Rates and types of urine drug screen false negative results compared with confirmatory toxicology testing in major trauma patients.

BACKGROUND: Trauma centers are required to screen patients for alcohol use, and if necessary, intervene and refer to treatment (SBIRT). Similar screening for illicit drug use is recommended but not required. Urine drug screening (UDS) underestimates problematic substance use. This study aimed to estimate the types and rates of UDS false negatives (FN) compared to comprehensive testing by liquid chromatography-mass spectrometry (LC-MS) in trauma patients. METHODS: We performed a prospective cohort study of deidentified urine samples from adult trauma and burn activation patients. Both UDS and LC-MS comprehensive testing of >200 analytes were performed by a reference laboratory on all samples. Iatrogenic medications were excluded from the FN count. Crosstab analyses were conducted for UDS versus LC-MS outcomes to establish FN types and rates. We dichotomized the results by creating an "intentionality" variable (intentional injuries by self/others versus accidental injuries). A series of crosstabs with odds ratios considered intentionality by substance class and demographics. Statistically significant variables by Chi-Square were assessed by logistic regression. RESULTS: Psychoactive FN were detected in 56/100 urine samples analyzed; the most frequent included anticonvulsants (primarily gabapentin, N = 13), opioid agonists (N = 12), antihistamines (primarily diphenhydramine, N = 10), and phenethylamines (primarily bupropion, N = 5). Nonpsychoactive FN were detected in 70/100 samples; the most common were nicotine (N = 33), caffeine (N = 23), acetaminophen (N = 22), and antidepressants (N = 12). Of substance classes included in the UDS and also tested by LC-MS, FN occurred for opiates (3%), amphetamines (5%) and opioids (25%). Polypharmacy was associated with fall injuries in elderly patients. Cocaine (p = 0.015) and cannabinoids (p = 0.002) were significantly associated with intentionality. CONCLUSIONS: Our results indicate that FN for potentially important psychoactive and nonpsychoactive substances are common when toxicologic testing is limited to routine UDS in trauma patients. We recommend expanding SBIRT in this patient population to include misuse of tobacco products, prescription analgesics, and over-the-counter antihistamines.

Aging shapes Cr(VI) speciation in five different soils.

To make sound decisions regarding management of heavy metal contamination in soils, it is necessary to understand contaminant transformations over extended periods. In this study, sequential extraction methods were applied to quantify the changes of Cr fractions [available Cr(VI), immobile Cr(VI) and immobile Cr(III)] in five contrasting soils spiked with Cr(VI) over a 240-day incubation. Results showed that available Cr(VI) in soils continually decreased during aging, with a sharp decline occurring in the first 30 days. The best fit of available Cr(VI) data was obtained using an Elovich model for Brunisol and Anthrosol-1, a fractional power model for Anthrosol-2, and a pseudo first-order kinetic model for Luvisol-1 and Luvisol-2. After aging for 240 days, immobile Cr(VI) increased by 4.5-31% and immobile Cr(III) increased by 68-95% of total spiked Cr(VI) in Brunisol, Anthrosol-1 and Anthrosol-2. The two Luvisol soils had relatively high reduction rates with no Cr(VI) immobilized. A multireaction model was developed in MATLAB Simulink toolbox to describe transformation flow rates among soluble Cr(VI), adsorbed Cr(VI), immobilized Cr(VI) and immobilized Cr(III) in soils with aging. We conclude that (i) Cr(VI) reduction and immobilization were occurring concurrently in soils and competing for available Cr(VI) species; (ii) Cr(VI) reduction is favored by low soil pH and high organic carbon, while Cr(VI) immobilization occurs with cations (such as Ca2+) and Fe oxides.

Failure of chelator-provoked urine testing results to predict heavy metal toxicity in a prospective cohort of patients referred for medical toxicology evaluation.

INTRODUCTION: Provoked urine testing (PUT), involving chelating agent administration prior to measuring urine metal excretion levels, is used by some alternative health care practitioners to diagnose patients with heavy metal poisoning. Multiple medical societies have advised against this practice due to its presumed unreliability, expense, and lack of validation. However, no prospective study of the predictive value of PUT for heavy metal poisoning has been undertaken. METHODS: This study utilized the Toxicology Consortium's prospective case registry to evaluate the reliability of PUT for diagnosing heavy metal poisoning. Inclusion criteria were toxicology clinic patients with PUT results who were subsequently evaluated by a board-certified medical toxicologist and had a determination made regarding whether their signs and symptoms were likely related or unrelated to toxicologic exposures. The primary outcome was the positive predictive value of PUT for heavy metal toxicity as diagnosed by the evaluating medical toxicologist. Patients presenting to participating toxicology clinics without PUT served as a comparison group. RESULTS: 74 of 106 cases presenting with PUT results met inclusion criteria and were analyzed. 15 cases were determined by the examining toxicologist to be likely related to a toxicologic exposure. Only three cases were found to be related to heavy metal exposure, giving a positive predictive value of 4.3%. 20.2% of patients with PUT were found to have signs or symptoms related to any toxicologic exposure, compared to 14.3% of clinic patients without PUT. Demographics of toxicology clinic patients with and without PUT results were not significantly different except for age. DISCUSSION: Our results provide empiric support that PUT is an inaccurate predictor of a diagnosis of heavy metal poisoning by a board-certified medical toxicologist. Given the inability to properly interpret PUT results along with the increased cost burden and risk of false positives, PUT should not be performed.

Impact of pyrolysis temperature and activation on oily sludge-derived char for Pb(II) and Cd(II) removal from aqueous solution.

This study investigated the Pb(II) and Cd(II) sorption from aqueous solution by oily sludge-derived char (OSDC) prepared at different pyrolysis temperatures and chemical activation. The maximum Pb(II) sorption capacity for OSDC at pyrolysis temperature of 500 °C (OS500) was found as 351.48 mg/g, which was greater than that of OSDC produced at other temperatures. Post-sorption characterizations using X-ray diffraction (XRD), Fourier transform infrared spectroscopy (FTIR), and sequential extraction test indicated the precipitation was the principal mechanism of sorption of Pb(II) onto OSDC prepared at low pyrolysis temperature (≤ 500 °C). The Pb(II) sorption capacity dramatically decreased as the pyrolysis increased from 500 to 900 °C. This is because the alkaline minerals decomposed at high temperature (≥ 700 °C), thereby the mineral precipitation with Pb(II) was inhibited. With increasing pyrolysis temperature from 500 to 900 °C, the contribution of precipitation to Pb(II) sorption decreased from 93.79 to 34.63%, while the contribution of complexation increased from 0 to 44.68%. The sorption capacity of Cd(II) was less than that of Pb(II), and no precipitation was formed during Cd(II) sorption by OSDC. Sorption results showed that OSDC prepared at pyrolysis temperature of 700 °C (OS700) had the best sorption capacity for Cd(II) (92.14 mg/g). The high sorption capacity of OS700 for Cd(II) was mainly attributed to the carboxyl/hydroxyl functional groups and complexation with mineral oxides. The hydrothermal treatment (8M NaOH solution) activated OS500 significantly with respect to surface area, cation exchange capacity (CEC), and total pore volume (PV). The substitution of Pb(II) with alkaline earth metals led to precipitation in the form of hydrocerussite (Pb3(CO3)2(OH)2) that was mainly responsible for Pb(II) sorption on activated OS500 (accounted for 93.79%). The activated OS500 showed a higher sorption capacity (90.06 mg/g) for Cd(II) than OS500 (23.95 mg/g) because the conversion of barite (BaSO4) to witherite (BaCO3) after chemical activation favored the precipitation of Cd carbonate. The contributions of precipitation to the total Cd(II) removal was 0% for OS500 but 76.12% for the activated OS500.

Formation and Immobilization of Cr(VI) Species in Long-Term Tannery Waste Contaminated Soils.

Chromium speciation in naturally contaminated soils appears more complex than spiked studies have shown. This study characterized Cr speciation (oxidation states; availability; molecular geometry) intended to highlight the genesis of immobile Cr(VI) species in long-term tannery waste-contaminated soils. In a series of samples obtained from Shuitou in China, chemical extraction methods showed that Cr(III) was dominant(>96.7% of total Cr), with Cr(VI) concentration up to 144 mg kg-1. Of the total Cr(VI) present, immobile Cr(VI) represents >90%. Synchrotron-based X-ray near-edge structure spectroscopy (XANES) showed the occurrence of Cr(VI), which was not removed by phosphate buffer extraction, confirming a significant amount of immobile Cr(VI) fractions in soils. X-ray fluorescence maps exhibited the heterogeneous distribution of Cr in soils associated with both Mn and Fe. Such a distribution suggests Cr(III) oxidation to Cr(VI) by Mn oxides and a possible immobilization of both Cr(III) and Cr(VI) onto Fe (hydr)oxides. Linear combination fitting of XANES spectra revealed that fractional weights (%) in samples were CrFeO3 (49.3-53.6), CrOOH (22.3-30.8), and CaCrO4 (13.2-25.3). Our results demonstrate that (i) Cr(VI) is immobilized in soils and (ii) mechanisms of Cr(VI) immobilization are CaCrO4 precipitation and recrystallization with Fe (hydr)oxides.

Intense pulsed light treatment for dry eye disease due to meibomian gland dysfunction; a 3-year retrospective study.

OBJECTIVE: The purpose of this study was to determine the clinical benefits of intense-pulsed-light therapy for the treatment of dry-eye disease caused by meibomian gland dysfunction (MGD). BACKGROUND DATA: MGD is the leading cause of evaporative dry eye disease. It is currently treated with a range of methods that have been shown to be only somewhat effective, leading to the need for advanced treatment options. METHODS: A retrospective noncomparative interventional case series was conducted with 91 patients presenting with severe dry eye syndrome. Treatment included intense-pulsed-light therapy and gland expression at a single outpatient clinic over a 30-month study. Pre/post tear breakup time data were available for a subset of 78 patients. For all patients, a specially developed technique for the treatment of dry eye syndrome was applied as a series of monthly treatments until there was adequate improvement in dry eye syndrome symptoms by physician judgment, or until patient discontinuation. RESULTS: Primary outcomes included change in tear breakup time, self-reported patient satisfaction, and adverse events. Physician-judged improvement in dry eye tear breakup time was found for 68 of 78 patients (87%) with seven treatment visits and four maintenance visits on average (medians), and 93% of patients reported post-treatment satisfaction with degree of dry eye syndrome symptoms. Adverse events, most typically redness or swelling, were found for 13% of patients. No serious adverse events were found. CONCLUSIONS: Although preliminary, study results of intense-pulsed-light therapy treatment for dry eye syndrome caused by meibomian gland dysfunction are promising. A multisite clinical trial with a larger sample, treatment comparison groups, and randomized controlled trials is currently underway.

LinkIT: a ludic elicitation game for eliciting risk perceptions.

The mental models approach, a leading strategy to develop risk communications, involves a time- and labor-intensive interview process and a lengthy questionnaire to elicit group-level risk perceptions. We propose that a similarity ratings approach for structural knowledge elicitation can be adopted to assist the risk mental models approach. The LinkIT game, inspired by games with a purpose (GWAP) technology, is a ludic elicitation tool designed to elicit group understanding of the relations between risk factors in a more enjoyable and productive manner when compared to traditional approaches. That is, consistent with the idea of ludic elicitation, LinkIT was designed to make the elicitation process fun and enjoyable in the hopes of increasing participation and data quality in risk studies. Like the mental models approach, the group mental model obtained via the LinkIT game can hence be generated and represented in a form of influence diagrams. In order to examine the external validity of LinkIT, we conducted a study to compare its performance with respect to a more conventional questionnaire-driven approach. Data analysis results conclude that the two group mental models elicited from the two approaches are similar to an extent. Yet, LinkIT was more productive and enjoyable than the questionnaire. However, participants commented that the current game has some usability concerns. This presentation summarizes the design and evaluation of the LinkIT game and suggests areas for future work.

An observational study to assess an electronic point-of-care wound documentation and reporting system regarding user satisfaction and potential for improved care.

The integration of information technology into daily patient care potentially provides a means to standardize care and enable continuous quality improvement through improved communication among care teams. A 2-month observational study was conducted on 38 residents with pressure ulcers at a 51-bed skilled nursing facility to rate the Ease of Use and Wound Management Effectiveness of a point-of-care electronic wound documentation system. Nine nurses evaluated the use of handheld "smart phone" devices equipped with a digital camera to document pressure ulcer assessment and treatment at point of care. Ease of Use (five items) was scored on a 5-point Likert scale (5 = very easy); Wound Management Effectiveness (eight items) was scored on a 5-point Likert scale (5 = very effective). Statistically significant mean changes in nurses' ratings were found for baseline compared to 2-month follow-up by paired t-test. Ease of Use ratings across the five criteria increased from an overall mean of 3.3 at baseline to 4.7 at follow-up (P = 0.5), while Wound Management Effectiveness increased from an overall mean of 3.3 at baseline to 4.4 at follow-up (P = 0.5) . The greatest gains for single items were reviewing wound progress (mean difference = 2.35; P = 0.000) and recognizing changes in wound status (mean difference = 1.78; P = 0.001) within the Ease of Use and Wound Management Effectiveness scales, respectively. The smallest change occurred in reading charts and notes (mean difference = 0.89) and ability to determine resident's risk level (mean difference = 0.39). Further research is needed to assess use of a wound documentation system in this and other settings, as well as to ascertain validity and reliability.

Bilateral, geographic, peripapillary, chorioretinal atrophy in a patient with porphyria cutanea tarda and high iron stores.

PURPOSE: Porphyria cutanea tarda (PCT) is a systemic disease caused by a deficiency of the enzyme uroporphyrinogen decarboxylase, which is the fifth enzyme in the heme biosynthetic pathway. This deficiency prevents porphyrin and its byproducts from producing heme. CASE REPORT: This case report presents a patient with PCT that is further complicated by high iron stores, chronic hepatitis C virus (HCV), and a history of alcoholism. Bilateral, geographic, peripapillary chorioretinal atrophy is evident and shows progression over a significant period despite improving the PCT. CONCLUSION: A bilateral and progressive appearance of a retinal pathology in a middle-age male patient, with no family ocular history, suggests systemic causation. One theory includes a back flow of porphyrin byproducts from PCT. This is exacerbated by a less-than-productive liver caused by high iron stores, chronic HCV, and a history of alcoholism, which prevents the normal filtering process to occur. We believe this is the first report of a case of presumed bilateral, geographic, peripapillary chorioretinal atrophy in a patient with PCT, complicated by high iron stores, HCV, and alcoholism.

Risk analysis for critical asset protection.

This article proposes a quantitative risk assessment and management framework that supports strategic asset-level resource allocation decision making for critical infrastructure and key resource protection. The proposed framework consists of five phases: scenario identification, consequence and criticality assessment, security vulnerability assessment, threat likelihood assessment, and benefit-cost analysis. Key innovations in this methodology include its initial focus on fundamental asset characteristics to generate an exhaustive set of plausible threat scenarios based on a target susceptibility matrix (which we refer to as asset-driven analysis) and an approach to threat likelihood assessment that captures adversary tendencies to shift their preferences in response to security investments based on the expected utilities of alternative attack profiles assessed from the adversary perspective. A notional example is provided to demonstrate an application of the proposed framework. Extensions of this model to support strategic portfolio-level analysis and tactical risk analysis are suggested.

Critical asset and portfolio risk analysis: an all-hazards framework.

This article develops a quantitative all-hazards framework for critical asset and portfolio risk analysis (CAPRA) that considers both natural and human-caused hazards. Following a discussion on the nature of security threats, the need for actionable risk assessments, and the distinction between asset and portfolio-level analysis, a general formula for all-hazards risk analysis is obtained that resembles the traditional model based on the notional product of consequence, vulnerability, and threat, though with clear meanings assigned to each parameter. Furthermore, a simple portfolio consequence model is presented that yields first-order estimates of interdependency effects following a successful attack on an asset. Moreover, depending on the needs of the decisions being made and available analytical resources, values for the parameters in this model can be obtained at a high level or through detailed systems analysis. Several illustrative examples of the CAPRA methodology are provided.

Petroleum hydrocarbon contamination in boreal forest soils: a mycorrhizal ecosystems perspective.

The importance of developing multi-disciplinary approaches to solving problems relating to anthropogenic pollution is now clearly appreciated by the scientific community, and this is especially evident in boreal ecosystems exposed to escalating threats of petroleum hydrocarbon (PHC) contamination through expanded natural resource extraction activities. This review aims to synthesize information regarding the fate and behaviour of PHCs in boreal forest soils in both ecological and sustainable management contexts. From this, we hope to evaluate potential management strategies, identify gaps in knowledge and guide future research. Our central premise is that mycorrhizal systems, the ubiquitous root symbiotic fungi and associated food-web communities, occupy the structural and functional interface between decomposition and primary production in northern forest ecosystems (i.e. underpin survival and productivity of the ecosystem as a whole), and, as such, are an appropriate focal point for such a synthesis. We provide pertinent basic information about mycorrhizas, followed by insights into the ecology of ecto- and ericoid mycorrhizal systems. Next, we review the fate and behaviour of PHCs in forest soils, with an emphasis on interactions with mycorrhizal fungi and associated bacteria. Finally, we summarize implications for ecosystem management. Although we have gained tremendous insights into understanding linkages between ecosystem functions and the various aspects of mycorrhizal diversity, very little is known regarding rhizosphere communities in PHC-contaminated soils. This makes it difficult to translate ecological knowledge into environmental management strategies. Further research is required to determine which fungal symbionts are likely to survive and compete in various ecosystems, whether certain fungal - plant associations gain in ecological importance following contamination events, and how PHC contamination may interfere with processes of nutrient acquisition and exchange and metabolic processes. Research is also needed to assess whether the metabolic capacity for intrinsic decomposition exists in these ecosystems, taking into account ecological variables such as presence of other organisms (and their involvement in syntrophic biodegradation), bioavailability and toxicity of mixtures of PHCs, and physical changes to the soil environment.

The changing incidence of ventricular fibrillation in Milwaukee, Wisconsin (1992-2002).

OBJECTIVES: To investigate the changes in annual incidence and survival of out-of-hospital cardiac-etiology arrests of different initial rhythms, particularly ventricular fibrillation (VF) and ventricular tachycardia (VT), among adults (> 21 years old) in Milwaukee County between 1992 and 2002 and establish correlations with patient and emergency medical services (EMS) system-dependent factors. METHODS: The study was a retrospective, observational study of all adult (> 21-year-old) patients with out-of-hospital cardiac-etiology arrests with identifiable rhythm and resuscitation attempted by the Milwaukee County EMS system from 1992 to 2002. Nine thousand one hundred seventy cases were enrolled. Primary outcome measures were changes in annual incidence of initial cardiac arrest rhythm, with a focus on VF/VT. Secondary outcome measures were changes in survival to hospital admission and hospital discharge for VF and VT. Patient and EMS system factors potentially affecting the outcome measures were identified and modeled using multivariate logistic regression. RESULTS: The incidence of out-of-hospital VF/VT arrests decreased steadily from 37.1 per 100,000 in 1992 to 19.4 per 100,000 in 2002. While the incidences of pulseless electrical activity and overall cardiac arrest remained unchanged, the incidence of asystole during the study period increased from 27.3/100,000 to 44.9/100,000. Multivariate regression analyses revealed that age < 80 years, male gender, white race, previous cardiac surgery, and cardiac history were patient-dependent factors predictive of VF/VT. Witnessed arrest, public location, and shorter response time were EMS system-dependent factors predictive of VF/VT. Based on observed trends, none of these correlated factors could explain the decrease in the incidence of VF/VT arrests. Rates of patient survival to hospital admission and discharge were not significantly changed over time. EMS system factors predictive of survival to admission and discharge were witnessed arrest, public location, and decreased number of defibrillations. Prior cardiac surgery and absence of chronic problems were the only patient factors predictive of survival to hospital admission but were not significantly related to survival to hospital discharge. CONCLUSIONS: The incidence of out-of-hospital cardiac arrests in adult patients with presenting rhythm of VF/VT declined, while an increase in asystole occurred. This was not explained by any patient or EMS system-dependent factor. Rate of survival for VF/VT arrest did not significantly change over time. Survival was primarily influenced by EMS system factors and unrelated to patient-dependent factors.