicates that the observed variability in MTX clearance is not totally random.

Effects of ketoconazole on methylprednisolone pharmacokinetics and cortisol secretion.

The disposition of methylprednisolone was examined in six normal subjects after the injection of 20 mg iv methylprednisolone sodium succinate. Disposition studies were performed both without and with ketoconazole, 200 mg/day, for 6 days. Ketoconazole increased the methylprednisolone AUC and mean residence time (by 135% and 66%, respectively) and decreased clearance (60%), the terminal phase slope, and the volume of distribution. These findings are typical of macrolide antibiotic alteration of methylprednisolone disposition and consistent with reports of inhibition of drug metabolism by ketoconazole. Methylprednisolone reduced the 24-hour cortisol AUC by 44%, but morning cortisol concentrations returned to normal. Ketoconazole with methylprednisolone further reduced the 24-hour cortisol AUC and suppressed morning cortisol concentrations. Thus ketoconazole inhibits methylprednisolone disposition and extends the adrenal suppression effects of this corticosteroid.

Organochlorines and endometrial cancer risk.

There is concern that persistent environmental pollutants such as dichlorodiphenyltrichloroethane (DDT) and polychlorinated biphenyls (PCBs) increase breast cancer risk, at least partially through estrogenic effects. Because the endometrium is more sensitive to estrogenic stimulation than the breast, such a carcinogenic effect should be more pronounced in the endometrium than the breast. In a population-based case-control study in Sweden, we measured serum concentrations of 10 chlorinated pesticides and 10 PCB congeners in 154 endometrial cancer cases and 205 population controls. Information on potential confounders was obtained by mailed questionnaires. We used logistic regression to calculate odds ratios (ORs) as measures of relative risk. We performed analyses for lipid-adjusted concentrations of each individual substance and after grouping substances according to putative hormonal effects. We found no significant associations of increasing levels of pesticide or PCB exposure with endometrial cancer risk. The multivariate OR was 1.0 (95% confidence interval, 0.6-2.0; P for trend, 0.78) for the highest compared with the lowest quartile of dichlorodiphenyldichloroethylene (DDE), the predominant dichlorodiphenyltrichloroethane metabolite. Corresponding ORs were 1.0 for hexachlorobenzene, 0.9 for beta-hexachlorocyclohexane, 1.4 for oxychlordane, and 1.2 for trans-nonachlor. Analyses of substances grouped by putative hormonal effect also showed no associations with endometrial cancer risk. For all estrogenic compounds, the OR for the highest compared with the lowest quartile was 1.1 (95% confidence interval, 0.6-2.2; P for trend, 0.90). Our data do not support the hypothesis that the organochlorine exposure studied increases the risk for endometrial cancer.

Methyl mercury and inorganic mercury in Swedish pregnant women and in cord blood: influence of fish consumption.

We studied exposure to methyl mercury (MeHg) in Swedish pregnant women (total mercury [T-Hg] in hair) and their fetuses (MeHg in cord blood) in relation to fish intake. The women were recruited at antenatal care clinics in late pregnancy to participate in an exposure study of environmental pollutants. Fish consumption was evaluated using food frequency questionnaires including detailed questions on fish consumption. In addition, we determined inorganic mercury (I-Hg) and selenium (Se) in cord blood. On average, the women consumed fish (all types) 6.7 times/month (range 0-25 times/month) during the year they became pregnant. They reported less consumption of freshwater fish--species that might contain high concentrations of MeHg--during than before pregnancy. T-Hg in maternal hair (median 0.35 mg/kg; range 0.07-1.5 mg/kg) was significantly associated (R2 = 0.53; p < 0.001) with MeHg in cord blood (median 1.3 microg/L; range 0.10-5.7 microg/L). Both hair T-Hg and cord blood MeHg increased with increasing consumption of seafood (r = 0.41; p < 0.001 and r = 0.46; p < 0.001, respectively). Segmental hair analysis revealed that T-Hg closer to the scalp was lower and more closely correlated with MeHg in cord blood than T-Hg levels in segments corresponding to earlier in pregnancy. We found a weak association between Se (median 86 microg/L; range 43-233 microg/L) and MeHg in cord blood (r = 0.26; p = 0.003), but no association with fish consumption. I-Hg in cord blood (median 0.15 microg/L; range 0.03-0.53 microg/L) increased significantly with increasing number of maternal dental amalgam fillings.

Serological diagnosis of HIV infection: practice and performance in western Europe.

Current laboratory practice in testing for HIV antibodies in western Europe was investigated by means of a questionnaire addressed to the 12 EC countries and Finland, Norway, Sweden and Switzerland. Despite inevitable regional differences there was a fair degree of homogeneity in broad laboratory organisation and in the types of tests and confirmatory strategies used. The primary test is always some form of enzyme linked immunosorbent assay (ELISA), though a number of laboratories also use agglutination tests. Confirmation is by an ELISA of a different type, or by Western blot, or both. The size and workload of laboratories covered a wide range. It is suggested that laboratories doing only a small number of tests at infrequent intervals should take extra care in validating their results and should be closely monitored. Twelve of the 16 countries studied have a quality assurance scheme for monitoring laboratory performance. Participation is voluntary but is invaluable even for the largest laboratories. The results suggest that the standard of laboratory diagnosis is reasonably uniform throughout the region, which is not only important for the individual patient but means that epidemiological comparisons of data from different areas have at least a sound technical base.

Identification of clinical isolates of Neisseria gonorrhoeae by a coagglutination test.

Ninety-eight per cent of laboratory isolates of Neisseria gonorrhoeae from a veneral disease clinic gave positive reactions with a gonococcal coagglutination test. The prototype reagent, however, was poor at distinguishing between different species of the genus Neisseria: 75% of strains of Neisseria meningitidis and 40% of other Neisseria species tested gave positive reactions. None of the origanisms other than Neisseria growing on the diagnostic cultures from the clinic gave positive reactions. We therefore suggest that the present reagent is unsuitable for testing isolates from the upper respiratory tract. The technique is simple, rapid, and convenient and with a more specific antibody could be useful. Results of coagglutination reactions of 126 strains of Neisseria grown on serum-containing and serum-free media were very similar and there is no need to use special serum-free media.