Screening patients for unintentional carbon monoxide exposure in the Emergency Department: a cross-sectional multi-centre study.

BACKGROUND: Low-level exposure to carbon monoxide (CO) is a significant health concern but is difficult to diagnose. This main study aim was to establish the prevalence of low-level CO poisoning in Emergency Department (ED) patients. METHODS: A prospective cross-sectional study of patients with symptoms of CO exposure was conducted in four UK EDs between December 2018 and March 2020. Data on symptoms, a CO screening tool and carboxyhaemoglobin were collected. An investigation of participants' homes was undertaken to identify sources of CO exposure. RESULTS: Based on an ED assessment of 4175 participants, the prevalence of suspected CO exposure was 0.62% (95% CI; 0.41-0.91%). CO testing in homes confirmed 1 case of CO presence and 21 probable cases. Normal levels of carboxyhaemoglobin were found in 19 cases of probable exposure and in the confirmed case. CONCLUSION: This study provides evidence that ED patients with symptoms suggestive of CO poisoning but no history of CO exposure are at risk from CO poisoning. The findings suggest components of the CO screening tool may be an indicator of CO exposure over and above elevated COHb. Clinicians should have a high index of suspicion for CO exposure so that this important diagnosis is not missed.

Tumours modulate the systemic vascular response to anti-angiogenic therapy.

Toxicologic evaluation of new drug candidates routinely utilizes healthy animals. In oncology, there remains a limited understanding of the effects of novel test candidates in a diseased host. For vascular modulating agents (VMAs), an increased understanding of preclinical tumour-host interaction, and its potential to exacerbate or alleviate 'off-target' effects of anti-angiogenic administration, could aid in the prediction of adverse clinical outcomes in a defined cancer patient. We have previously reported that the implantation and growth of a range of human- and mouse-derived tumours leads to structural vascular and, potentially, functional signalling changes within host mouse endocrine tissues, indicating possible roles for tumour- and host-derived cytokines/growth factors and the liberation of myeloid-derived suppressor cells in this phenomenon. Here, we further demonstrate that the growth of the Calu-6 xenograft is associated with a resistance to VMA-induced mouse peripheral endocrine vascular rarefaction (toxicity), with potential functional impact, notably with respect to mixed tyrosine kinase inhibition. The pathogenesis of these findings indicates a potential role for both tumour- and host-derived basic fibroblast growth factor (bFGF), with associated upregulation in the intra-tumoural autotaxin-lysophosphatic acid signalling axis.

Tumors modulate fenestrated vascular beds and host endocrine status.

Allograft and xenograft transplantation into a mouse host is frequently utilized to study cancer biology, tumor behavior, and response to treatment. Preclinical studies employing these models often focus solely upon the intra-tumoral effects of a given treatment, without consideration of systemic toxicity or tumor-host interaction, nor whether this latter relationship could modulate the toxicologic response to therapy. Here it is demonstrated that the implantation and growth of a range of human- and mouse-derived cell lines leads to structural vascular and, potentially, functional changes within peripheral endocrine tissues, a process that could conceivably ameliorate the severity of anti-angiogenic-induced fenestrated vessel attenuation. Observations suggest a multifactorial process, which may involve host- and tumor-derived cytokines/growth factors, and the liberation of myeloid-derived suppressor cells. Further investigation revealed a structurally comparable response to the administration of exogenous estrogen. These findings, in addition to providing insight into the development of clinical anti-angiogenic "adaptation," may be of significance within the "cancer-cachexia" and cancer-related anemia syndromes in man.

Automated image analysis of intra-tumoral and peripheral endocrine organ vascular bed regression using 'Fibrelength' as a novel structural biomarker.

The study of vascular modulation has received a great deal of attention in recent years as knowledge has increased around the role of angiogenesis within disease contexts such as cancer. Despite rapidly expanding insights into the molecular processes involved and the concomitant generation of a number of anticancer vascular modulating chemotherapeutics, techniques used in the measurement of structural vascular change have advanced more modestly, particularly with regard to the preclinical quantification of off-target vascular regression within systemic, notably endocrine, blood vessels. Such changes translate into a number of major clinical side effects and there remains a need for improved preclinical screening and analysis. Here we present the generation of a novel structural biomarker, which can be incorporated into a number of contemporary image analysis platforms and used to compare tumour versus systemic host tissue vascularity. By contrasting the measurements obtained, the preclinical efficacy of vascular modulating chemotherapies can be evaluated in light of the predicted therapeutic window. Copyright © 2017 John Wiley & Sons, Ltd.

Preliminary evaluation of military, commercial and novel skin decontamination products against a chemical warfare agent simulant (methyl salicylate).

Rapid decontamination is vital to alleviate adverse health effects following dermal exposure to hazardous materials. There is an abundance of materials and products which can be utilised to remove hazardous materials from the skin. In this study, a total of 15 products were evaluated, 10 of which were commercial or military products and five were novel (molecular imprinted) polymers. The efficacies of these products were evaluated against a 10 µl droplet of (14)C-methyl salicylate applied to the surface of porcine skin mounted on static diffusion cells. The current UK military decontaminant (Fuller's earth) performed well, retaining 83% of the dose over 24 h and served as a benchmark to compare with the other test products. The five most effective test products were Fuller's earth (the current UK military decontaminant), Fast-Act® and three novel polymers [based on itaconic acid, 2-trifluoromethylacrylic acid and N,N-methylenebis(acrylamide)]. Five products (medical moist-free wipes, 5% FloraFree™ solution, normal baby wipes, baby wipes for sensitive skin and Diphotérine™) enhanced the dermal absorption of (14)C-methyl salicylate. Further work is required to establish the performance of the most effective products identified in this study against chemical warfare agents.

The new normal chemical landscape: the future of risk assessment toward optimum consumer safety.

The further optimization of consumer safety through risk assessment of chemicals present in food will require adaptability and flexibility to utilize the accelerating developments in safety science and technology. New Approach Methodologies (NAMs) are gaining traction as a systematic approach to support informed decision making in chemical risk assessment. The vision is to be able to predict risk more accurately, rapidly and efficiently. The opportunity exists now to use these approaches which requires a strategy to translate the science into future regulatory implementation. Here we discuss new insights obtained from three recent workshops on how to translate the science into future regulatory implementation. To assist the UK in this endeavor, the Food Standards Agency (FSA) and the scientific advisory committee on chemical toxicity (COT) have been developing a roadmap. In addition, we discuss how these new insights fit into the bigger picture of the new chemical landscape for better consumer safety and the importance of international harmonization.

Comparative analysis of showering protocols for mass-casualty decontamination.

A well-established provision for mass-casualty decontamination that incorporates the use of mobile showering units has been developed in the UK. The effectiveness of such decontamination procedures will be critical in minimizing or preventing the contamination of emergency responders and hospital infrastructure. The purpose of this study was to evaluate three empirical strategies designed to optimize existing decontamination procedures: (1) instructions in the form of a pictorial aid prior to decontamination; (2) provision of a washcloth within the showering facility; and (3) an extended showering period. The study was a three-factor, between-participants (or "independent") design with 90 volunteers. The three factors each had two levels: use of washcloths (washcloth/no washcloth), washing instructions (instructions/no instructions), and shower cycle duration (three minutes/six minutes). The effectiveness of these strategies was quantified by whole-body fluorescence imaging following application of a red fluorophore to multiple, discrete areas of the skin. All five showering procedures were relatively effective in removing the fluorophore "contaminant", but the use of a cloth (in the absence of instructions) led to a significant ( appox. 20%) improvement in the effectiveness of decontamination over the standard protocol (p <0.05). Current mass-casualty decontamination effectiveness, especially in children, can be optimized by the provision of a washcloth. This simple but effective approach indicates the value of performing controlled volunteer trials for optimizing existing decontamination procedures.

Further studies of the efficacy of military, commercial and novel skin decontaminants against the chemical warfare agents sulphur Mustard, Soman and VX.

BACKGROUND/AIMS: Following an incident involving toxic chemicals, deployment of countermeasures before the arrival of specialised services at the scene may provide a "therapeutic" window in which to mitigate skin absorption. METHODS: Five potential candidates (itaconic acid, N,N'-methylenebisacrylamide, 2-trifluoromethylacrylic acid, fuller's earth and Fast-Act®) previously found effective against a simulant (methyl salicylate) were evaluated against a 10 µL droplet of 14C-sulphur mustard (HD), soman (GD) or VX applied to the surface of porcine skin mounted on static skin diffusion cells. RESULTS: All the decontaminants applied to the skin 5 min post exposure achieved a marked reduction in the amount of 14C contaminant remaining within the skin at 24 h. Itaconic acid significantly (p < .05) reduced the amount of 14C-HD, GD and VX remaining in the skin at 24 h. Additionally, 2-trifluoromethylacrylic acid significantly reduced the amount of 14C-HD, whilst fuller's earth significantly reduced the amounts of 14C-HD and VX recovered within the skin at 24 h. CONCLUSION: All of the products evaluated in this study performed well in reducing the dermal absorption of all the chemical warfare agents tested.

Role of mitochondria in drug-induced cholestatic injury.

Mitochondria have multiple functions in eukaryotic cells and are organized into dynamic tubular networks that continuously undergo changes through coordinated fusion and fission and migration through the cytosol. Mitochondria integrate cell-signaling networks, especially those involving the intracellular messenger Ca(2+), into the regulation of metabolic pathways. Recently, it has become clear that mitochondria are central to the three main cell death pathways, namely necrosis, apoptosis, and autophagic cell death. This article discusses the role of mitochondria in drug-induced cholestatic injury to the liver. The role of mitochondria in the cellular adaptation against the toxic effects of bile acids is discussed also.

Arm elevation and coordinated breathing strategies in patients with COPD.

BACKGROUND: Hyperinflated patients with COPD breathe against an increased elastic load during physical activity. Arm activities are especially demanding. Some pulmonary rehabilitation programs instruct patients to inhale while raising their arms, whereas others recommend the opposite. This study aimed to determine the effect of coordinating breathing with arm movements on the endurance of a lifting task. METHODS: Participants with COPD and hyperinflation completed two (high intensity and severe intensity) rhythmic, constant load-lifting tasks to intolerance (tlimit) before and after attending four "teaching" sessions. Participants were randomly assigned to one of three groups: (1) taught to inhale during the lift, (2) taught to exhale during the lift, or (3) sham (unconstrained coordination). RESULTS: Thirty-six participants (FEV1 % predicted [SD], 34 [13]; FEV1/FVC [SD], 33% [10%]; thoracic gas volume % predicted [SD], 179 [44]) completed the study. There was an effect of group on the change in tlimit (P<.01) regardless of task intensity (P=.47). The change in tlimit in the exhalation group was greater than in both the sham (difference [95% CI]: 2.82 [0.21-5.44] min; P<.05) and inhalation (difference [95% CI]: 3.29 [0.65-5.92] min; P<.05) groups at the high intensity. There was no difference in the change in tlimit between the inhalation and sham groups. CONCLUSIONS: A specific breathing strategy, exhalation during the lift, improved task performance. Coordinating exhalation with lifting may be of value to hyperinflated patients with COPD who are engaged in arm and shoulder training exercises or daily activities that involve arm elevation. TRIAL REGISTRY: ClinicalTrials.gov; No: NCT00836108; URL: www.clinicaltrials.gov.

European initiative towards quality standards in education and training for discovery, development and use of medicines.

This position paper recommends a set of standards for quality assessment of continuing professional development (CPD) for medicines research and development (R&D). We have developed these standards to help us achieve the education and training goals of the Innovative Medicines Initiative (IMI; www.imi.europa.eu/), which is developing courses to address the skills gaps in European medicines R&D. The IMI shared standard for course quality will enable professionals in medicines R&D to create a personalized portfolio of education and training that best suits their needs. Individuals already working in the pharmaceutical industry will be able to select modules for study on an as-needs basis, which may be combined to gain a qualification that is recognized throughout Europe. By seeking input from the medicines R&D community, especially professional bodies involved in the career development of biomedical scientists, we hope to initiate the creation of a mutually recognized framework for lifelong learning in medicines R&D. The shared standards call for defined and transparent admission criteria, a predefined set of teaching objectives leading to defined learning outcomes, assessment of the students' achievement, a system for collecting, assessing and addressing feedback, and provision of appropriate and updated reference material. This framework will make it easier for professionals to develop the skills required by industry, and easier for employers to recognize professionals with appropriate skills. It will obviate some of the need for retraining personnel who have already developed appropriate skills in a different setting, thereby saving the industry additional effort. Fulfilment of quality standards by course providers will be made transparent within the IMI's catalogue of courses, on-course (www.on-course.eu), which will be made publicly available during 2012.

Involvement of mitochondria in acetaminophen-induced apoptosis and hepatic injury: roles of cytochrome c, Bax, Bid, and caspases.

The role of apoptosis in acetaminophen (AAP)-induced hepatic injury was investigated. Six hours after AAP administration to BALB/c mice, a significant loss of hepatic mitochondrial cytochrome c was observed that was similar in extent to the loss observed after in vivo activation of CD95 by antibody treatment. AAP-induced loss of mitochondrial cytochrome c coincided with the appearance in the cytosol of a fragment corresponding to truncated Bid (tBid). At the same time, tBid became detectable in the mitochondrial fraction, and concomitantly, Bax was found translocated to mitochondria. However, AAP failed to activate the execution caspases 3 and 7 as evidenced by a lack of procaspase processing and the absence of an increase in caspase-3-like activity. In contrast, the administration of the pan-inhibitor of caspases, benzyloxycarbonyl-Val-Ala-DL-Asp-fluoromethylketone (but not its analogue benzyloxycarbonyl-Phe-Ala-fluoromethylketone) prevented the development of liver injury by AAP and the appearance of apoptotic parenchymal cells. This correlated with the inhibition of the processing of Bid to tBid. The caspase inhibitor failed to prevent both the redistribution of Bax to the mitochondria and the loss of cytochrome c. In conclusion, apoptosis is an important causal event in the initiation of the hepatic injury inflicted by AAP. However, as suggested by the lack of activation of the main execution caspases, apoptosis is not properly executed and degenerates into necrosis.