Review of the impact of stormwater and leaching from pavements on the environment.

The intensive growth of roadway infrastructure worldwide leads to growing concerns over the health impacts of stormwater runoff and leachate from roadway materials. This comprehensive review combines various sources of information from the last 30 years of research on the impact of pavement stormwater runoff and leaching on the environment. Of the 95 papers found in library searches, 42 papers add significantly to the body of literature around this subject after review of content and quality. Normally constructed asphalt and concrete pavements were found to release low levels of contaminants during their life. However, deposition from atmospheric pollutants and materials dispersed by vehicles on pavements do have a measurable impact on the quality of stormwater runoff. These tend to be expressed in initial flush from stormwater events. Reuse of old pavements at end of life tend to have little environmental impact when recycled. However, because of deposition of pollutants over their life these materials can have an impact when used in unbound layers of the pavement or in storage before reuse. Water quality can be improved by porous pavements, which allow infiltration of water and drainage to lower layers, thereby filtering many pollutants in stormwater runoff. The challenge is preventing the high initial pavement porosity from plugging over time. Pavement sealers containing coal tar pitch have high levels of polycyclic aromatic compounds and have been shown to impact aquatic life negatively and produce sediment buildup in ponds and streams. Recent studies have investigated photooxidation of pavements and its influence on leaching, but these remain as laboratory-scale studies. Tables outline materials tested, analytical parameters measured, and methodologies to allow readers to easily identify studies most relevant to their focus on impact of stormwater and leaching from pavements on the environment.

Evaluation of reproductive/developmental and repeated dose (subchronic) toxicity and cytogenetic effects in rats of a roofing asphalt fume condensate by nose-only inhalation.

A Type III Built-up Roofing Asphalt (BURA) fume condensate was evaluated for subchronic systemic toxicity and reproductive/developmental toxicity screening in Wistar rats, by OECD protocol 422 and OECD cytogenetic protocol 474. Animals were exposed by nose-only inhalation to target concentrations of 30, 100 and 300 mg/m³ total hydrocarbons (actual concentrations, 30.0, 100.1 and 297.3 mg/m³). The study was performed to assess potential hazards from asphalt fumes to which humans could be exposed during application. No adverse effects were seen for spermology, reproductive or developmental parameters or early postnatal development of offspring from day 1 to 4 postpartum. BURA fume condensate did not induce any significant increases in micronucleus frequency in polychromatic erythrocytes of rat bone marrow nor was neurobehavioral toxicity observed at any dose. Systemic effects were slight and seen at doses above those measured at work sites. The systemic NOAEC of 100 mg/m³ for males was based on decreased body weight gain, food consumption and increased absolute and relative lung wet weight correlated with slight histological changes in the lung, primarily adaptive in nature at 300 mg/m³. The female NOAEC of 30 mg/m³ was based on a statistically significant increase in relative wet lung weight at higher doses, correlated with slight histopathologic effects in the lungs at the highest dose. However, no increase in relative lung weight was seen in breeding females at 100 mg/m³.

Deaths and injuries from house fires.

BACKGROUND: We sought to define the factors associated with house fires and related injuries by analyzing the data from population-based surveillance. METHODS: For 1991 through 1997, we linked the following data for Dallas: records from the fire department of all house fires (excluding fires in apartments and mobile homes), records of patients transported by ambulance, hospital admissions, and reports from the medical examiner of fatal injuries. RESULTS: There were 223 injuries (91 fatal and 132 nonfatal) from 7190 house fires, for a rate of 5.2 injured persons per 100,000 population per year. Rates of injury related to house fires were highest among blacks (relative risk, 2.8; 95 percent confidence interval, 2.1 to 3.6) and in people 65 years of age or older (relative risk, 2.6; 95 percent confidence interval, 1.9 to 3.5). Census tracts with low median incomes had the highest rates of injury related to house fires (relative risk as compared with census tracts with high median incomes, 8.1; 95 percent confidence interval, 2.5 to 32.0). The rate of injuries was higher for fires that began in bedrooms or living areas (relative risk, 3.7); that were started by heating equipment, smoking, or children playing with fire (relative risk, 2.6); or that occurred in houses built before 1980 (relative risk, 6.6). Injuries occurred more often in houses without functioning smoke detectors (relative risk, 1.5; 95 percent confidence interval, 1.0 to 2.4). The prevalence of functioning smoke detectors was lowest in houses in the census tracts with the lowest median incomes (P<0.001). CONCLUSIONS: Rates of injuries related to house fires are highest in elderly, minority, and low-income populations and in houses without functioning smoke detectors. Efforts to prevent injuries and deaths from house fires should target these populations.

Luminescence spectroscopy as a screening tool for the potential carcinogenicity of asphalt fumes.

A subset of polycyclic aromatic compounds (PACs), which contain 4-6 annulated rings, has been documented as the source of carcinogenicity in animal skin painting studies of petroleum products and asphalt fumes (M. L. Machado, P. W. Beatty, J. C. Fetzer, A. H. Glickman and E. L. McGinnis, Fundam. Appl. Toxicol., 1993, 21, 492; T. A. Roy, S. W. Johnson, G. R. Blackburn and C. R. Mackerer, Fundam. Appl. Toxicol., 1988, 10, 466). Because of the chemical complexity of these materials, it has been difficult to identify the specific compounds within this broad range of PACs responsible for their carcinogenicity. An alternative approach using luminescence spectroscopy was taken in this study to quantify, without identification, a subset of these compounds that appears to cause cancer. The fluorescence response at a specific wavelength pair was obtained for 39 laboratory asphalt fume condensates from animal skin painting studies, yielding a linear correlation coefficient of R2 = 0.96 between the fluorescence response in these materials and the carcinogenicity found in animal studies. In the absence of other asphalt fume condensates from animal studies, 17 petroleum oils were also evaluated using this method and compared with the available animal skin painting data. The details of the method include a clean-up step that removes the highly polar compounds and spectral subtraction of two- and three-ring PAC interference, both of which add to the fluorescence response, yet were not found to contribute to a carcinogenic response from skin painting studies. Full scan fluorescence plots also produce a fingerprint which can be used to assess contamination, such as coal tar products or mixtures of materials, that are not defined as asphalt, yet may be present in the working environment.

Final report of the FOPE II Financing of Pediatric Education Workgroup.

Some of the challenges of financing pediatric medical education are shared with all medical education; others are specific to pediatrics. The general disadvantage that funding of graduate medical education (GME) is linked to reimbursement for clinical care has uniquely negative consequences for freestanding children's hospitals because they therefore receive little Medicare GME support. This represents both a competitive disadvantage for such hospitals and an aggregate federal underinvestment in children's health care that now amounts to billions of dollars. The need to subsidize medical student and subspecialty education with clinical practice revenue jeopardizes both activities in pediatric departments already burdened by inadequate reimbursement for children's health care and the extra costs of ambulatory care. The challenges of funding are complicated by rising costs as curriculum expands and clinical education moves to ambulatory settings. Controversies over prioritization of resources are inevitable. Solutions require specification of costs of education and a durable mechanism for building consensus within the pediatric community. Pediatrics 2000;106(suppl):1256-1269; medical student education, continuing medical education, medical subspecialties, children, pediatrics, health maintenance organizations, managed care, hospital finances, children's hospitals.

The management of depression: the implications for managed care--roundtable discussion: Part 3.

From the standpoint of managed care, the rising cost of depression can be addressed in multiple ways. In the final portion of the roundtable discussion, the faculty discuss not only disease management programs for depression, but other initiatives health plans (including at the pharmacy level) are undertaking to address the rising costs associated with depression. They also discuss the effect of mental health coverage "parity" laws, which can be expected to drive costs even higher.

The management of depression: the implications for managed care--roundtable discussion: Part 2.

One of the most commonly utilized drug classes today is antidepressant therapy, which accounts for billions of dollars in spending. Pharmacoeconomic tools may play an influential role in formulary decision making, particularly in this drug class. In part 2 of the roundtable discussion, a pharmacoeconomic model is presented that may clarify the health economic effects of placing serotonin-norepinephrine reuptake inhibitors on the drug formulary, particularly in the context of other antidepressant medications.

Results of resting and ambulatory electrocardiograms in patients with hypothyroidism and after return to euthyroid status.

Hypothyroidism is not infrequently associated with an abnormally long QTc interval (> or = 450 msec). Rarely, marked prolongation of the QTc interval and malignant ventricular arrhythmias have been reported. In this study, QTc intervals on resting electrocardiograms (ECGs) were compared in 10 patients before and after treatment of hypothyroidism. The QTc interval increased in seven patients during euthyroidism compared with hypothyroidism, and decreased in three patients. During hypothyroidism, the QTc interval was mildly prolonged in 2 of the 14 patients; both had mild decreases in triiodothyronine (T3) or thyroxine (T4). The 24-hour ambulatory ECGs measured during hypothyroidism and after restoration of biochemical euthyroidism also were compared in 9 patients. There was no significant difference in ventricular ectopy. None of the 13 patients assessed during hypothyroidism had > or = 4 beats of ventricular tachycardia. There was no relationship between thyroid-stimulating hormone (TSH) or T3 levels and QTc intervals during hypothyroidism. A moderate correlation between lesser degrees of T4 depression and increasing QTc interval was present. Mild QTc prolongations are relatively common in patients with hypothyroidism and are usually associated with milder degrees of thyroid underactivity, but are not associated with clinically significant ventricular tachyarrhythmias.

Rey-Osterrieth Complex Figure Test performance in acute, chronic, and remitted schizophrenia patients.

To assess visual memory disturbance in different forms of schizophrenia, we compared Rey-Osterrieth Complex Figure Test (RCF) performance in acutely psychotic, chronically psychotic, and outpatient schizophrenia patients and in a control group of acutely psychotic patients with disorders other than schizophrenia. There were no group differences on the copy condition of the RCF. The chronic schizophrenia group utilized more abnormal copying strategies, however, than the outpatient or nonschizophrenia groups. Moreover, the chronic schizophrenia group demonstrated significantly poorer recall than the outpatient or nonschizophrenia groups, and a trend toward poorer performance than the acute schizophrenia group. Both groups of inpatient schizophrenia patients were characterized by a lack of relationship between copying strategies and recall accuracy. These data suggest that (a) chronic schizophrenia patients are characterized by more severe memory impairment than are nonchronic schizophrenia patients, and (b) visual memory disturbance in chronic schizophrenia is not solely a function of encoding difficulties.

Vagally mediated multivessel coronary artery spasm during coronary angiography.

We report on a case of multivessel coronary artery spasm preceded by vagal signs and symptoms, which resolved after administration of atropine. This supports that the spasm was triggered by endogenous acetylcholine.

Organizational responses to managed care: issues for academic health centers and implications for pediatric programs.

The health care market dynamics that supported and directed the growth and development of Academic Health Centers (AHCs) have changed dramatically in the last 10 years. AHCs are struggling to adapt to new reimbursement mechanisms and to compete effectively for limited dollars, but are constrained by administrative and governance structures that are slow to evolve. Their multiple missions, including education, research, and care for complex patients and underserved populations, are at risk. Although most recognize the need for substantive reorganization, available resources and market specifics vary dramatically from one AHC to another. The current approaches to adaptation by four AHCs are described, along with some of the unique challenges confronted by academic pediatric programs.

Resolution of exercise intolerance secondary to ischemic sinus node dysfunction following percutaneous transluminal angioplasty.

We report on a case of significant exertional symptoms secondary to occlusion of a nondominant right coronary artery proximal to the sino-atrial branch, with associated exercise-induced sinus node dysfunction. Successful angioplasty of the occluded right coronary artery restored a normal functional capacity and sinus tachycardia response to exercise.

Indwelling pericardial drainage catheter break secondary to heart movement and catheter angulation.

We report on a case of a pericardial drainage catheter that severed on attempted removal. Surgery was required to remove the retained portion. No manufacturing defects were found on analysis of the catheter. Shear forces due to heart movement and the angle of catheter entry into the pericardium were the suspected reasons for the catheter disruption.

Implementing community-based education: essential elements and recommendations.

Two elements are essential for implementing community-based educational programs: a vision of how community experiences fit into the training of the health professionals of the future and a local environment that will support innovation, change, and growth. Change cannot occur unless very basic assumptions regarding medical education are challenged. What is "quality education"? Can programs oriented toward tertiary and specialty care adequately provide the training that should be the core of a 3-year general training program? Do schools and programs select and train physicians to function within the microcosm of the academic center, or do they prepare physicians to manage the country's health care needs? National consensus has had little influence over local environments. Each medical school, training program, and teaching facility must reexamine its values and its culture. Each must have a vision of the physicians of the future and a commitment to train them appropriately. The role of vision and culture in creating successful programs has been clearly described. Several key elements have been found to be consistent with success, the first being vision. Four basic principles will bring the vision to fruition: (1) preserving core values while still stimulating progress; (2) emphasizing the process by which programs are created, implemented, and changed rather than the product; (3) avoiding the "tyranny of the or," learning to be inclusive with a broad vision rather than limited to an "either-or" approach; and (4) aligning the process, management, and values in working toward envisioned progress for the future. Effective leadership is essential for a group or organization to accomplish its mission, as is an organizational structure that aligns responsibility, authority, resources, and accountability.

Stimulus configuration and context effects in perceptual organization in schizophrenia.

Two studies assessed perceptual organization in schizophrenia to determine (a) whether inpatient and outpatient groups with poor premorbid schizophrenia have comparable levels of perceptual organization deficit; and (b) whether the deficit could be eliminated by task manipulations. In Study 1, inpatients demonstrated clear evidence of a perceptual organization deficit, whereas outpatients performed similarly to the control groups. In Study 2, a performance pattern that operationally defined a perceptual organization deficit was eliminated by a task manipulation thought to aid in context processing. The perceptual organization deficit is most pronounced in actively symptomatic patients with poor premorbid schizophrenia, and the deficit reflects, in part, deficient top-down influences to basic perceptual processes.

Structure of a functional fragment of VCAM-1 refined at 1.9 a resolution.

The crystal structure of the functional amino-terminal two-domain fragment of human vascular cell adhesion molecule 1 (VCAM-1) has been determined at 1.9 A resolution. The crystals contain two copies of the molecule in the asymmetric unit. The structure was solved by multiple isomorphous replacement, using lead and selenium derivatives. Anomalous scattering had to be used to resolve the phase ambiguity of a lead derivative. Since the selenium derivative has very small isomorphous differences, the local scaling algorithm had to be used to obtain an interpretable difference Patterson map. The initial phases were improved by non-crystallographic averaging, solvent flattening and histogram matching. The structure has been refined to a crystallographic R factor of 20.4% (15-1.9 A, F>/= 3sigma) and consists of two Ig domains (D1 and D2). The angle between these domains differs by 12 degrees between the two copies of the molecule in the crystallographic asymmetric unit, demonstrating that some movement is possible at the interface. In the amino-terminal domain D1 there is an 'extra' disulfide bond, in addition to the conserved cross-sheet disulfide bond, at the top of the molecule. This bond, a hallmark of the integrin-binding subclass of Ig superfamily proteins, makes the top of this domain very compact. The feature that projects most prominently from D1 is the CD loop, near the base of the domain. The key residue for integrin binding, Asp40, is located in this loop and is easily accessible.

Anomalous origin of left internal mammary artery from the lateral junction of the left subclavian artery and aorta.

We describe the first reported case of an internal mammary artery originating from the junction of the left subclavian artery and aorta. Noting this, along with other reported anomalies and various pathologic conditions, it appears warranted to perform routine preoperative internal mammary artery angiography before coronary artery bypass surgery.