Formulation Controls the Potential Neuromuscular Toxicity of Polyethylene Photoproducts in Developing Zebrafish.

Sunlight transforms plastic into water-soluble products, the potential toxicity of which remains unresolved, particularly for vertebrate animals. We evaluated acute toxicity and gene expression in developing zebrafish larvae after 5 days of exposure to photoproduced (P) and dark (D) leachates from additive-free polyethylene (PE) film and consumer-grade, additive-containing, conventional, and recycled PE bags. Using a "worst-case" scenario, with plastic concentrations exceeding those found in natural waters, we observed no acute toxicity. However, at the molecular level, RNA sequencing revealed differences in the number of differentially expressed genes (DEGs) for each leachate treatment: thousands of genes (5442 P, 577 D) for the additive-free film, tens of genes for the additive-containing conventional bag (14 P, 7 D), and none for the additive-containing recycled bag. Gene ontology enrichment analyses suggested that the additive-free PE leachates disrupted neuromuscular processes via biophysical signaling; this was most pronounced for the photoproduced leachates. We suggest that the fewer DEGs elicited by the leachates from conventional PE bags (and none from recycled bags) could be due to differences in photoproduced leachate composition caused by titanium dioxide-catalyzed reactions not present in the additive-free PE. This work demonstrates that the potential toxicity of plastic photoproducts can be product formulation-specific.

Synergy between Sunlight, Titanium Dioxide, and Microbes Enhances Cellulose Diacetate Degradation in the Ocean.

Sunlight chemically transforms marine plastics into a suite of products, with formulation─the specific mixture of polymers and additives─driving rates and products. However, the effect of light-driven transformations on subsequent microbial lability is poorly understood. Here, we examined the interplay between photochemical and biological degradation of fabrics made from cellulose diacetate (CDA), a biobased polymer used commonly in consumer products. We also examined the influence of ∼1% titanium dioxide (TiO2), a common pigment and photocatalyst. We sequentially exposed CDA to simulated sunlight and native marine microbes to understand how photodegradation influences metabolic rates and pathways. Nuclear magnetic resonance spectroscopy revealed that sunlight initiated chain scission reactions, reducing CDA's average molecular weight. Natural abundance carbon isotope measurements demonstrated that chain scission ultimately yields CO2, a newly identified abiotic loss term of CDA in the environment. Measurements of fabric mass loss and enzymatic activities in seawater implied that photodegradation enhanced biodegradation by performing steps typically facilitated by cellulase. TiO2 accelerated CDA photodegradation, expediting biodegradation. Collectively, these findings (i) underline the importance of formulation in plastic's environmental fate and (ii) suggest that overlooking synergy between photochemical and biological degradation may lead to overestimates of marine plastic persistence.

YouTube as a Source of Information on Blenderised Tube Feeding.

ABSTRACT: Blenderised tube feeding (BTF) has become an increasingly popular method of nutrition support for long-term tube-fed patients mostly children. This study surveyed perceptions and experiences on BTF shared on YouTube. From 71 videos analysed, attitudes towards BTF were mostly positive (91%) and included psychosocial benefits and improvements in gastrointestinal symptoms; no differences between caregivers and healthcare professionals were observed. Very few speakers (8%) felt there was a lack of support regarding use of BTF in schools and from healthcare professionals, because it is not part of the standard clinical management protocols. The most commonly used food items in blends included carrots (n = 16) and chicken (n = 11), and experiences from those who have used BTF included tips on recipes for blends, storing feeds and ensuring nutritional adequacy. Analysis of YouTube content on BTF was considerably positive and suggests that BTF is feasible and safe way to provide nutrition to tube-fed patients.

Plastic Formulation is an Emerging Control of Its Photochemical Fate in the Ocean.

Sunlight exposure is a control of long-term plastic fate in the environment that converts plastic into oxygenated products spanning the polymer, dissolved, and gas phases. However, our understanding of how plastic formulation influences the amount and composition of these photoproducts remains incomplete. Here, we characterized the initial formulations and resulting dissolved photoproducts of four single-use consumer polyethylene (PE) bags from major retailers and one pure PE film. Consumer PE bags contained 15-36% inorganic additives, primarily calcium carbonate (13-34%) and titanium dioxide (TiO2; 1-2%). Sunlight exposure consistently increased production of dissolved organic carbon (DOC) relative to leaching in the dark (3- to 80-fold). All consumer PE bags produced more DOC during sunlight exposure than the pure PE (1.2- to 2.0-fold). The DOC leached after sunlight exposure increasingly reflected the 13C and 14C isotopic composition of the plastic. Ultrahigh resolution Fourier transform ion cyclotron resonance mass spectrometry revealed that sunlight exposure substantially increased the number of DOC formulas detected (1.1- to 50-fold). TiO2-containing bags photochemically degraded into the most compositionally similar DOC, with 68-94% of photoproduced formulas in common with at least one other TiO2-containing bag. Conversely, only 28% of photoproduced formulas from the pure PE were detected in photoproduced DOC from the consumer PE. Overall, these findings suggest that plastic formulation, especially TiO2, plays a determining role in the amount and composition of DOC generated by sunlight. Consequently, studies on pure, unweathered polymers may not accurately represent the fates and impacts of the plastics entering the ocean.

COVID-19 Vaccination: Guidance for Ethical, Informed Consent in a National Context.

This Guidance addresses the essential elements of informed consent to novel, provisionally registered COVID-19 vaccines which conform to the current definition of an investigational vaccine namely, lacking requirements for approval for full registration. 1 First, it addresses the ethical obtaining of informed consent in a setting of short and long term knowns and unknowns, by structuring the personal nature of informed consent into its twelve component parts. Second, as a guidance for family physicians, it explores reasonable medical concerns arising for individuals from both knowns and unknowns about COVID-19 disease and vaccines.Where there are waves of pandemic pressure impelling political, economic, social and public health forces to promote vaccination to health care providers and their patients, the necessary constituents of valid informed consent can be sublimated and possibly forfeited. This context of informed consent for COVID-19 vaccines is not unique to Australia. The analysis and presentation of international data by Australian Government agencies is a process occurring in all countries. Therefore, the Australian experience of consenting for vaccination is relevant to informed consent across the globe.The purpose of this Guidance is to assist personalised risk-benefit assessment for the informed consent of the vaccinee. Its aim is not to give a therapeutic guide nor to draw conclusions which can only rightly be drawn pertaining to each individual recipient in discussion with a health care provider. This is especially true in the setting of incomplete research where the many unknowns may be more significant for some than others. Since data is changing over time, national tables have not been used for specifics which the vaccine provider should access at the time of consultation.While we recommend the Guidance be read in conjunction with Government issued information, this Guidance will address specific fields relevant to informed consent which may not be addressed in those communications, but which a consenting individual as a person with their own values and experiences may wish to know. Aim: To address the requirements of ethical informed consent of the individual adult in the context of reasonable concerns pertaining to the unknowns and incomplete research attending novel, provisionally registered COVID-19 vaccines. Methodology: To elucidate what might be reasonable concerns for individuals considering vaccination, Public Assessment Reports of regulatory authorities (Food and Drug Administration and Therapeutic Goods Administration) and published trials of currently available vaccines were reviewed. International Covid-19 vaccine safety discussions were observed for peer-reviewed and, if necessary, pre-print references base. These references were studied for potential relevance to vaccine recipients. Vaccine Development Guidelines were also reviewed for pre-clinical requirements and compared with pre-clinical data presented at licensing. Missing information was requested from the Therapeutic Goods Administration (TGA).Pertinent unknowns were thereby identified as issues potentially relevant to fully informed consent, and compared with the content of standard Government-issued vaccine consent advice forms. Disparities were selected as relevant unknowns or reflecting incomplete research.Pertinent issues were incorporated into a twelve point structure for reasonable consideration to guide ethical inform consent. Paediatric COVID disease and vaccination are mentioned briefly due to paediatric vaccination being unapproved in Australia at the time of writing in under 12-year-olds, and exclusion of minors from phase III safety and efficacy trials. Conclusion: The provision of ethically obtained, fully informed consent is very pertinent to an investigational vaccine notwithstanding the pandemic context. To ascertain informed consent to the best of our ability, the gap between officially delivered information and reasonable concerns generated by knowns and relevant unknowns, can be addressed in a structured manner by physicians. Consent should not be coerced but be free of inducements and reprisals, respecting declarations of human rights, particularly given the investigational nature of COVID-19 vaccines. Each recipient requires adequate information to make their own judgment. The process of validly informed consent will therefore include discussion of concerns and of relevant information we do and do not yet have. Ethical informed consent should address those concerns as best is possible.

Rural health research capacity building: an anchored solution.

Rural physicians face many challenges with providing rural health care, which often leads to innovative solutions. Despite their creativity with overcoming barriers, there is a lack of support for rural health research - an area of health care where research makes great impacts on small communities. Rural research capacity building (RRCB) is essential to support rural physicians so that they can conduct relevant research, but RRCB programs are sparse. Thus, our team at Memorial University of Newfoundland, Canada, has created an RRCB ecosystem through the 6for6 and Rural360 programs, which outline a pathway for rural physicians to make meaningful contributions to their communities through research. This article describes the RRCB ecosystem and explains how the 6for6 and Rural360 programs address the need for RRCB. Designed to train six rural physicians over six sessions per year, 6for6 fosters learning of research practices through a conceptual framework that envelops complexity science, systems thinking, and anchored instruction. The use of this framework allows the learning to be grounded in issues that are locally relevant for each participant and follows guiding principles that enable many types of learning. Rural360 continues the pathway by providing an in-house funding opportunity with an iterative review process that allows participants to continue developing their research skills and, ultimately, secure funding for their project. This anchored delivery model of RRCB programming is made possible through many support systems including staff, librarians, instructors, the university, and other stakeholders. It has successfully helped form communities of practice, promotes collaboration both between learners and with third parties, encourages self-organization with flexibility for learners outside of the in-house sessions, and ultimately drives social accountability in addressing local healthcare issues.

COVID-19 infection is related to differences in the use of personal protective equipment by orthopaedic specialist trainees caring for hip fracture patients during the second surge of COVID-19 in the North West of England.

INTRODUCTION: Personal protective equipment (PPE) may protect health-care workers from COVID-19 infection and limit nosocomial spread to vulnerable hip fracture patients. METHODS: We performed a cross-sectional survey amongst orthopaedic trainees to explore PPE practice in 19 hospitals caring for hip fracture patients in the North West of England. RESULTS: During the second wave of the pandemic, 14/19 (74%) hospitals experienced an outbreak of COVID-19 amongst staff or patients on the orthopaedic wards. An FFP3 respirator mask was used by doctors in only 6/19 (32%) hospitals when seeing patients with COVID-19 and a cough and in 5/19 (26%) hospitals when seeing asymptomatic patients with COVID-19. A COVID-19 outbreak was reported in 11/13 (85%) orthopaedic units where staff wore fluid resistant surgical masks compared to 3/6 (50%) units using an FFP3 respirator mask (RR 1.69, 95% CI 0.74-3.89) when caring for symptomatic patients with COVID-19. Similarly, a COVID-19 outbreak was reported in more orthopaedic units caring for asymptomatic patients with COVID-19 where staff wore fluid resistant surgical masks (12/14 (86%)) as compared to an FFP3 respirator mask (2/5 (40%)) (RR 2.14, 95% CI 0.72-6.4). CONCLUSION: Urgent re-evaluation of PPE use is required to reduce nosocomial spread of COVID-19, amongst highly vulnerable patients with hip fracture.

Examining the Influence of Social Support on Psychological Distress in a Canadian Population with Symptoms of Mania.

Individuals who experience symptoms of mania in the form of a manic episode (ME) are at a greater risk of experiencing psychological distress. Given that a ME is a period during which one can become extremely socially dysfunctional, the potential influence of social support is especially important to explore. The primary objective of this study was to examine whether perceived social support predicts psychological distress in a sample of Canadian adults who have self-reported ME symptoms within the last 12-months. Using a cross-sectional, national datafile, 220 Canadians between 20 and 64 years who met the criteria for a ME within the last 12-months were investigated using the Social Provisions Scale (SPS), and the Kessler Psychological Distress Scale (K10). Results indicated that the ME sample experienced significantly higher distress and significantly lower perceived social support than the adult Canadian population. Further, social support in the form of reassurance of worth was associated with lower levels of psychological distress, but only for the male ME sample, and the overall (male and female combined) ME sample. Despite some limitations, this study adds to the research on mania as its own experience outside of comorbidities and indicates the important and specific role social support plays in terms of psychological well-being.

Orbital Pheochromocytoma Metastasis in 2 Patients With Known Pheochromocytoma.

Two patients with previously diagnosed pheochromocytoma presented with facial pain and ptosis. Imaging revealed orbital lesions. Both patients were referred for surgical evaluation of the orbital mass. Surgical excision was performed for both. Pathology confirmed metastatic pheochromocytoma. Pheochromocytomas commonly metastasize to bone, liver, and other tissues. Five cases of metastasis to orbital bone have been previously described. These 2 cases are unique in that the metastases were not hormonally active, presented soon after initial diagnosis, and were treated palliatively with surgical excision. Previous treatment of orbital bony metastasis used radiotherapy. These cases demonstrate that surgical resection is a viable treatment option in these situations. Orbital metastasis of pheochromocytomas should be considered with the appropriate clinical presentation. These are the first documented cases of intraorbital metastasis, separate from the bony walls. Previously, orbital bony wall metastases were treated with radiation. Surgical excision is a viable option for treatment of such metastases.Orbital involvement should be considered in patients with systemic disease presenting with new ocular findings.

Abortion Decriminalisation in New South Wales: An Analysis of the Abortion Law Reform Act 2019 (NSW).

Abortion was decriminalised in New South Wales in October 2019. While New South Wales is the seventh jurisdiction in Australia to decriminalise abortion and regulate it under health legislation, the recent passage of the Abortion Law Reform Act 2019 (NSW) (the Act) saw the adoption of a number of principle-based amendments that distinguish it from abortion legislation in other Australian jurisdictions. This article critiques key sections of the Act regarding sex selection abortion, a doctor's duties in relation to offering a woman counselling, the distinct crime of abortion coercion, and the protection of conscience for health professionals. It also identifies where future research may assist us in understanding both the application of these new legal requirements, and the community's experiences with abortion.

Arterial Injury in the Upper Limb Resulting from Dog Bite.

Dog bites in the upper limbs have particular significance, because despite the small size of the puncture wounds, penetration is deep, causing serious injuries to deeper structures. There is currently very little data relating to upper extremity dog bite arterial injury. We present the case of a 32-year-old man who sustained a dog bite injury to his right arm, leading to direct puncture and spasm of the brachial artery. He was successfully treated with a jump bypass graft to the right brachial artery, with the use of the reversed ipsilateral cephalic vein as a conduit. We identified 34 cases in the literature reporting upper limb arterial injury secondary to dog bite. Twenty-two cases in the literature detailed axillobrachial artery damage (65%), 24% radial artery, 3% ulnar artery, and 9% combined. Presentation was most commonly with diminished pulses found in at least 45% of the patients. Arterial thrombosis occurred in 29% of cases of single artery injury, transection in 15%, intimal tear in 9% of cases, and undisclosed in 44%. Management most commonly included interposition graft (47%) and primary repair (20%), while 15% did not undergo surgical intervention, 9% underwent ligation, and 3% were treated with thromboembolectomy. Follow-up data for these patients are scarce, with some experiencing residual neurological deficit. This report highlights the importance of prompt recognition and treatment of vascular injury following dog bite to attain an optimal outcome and minimize complications.

The influence of social support on psychological distress in Canadian adults with bipolar disorder.

INTRODUCTION: Individuals with bipolar I disorder (BD-I) and bipolar II disorder (BD-II) are at higher risk for experiencing high levels of psychological distress and low levels of social support. OBJECTIVES: The primary objectives of this study were to examine perceived social support and psychological distress among Canadian adults with self-reported BD-I or BD-II as diagnosed by a health professional and explore the relationship between types of social support and psychological distress within this sample. METHODS: Using a cross-sectional, national datafile, 563 Canadian male and female adults (20-64 years) who reported being diagnosed with BD-I or BD-II were investigated using the Social Provisions Scale (SPS), and the Kessler Psychological Distress Scale (K10). RESULTS: It was observed that while the BD-I or BD-II sample had significantly lower SPS scores and significantly higher K10 scores than the overall Canadian sample, age and support in the form of reassurance of worth and social integration were associated with decreased psychological distress. Further, a diagnosis of BD-I and BD-II was found to moderate the effect of social support on psychological distress. CONCLUSIONS: Despite the limitations, which include self-reported diagnosis of BD-I and BD-II and potential exclusion of those who are not diagnosed but have BD-I or BD-II, these findings suggest that reassurance of worth and social integration may act as protective factors for psychological distress among individuals with BD-I or BD-II.

Freedom of Expression, Belief and Assembly: The Banning of Protests Outside of Abortion Clinics in Australia.

This article considers the phenomenon of safe access zone laws in Australia that seek to prohibit certain activities that occur outside abortion facilities during protests. While they are characterised as a reasonable reaction to concerns that certain activities may harm women and infringe their rights to privacy and security, such laws do so at the expense of the protesters' right to freedom of political communication and cover activities such as sidewalk counselling and praying. This article critically examines the content and scope of these laws in each jurisdiction, identifies recent cases involving prosecutions for violations of safe access zone laws and considers the impact of the implied freedom of political communication on their constitutional validity in light of recent High Court decisions.

Improvements in Glucose Regulation in Children and Young People with Cystic Fibrosis-Related Diabetes following Initiation of Elexacaftor/Tezacaftor/Ivacaftor.

INTRODUCTION: Cystic fibrosis transmembrane conductance regulator (CFTR) modulators are increasingly used in children and young people with cystic fibrosis (CF). Data in adults show there may be an impact on glycaemic control in those with CF-related diabetes (CFRD). Paediatric data are rare. Case Series/Presentation: Children aged >12 years with CFRD, who were eligible for elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) were commenced on treatment. Glucose monitoring via the FreeStyle Libre system was commenced prior to, immediately after, and several months after commencing ELX/TEZ/IVA. Glycaemic control, shown by time in range (3-10 mmol/L), percentage of time spent hypoglycaemic (<3 mmol/L), and percentage of time spent hyperglycaemic (>10 mmol/L) on Insulin doses were recorded. Following ELX/TEZ/IVA, four of seven children stopped insulin, two required substantially reduced doses of insulin, one showed no response. Glycaemic control remained similar on lower doses or no insulin. Hypoglycaemia was detected in those not requiring insulin. CONCLUSION: ELX/TEZ/IVA has a positive impact on glycaemic control and insulin requirements in children with CFRD. Close monitoring is required when commencing treatment. Children with CFRD need counselling regarding possible reductions in insulin requirement and re-education regarding symptoms, signs, and management of hypoglycaemia.

Long term results and patient reported outcome measures following lisfranc injuries treated with memory staple fixation.

INTRODUCTION: Various modalities of fixation have been proposed for Lisfranc injuries. Memory staple fixation offers a simple option for transarticular fixation in suitable fracture configuration with no diaphyseal extension. However there is little evidence available in the literature regarding its efficacy and patient reported outcomes. Aim of the study was to present the long term outcomes of Lisfranc injuries treated with memory staple fixation and patient reported outcomes at average follow-up of four years. METHOD: This was a retrospective analysis of all the patients who underwent fixation for Lisfranc injury using shape memory alloy (Nitinol) staples from December 2010 to October 2018. Patient demography, mechanism of injury, classification of Lisfranc injury, duration of followup, complication, revision surgery, implant removal and patient reported outcomes (AOFAS midfoot score) was noted. RESULTS: 31 patients satisfied the inclusion criteria. Mean age was 50 years and 17 patients were females. 54 % patients reported low to moderate energy trauma which included simple fall from standing height or twisting injury. 28 (90.3 %) had B2 type of fracture pattern. 13 had fixation with staples only, 15 with a staple and home run screw. No patient had primary fusion. One patient had superficial infection treated with antibiotics only. Three patients developed symptomatic arthritis, out of which one proceeded to fusion. Six had implant removal for hardware related symptoms. Average AOFAS midfoot score at average four years follow-up was 77.8 which are satisfactory. CONCLUSION: This paper highlights good outcome following memory staple fixation for Lisfranc injuries. We believe staples are more suited for the dorsal buttressing that is typically required and provide stable, reproducible fixation Our findings also suggest less need for implant removal compared to transarticular screw or plate fixation though larger studies would be required to make definitive conclusions.

Survivorship of the C-Stem total hip replacement using the "French Paradox" technique.

BACKGROUND: This study evaluates the survivorship of the C-Stem total hip replacement, using the "French Paradox" method, at medium-term follow-up. METHODS: 321 cemented total hip replacements in 307 patients were performed, using the canal-filling technique for the femoral stem. Survival analysis was performed for all-cause revision. The secondary outcome was aseptic loosening of the stem. RESULTS: Revision rate for all reasons was 2%. Overall ten-year survival was 95%. There were no revisions for femoral stem aseptic loosening. CONCLUSION: This is a unique study demonstrating successful outcomes of total hip replacement using the "French Paradox" technique with a triple-tapered stem.

Nutcracker syndrome, conservative approach: a case report.

The nutcracker phenomenon (NCP) refers to the compression of the left renal vein, most commonly between the aorta and the superior mesenteric artery (SMA). Nutcracker syndrome (NCS) should be limited to patients who present with the characteristic clinical signs and symptoms alongside diagnostic imaging of the anatomy associated with the syndrome. We report a case of NCS presenting with painless visible hematuria and left flank pain. Imaging showed a left renal vein stenosis at the origin of the SMA with collateralization. Diagnosis of NCP is made by a variety of imaging techniques; approaches to the treatment of NCS include conservative methods, open surgical, laparoscopic or endovascular techniques. Correlation with symptoms, laboratory results and excluding other causes continues to be important in the workup of NCS. Collaboration with the establishment of an International Consortium database will aid in the understanding of this rare disease.

Patient-centered care in the emergency department: a systematic review and meta-ethnographic synthesis.

BACKGROUND: Patient-centered care (PCC) is an emerging priority in many healthcare settings but lacks clarity in the emergency department (ED). It is of interest to know what PCC practices are most important to patients to better their experience. The objective of this study was to conduct a mixed-methods systematic review of PCC in the ED. METHODS: We used stakeholder and patient engagement to consult with clinicians, subject-matter experts, patient partners, and community organizations to determine patient needs. We examined all articles in the ED context with PCC as the intervention. Two independent reviewers screened 3136 articles and 13 were included. A meta-ethnographic analysis was conducted to determine common themes of PCC. RESULTS: Themes included emotional support, communication, education, involvement of patient/family in information sharing and decision making, comfort of environment, respect and trust, continuity, and transition of care. Challenges in the ED reflected a lack of PCC. Moreover, implementation of PCC had many benefits including higher patient satisfaction with their care. Though there were commonalities of PCC components, there was no consistently used definition for PCC in the ED. CONCLUSION: The findings of this review support the evidence that PCC is of high value to the ED setting and should be standardized in practice.

The M/V X-Press Pearl Nurdle Spill: Contamination of Burnt Plastic and Unburnt Nurdles along Sri Lanka's Beaches.

In May 2021, the M/V X-Press Pearl cargo ship caught fire 18 km off the west coast of Sri Lanka and spilled ∼1680 tons of spherical pieces of plastic or "nurdles" (∼5 mm; white in color). Nurdles are the preproduction plastic used to manufacture a wide range of end products. Exposure to combustion, heat, and chemicals led to agglomeration, fragmentation, charring, and chemical modification of the plastic, creating an unprecedented complex spill of visibly burnt plastic and unburnt nurdles. These pieces span a continuum of colors, shapes, sizes, and densities with high variability that could impact cleanup efforts, alter transport in the ocean, and potentially affect wildlife. Visibly burnt plastic was 3-fold more chemically complex than visibly unburnt nurdles. This added chemical complexity included combustion-derived polycyclic aromatic hydrocarbons. A portion of the burnt material contained petroleum-derived biomarkers, indicating that it encountered some fossil-fuel products during the spill. The findings of this research highlight the added complexity caused by the fire and subsequent burning of plastic for cleanup operations, monitoring, and damage assessment and provides recommendations to further understand and combat the impacts of this and future spills.