Assessment of brominated flame retardants in a small mixed waste electronic and electrical equipment (WEEE) plastic recycling stream in the UK.

Identifying the presence of brominated flame retardants (BFRs) within individual polymer types prior to extrusion has given us a unique perspective on which polymers may be problematic in meeting European Union (EU) low persistent organic pollutant (POP) content limits (LPCLs) and the potential for mixed engineering plastics (MEP) to be used as a viable recycled product. Our findings suggest that careful management of the polymer types within the feed chips prior to extrusion could deliver extruded polymer pellets that meet the EU LPCL values for POP-BFRs (i.e. <1000 mg/kg). Within this study, three fractions of extruded polymer pellets ("light", "medium", and "heavy" MEP) were created using density separation. Each fraction was characterised for 28 legacy and novel BFRs with brominated diphenyl ether-209 (BDE-209) (68-37,000 mg/kg) and tetrabromobisphenol-A (TBBP-A) (17-120,000 mg/kg) both predominant and ubiquitous. Portable X-ray fluorescence (XRF) was utilised to measure Br in 120 individual MEP chips of various polymer types. Those chips that XRF flagged as having high Br concentrations (>2500 mg/kg) were subjected to further evaluation for BFR content via mass spectrometry analysis and the results compared with the XRF Br data. This revealed that in 22% of the 120 chips studied, XRF incorrectly identified the LPCL to be exceeded. Our data also identifies the presence of the novel BFRs decabromodiphenyl ethane (DBDPE) and 1,2-bis(2,4,6-tribromophenoxy) ethane (BTBPE) in plastics derived from waste electronic and electrical equipment (WEEE). While the "light-MEP" samples contained POP-BFR concentrations below LPCLs, the "medium-MEP" and "heavy-MEP" fractions exceeded such limits. Management of the polymer chips by colour sorting resulted in significant reductions in concentrations of all BFRs in the clear polymers such that LPCL limits were not exceeded; however, concentration reductions in white polymers were insufficient to meet LPCLs.

Nurse practitioner caseload in primary health care: Scoping review.

OBJECTIVES: To identify recommendations for determining patient panel/caseload size for nurse practitioners in community-based primary health care settings. DESIGN: Scoping review of the international published and grey literature. DATA SOURCES: The search included electronic databases, international professional and governmental websites, contact with experts, and hand searches of reference lists. Eligible papers had to (a) address caseload or patient panels for nurse practitioners in community-based primary health care settings serving an all-ages population; and (b) be published in English or French between January 2000 and July 2014. Level one testing included title and abstract screening by two team members. Relevant papers were retained for full text review in level two testing, and reviewed by two team members. A third reviewer acted as a tiebreaker. Data were extracted using a structured extraction form by one team member and verified by a second member. Descriptive statistics were estimated. Content analysis was used for qualitative data. RESULTS: We identified 111 peer-reviewed articles and grey literature documents. Most of the papers were published in Canada and the United States after 2010. Current methods to determine panel/caseload size use large administrative databases, provider work hours and the average number of patient visits. Most of the papers addressing the topic of patient panel/caseload size in community-based primary health care were descriptive. The average number of patients seen by nurse practitioners per day varied considerably within and between countries; an average of 9-15 patients per day was common. Patient characteristics (e.g., age, gender) and health conditions (e.g., multiple chronic conditions) appear to influence patient panel/caseload size. Very few studies used validated tools to classify patient acuity levels or disease burden scores. DISCUSSION: The measurement of productivity and the determination of panel/caseload size is complex. Current metrics may not capture activities relevant to community-based primary health care nurse practitioners. Tools to measure all the components of these role are needed when determining panel/caseload size. Outcomes research is absent in the determination of panel/caseload size. CONCLUSION: There are few systems in place to track and measure community-based primary health care nurse practitioner activities. The development of such mechanisms is an important next step to assess community-based primary health care nurse practitioner productivity and determine patient panel/caseload size. Decisions about panel/caseload size must take into account the effects of nurse practitioner activities on outcomes of care.

Maternal and neonatal outcomes for pregnancies before and after gastric bypass surgery.

BACKGROUND: Interaction between maternal obesity, intrauterine environment and adverse clinical outcomes of newborns has been described. METHODS: Using statewide birth certificate data, this retrospective, matched-control cohort study compared paired birth weights and complications of infants born to women before and after Roux-en-Y gastric bypass surgery (RYGB) and to matched obese non-operated women in several different groups. Women who had given birth to a child before and after RYGB (group 1; n=295 matches) and women with pregnancies after RYGB (group 2; n=764 matches) were matched to non-operated women based on age, body mass index (BMI) prior to both pregnancy and RYGB, mother's race, year of mother/s birth, date of infant births and birth order. In addition, birth weights of 13 143 live births before and/or after RYGB of their mothers (n=5819) were compared (group 3). RESULTS: Odds ratios (ORs) for having a large-for-gestational-age (LGA) neonate were significantly less after RYGB than for non-surgical mothers: ORs for groups 1 and 2 were 0.19 (0.08-0.38) and 0.33 (0.21-0.51), respectively. In contrast, ORs in all three groups for risk of having a small for gestational age (SGA) neonate were greater for RYGB mothers compared to non-surgical mothers (ORs were 2.16 (1.00-5.04); 2.16 (1.43-3.32); and 2.25 (1.89-2.69), respectively). Neonatal complications were not different for group 1 RYGB and non-surgical women for the first pregnancy following RYGB. Pregnancy-induced hypertension and gestational diabetes were significantly lower for the first pregnancy of mothers following RYGB compared to matched pregnancies of non-surgical mothers. CONCLUSION: Women who had undergone RYGB not only had lower risk for having an LGA neonate compared to BMI-matched mothers, but also had significantly higher risk for delivering an SGA neonate following RYGB. RYGB women were less likely than non-operated women to have pregnancy-related hypertension and diabetes.

A reanalysis of cluster randomized trials showed interrupted time-series studies were valuable in health system evaluation.

OBJECTIVES: There is often substantial uncertainty about the impacts of health system and policy interventions. Despite that, randomized controlled trials (RCTs) are uncommon in this field, partly because experiments can be difficult to carry out. An alternative method for impact evaluation is the interrupted time-series (ITS) design. Little is known, however, about how results from the two methods compare. Our aim was to explore whether ITS studies yield results that differ from those of randomized trials. STUDY DESIGN AND SETTING: We conducted single-arm ITS analyses (segmented regression) based on data from the intervention arm of cluster randomized trials (C-RCTs), that is, discarding control arm data. Secondarily, we included the control group data in the analyses, by subtracting control group data points from intervention group data points, thereby constructing a time series representing the difference between the intervention and control groups. We compared the results from the single-arm and controlled ITS analyses with results based on conventional aggregated analyses of trial data. RESULTS: The findings were largely concordant, yielding effect estimates with overlapping 95% confidence intervals (CI) across different analytical methods. However, our analyses revealed the importance of a concurrent control group and of taking baseline and follow-up trends into account in the analysis of C-RCTs. CONCLUSION: The ITS design is valuable for evaluation of health systems interventions, both when RCTs are not feasible and in the analysis and interpretation of data from C-RCTs.

Advanced practice nursing in Canada: overview of a decision support synthesis.

The objective of this decision support synthesis was to identify and review published and grey literature and to conduct stakeholder interviews to (1) describe the distinguishing characteristics of clinical nurse specialist (CNS) and nurse practitioner (NP) role definitions and competencies relevant to Canadian contexts, (2) identify the key barriers and facilitators for the effective development and utilization of CNS and NP roles and (3) inform the development of evidence-based recommendations for the individual, organizational and system supports required to better integrate CNS and NP roles into the Canadian healthcare system and advance the delivery of nursing and patient care services in Canada. Four types of advanced practice nurses (APNs) were the focus: CNSs, primary healthcare nurse practitioners (PHCNPs), acute care nurse practitioners (ACNPs) and a blended CNS/NP role. We worked with a multidisciplinary, multijurisdictional advisory board that helped identify documents and key informant interviewees, develop interview questions and formulate implications from our findings. We included 468 published and unpublished English- and French-language papers in a scoping review of the literature. We conducted interviews in English and French with 62 Canadian and international key informants (APNs, healthcare administrators, policy makers, nursing regulators, educators, physicians and other team members). We conducted four focus groups with a total of 19 APNs, educators, administrators and policy makers. A multidisciplinary roundtable convened by the Canadian Health Services Research Foundation formulated evidence-informed policy and practice recommendations based on the synthesis findings. This paper forms the foundation for this special issue, which contains 10 papers summarizing different dimensions of our synthesis. Here, we summarize the synthesis methods and the recommendations formulated at the roundtable.

Systematic reviews and original articles differ in relevance, novelty, and use in an evidence-based service for physicians: PLUS project.

OBJECTIVES: To describe the ratings from physicians, and use by physicians, of high quality, clinically pertinent original articles and systematic reviews from over 110 clinical journals and the Cochrane Database of Systematic Reviews (CDSRs). STUDY DESIGN AND SETTING: Prospective observational study. Data were collected via an online clinical rating system of relevance and newsworthiness for quality-filtered clinical articles and via an online delivery service for practicing physicians, during the course of the McMaster Premium LiteratUre Service Trial. Clinical ratings of articles in the MORE system by over 1,900 physicians were compared and the usage rates over 13 months of these articles by physicians, who were not raters, were examined. RESULTS: Systematic reviews were rated significantly higher than original articles for relevance (P<0.001), but significantly lower for newsworthiness (P<0.001). Reviews published in the CDSR had significantly lower ratings for both relevance (P<0.001) and newsworthiness (P<0.001) than reviews published in other journals. Participants accessed reviews more often than original articles (P<0.001), and accessed reviews from journals more often than from CDSR (P<0.001). CONCLUSION: Physician ratings and the use of high-quality original articles and systematic reviews differed, generally favoring systematic reviews over original articles. Reviews published in journals were rated higher and accessed more often than Cochrane reviews.

Calculating human exposure to endocrine disrupting pesticides via agricultural and non-agricultural exposure routes.

Endocrine Disrupting Chemicals (EDCs) are of increasing concern because of their potential impacts on the environment, wildlife and human health. Pesticides and some pesticide metabolites are an important group of EDC, and exposure to them is a poorly quantified source of human and environmental exposure to such chemicals generally. Models for estimating human exposure to Endocrine Disrupting (ED) pesticides are an important risk management tool. Probabilistic models are now being used in addition to deterministic ones in all areas of risk assessment. These can provide more realistic exposure estimates, because they are better able to deal with variation and uncertainty more effectively and better inform risk management decisions. Deterministic models are still used and are of great value where exposure data are scarce. Models or groups of models that provide holistic human ED pesticide exposure estimates are required if the risk posed to humans by ED pesticides is to be better assessed. Much more research is needed to quantify different exposure routes such as exposure from agricultural spray drift and the medical use of pesticides to develop such models. Most available probabilistic models of human exposure were developed in the USA and require modification for use elsewhere. In particular, datasets equivalent to those used to create and apply the American models are required. This paper examines the known routes of human pesticide exposure with particular reference to ED pesticides and their quantification as unlike pesticides generally, many ED pesticides are harmful at very low doses, especially if exposure occurs during sensitive stages of development, producing effects that may not manifest for many years or that affect descendants via epigenetic changes. It also summarises available deterministic and probabilistic models commonly used to calculate human exposure. The main requirement if such models are to be used in the UK is more quantitative data on the sources and pathways of human ED pesticide exposure.

Prediction of citation counts for clinical articles at two years using data available within three weeks of publication: retrospective cohort study.

OBJECTIVE: To determine if citation counts at two years could be predicted for clinical articles that pass basic criteria for critical appraisal using data within three weeks of publication from external sources and an online article rating service. DESIGN: Retrospective cohort study. SETTING: Online rating service, Canada. PARTICIPANTS: 1274 articles from 105 journals published from January to June 2005, randomly divided into a 60:40 split to provide derivation and validation datasets. MAIN OUTCOME MEASURES: 20 article and journal features, including ratings of clinical relevance and newsworthiness, routinely collected by the McMaster online rating of evidence system, compared with citation counts at two years. RESULTS: The derivation analysis showed that the regression equation accounted for 60% of the variation (R2=0.60, 95% confidence interval 0.538 to 0.629). This model applied to the validation dataset gave a similar prediction (R2=0.56, 0.476 to 0.596, shrinkage 0.04; shrinkage measures how well the derived equation matches data from the validation dataset). Cited articles in the top half and top third were predicted with 83% and 61% sensitivity and 72% and 82% specificity. Higher citations were predicted by indexing in numerous databases; number of authors; abstraction in synoptic journals; clinical relevance scores; number of cited references; and original, multicentred, and therapy articles from journals with a greater proportion of articles abstracted. CONCLUSION: Citation counts can be reliably predicted at two years using data within three weeks of publication.

Endocrine disrupting pesticides: implications for risk assessment.

Endocrine disrupting (ED) chemicals are compounds that alter the normal functioning of the endocrine system, potentially causing disease or deformity in organisms and their offspring. Pesticides are used widely to kill unwanted organisms in crops, public areas, homes and gardens and medicinally to kill parasites. Many are proven or suspected to be EDs. Ancient physiological similarities between different vertebrate groups suggest that disorders observed in wildlife may indicate risks to humans. This makes accurate risk assessment and effective legislation difficult. In this paper, the hazardous properties of pesticides which are known to have ED properties are reviewed in order to assess the implications for risk assessment. As well as data on sources of exposure in the United Kingdom (UK) an assessment of the evidence on the health effects of ED pesticides is also included. In total, 127 have been identified from the literature and their effects and modes of action are listed in this paper. Using the UK as a case study, the types and quantities of pesticides used, and their methods of application are assessed, along with their potential pathways to humans. In the UK reliable data are available only for agricultural use, so non-agricultural routes of pesticide exposure have been poorly quantified. The exposure of people resident in or visiting rural areas could also have been grossly under-estimated. Material links between ED pesticide use and specific illnesses or deformities are complicated by the multifactorial nature of disease, which can be affected by factors such as diet. Despite these difficulties, a large body of evidence has accumulated linking specific conditions to ED pesticides in wildlife and humans. A more precautionary approach to the use of ED pesticides, especially for non-essential purposes is proposed.

Which journals do primary care physicians and specialists access from an online service?

OBJECTIVE: The study sought to determine which online journals primary care physicians and specialists not affiliated with an academic medical center access and how the accesses correlate with measures of journal quality and importance. METHODS: Observational study of full-text accesses made during an eighteen-month digital library trial was performed. Access counts were correlated with six methods composed of nine measures for assessing journal importance: ISI impact factors; number of high-quality articles identified during hand-searches of key clinical journals; production data for ACP Journal Club, InfoPOEMs, and Evidence-Based Medicine; and mean clinician-provided clinical relevance and newsworthiness scores for individual journal titles. RESULTS: Full-text journals were accessed 2,322 times by 87 of 105 physicians. Participants accessed 136 of 348 available journal titles. Physicians often selected journals with relatively higher numbers of articles abstracted in ACP Journal Club. Accesses also showed significant correlations with 6 other measures of quality. Specialists' access patterns correlated with 3 measures, with weaker correlations than for primary care physicians. CONCLUSIONS: Primary care physicians, more so than specialists, chose full-text articles from clinical journals deemed important by several measures of value. Most journals accessed by both groups were of high quality as measured by this study's methods for assessing journal importance.

McMaster PLUS: a cluster randomized clinical trial of an intervention to accelerate clinical use of evidence-based information from digital libraries.

BACKGROUND: Physicians have difficulty keeping up with new evidence from medical research. METHODS: We developed the McMaster Premium LiteratUre Service (PLUS), an internet-based addition to an existing digital library, which delivered quality- and relevance-rated medical literature to physicians, matched to their clinical disciplines. We evaluated PLUS in a cluster-randomized trial of 203 participating physicians in Northern Ontario, comparing a Full-Serve version (that included alerts to new articles and a cumulative database of alerts) with a Self-Serve version (that included a passive guide to evidence-based literature). Utilization of the service was the primary trial end-point. RESULTS: Mean logins to the library rose by 0.77 logins/month/user (95% CI 0.43, 1.11) in the Full-Serve group compared with the Self-Serve group. The proportion of Full-Serve participants who utilized the service during each month of the study period showed a sustained increase during the intervention period, with a relative increase of 57% (95% CI 12, 123) compared with the Self-Serve group. There were no differences in these proportions during the baseline period, and following the crossover of the Self-Serve group to Full-Serve, the Self-Serve group's usage became indistinguishable from that of the Full-Serve group (relative difference 4.4 (95% CI -23.7, 43.0). Also during the intervention and crossover periods, measures of self-reported usefulness did not show a difference between the 2 groups. CONCLUSION: A quality- and relevance-rated online literature service increased the utilization of evidence-based information from a digital library by practicing physicians.

Optimal search strategies for detecting cost and economic studies in EMBASE.

BACKGROUND: Economic evaluations in the medical literature compare competing diagnosis or treatment methods for their use of resources and their expected outcomes. The best evidence currently available from research regarding both cost and economic comparisons will continue to expand as this type of information becomes more important in today's clinical practice. Researchers and clinicians need quick, reliable ways to access this information. A key source of this type of information is large bibliographic databases such as EMBASE. The objective of this study was to develop search strategies that optimize the retrieval of health costs and economics studies from EMBASE. METHODS: We conducted an analytic survey, comparing hand searches of journals with retrievals from EMBASE for candidate search terms and combinations. 6 research assistants read all issues of 55 journals indexed by EMBASE for the publishing year 2000. We rated all articles using purpose and quality indicators and categorized them into clinically relevant original studies, review articles, general papers, or case reports. The original and review articles were then categorized for purpose (i.e., cost and economics and other clinical topics) and depending on the purpose as 'pass' or 'fail' for methodologic rigor. Candidate search strategies were developed for economic and cost studies, then run in the 55 EMBASE journals, the retrievals being compared with the hand search data. The sensitivity, specificity, precision, and accuracy of the search strategies were calculated. RESULTS: Combinations of search terms for detecting both cost and economic studies attained levels of 100% sensitivity with specificity levels of 92.9% and 92.3% respectively. When maximizing for both sensitivity and specificity, the combination of terms for detecting cost studies (sensitivity) increased 2.2% over the single term but at a slight decrease in specificity of 0.9%. The maximized combination of terms for economic studies saw no change in sensitivity from the single term and only a 0.1% increase in specificity. CONCLUSION: Selected terms have excellent performance in the retrieval of studies of health costs and economics from EMBASE.

Laparoscopic adrenalectomy for pheochromocytoma. A comparison to aldosteronoma and incidentaloma.

BACKGROUND: Laparoscopic adrenalectomy is a safe and effective treatment for most surgical diseases of the adrenal gland. However it has been suggested that catecholamine effects associated with pheochromocytoma render the laparoscopic approach a more challenging and a more morbid procedure. The purpose of this study was to compare the operative characteristics and outcomes of laparoscopic adrenalectomy for pheochromocytoma to those of aldosteronoma and incidentaloma. METHOD: Patient records and operative reports were retrospectively reviewed for demographics, diagnoses, operative management, and outcomes for patients undergoing laparoscopic adrenalectomy between June 1994 and July 2002 at two academic medical centers. A total of 74 patients were included and analyzed by diagnosis. Differences were considered statistically significant at p < 0.05. RESULTS: Twenty-eight patients with pheochromocytoma, 27 with aldosteronoma, and 19 with incidentally discovered nonfunctioning adrenal masses underwent laparascopic adrenalectomy. Patients undergoing resection for pheochromocytoma trended toward more operative blood loss (150 ml) compared to aldosteronoma (88 ml) and incidentaloma (75 ml). Eight patients were converted to an open procedure for a 10.8% conversion rate. The mean operative time was 171 min and there was a 10.8% perioperative complication rate. The mean hospital stay was 3.4 days. These results were not statistically significant between diagnostic groups. CONCLUSION: Despite concern about increased operative times and morbidity associated with pheochromocytoma, our experience supports that laparoscopic adrenalectomy may be performed as safely as, and achieve outcomes similar to, those for other diseases.

A technique for real-time digital measurements in laparoscopic surgery.

BACKGROUND: The current techniques for the measurement of intracorporeal targets in laparoscopic surgery are relatively cumbersome and imprecise. METHODS: A structured light technique was used to obtain the length and width of two defects and an object in a laparoscopic training box. These measurements were compared against two current and standard laparoscopic techniques of intracorporeal measurement: the introduction of a plastic ruler and the use of an opened end of a laparoscopic instrument to approximate 2 cm. The time needed to measure the defects and object was recorded. RESULTS: Structured light-derived measurements were closest to the criterion standard, followed by plastic ruler measurements, then by instrument-end measurements. Digital measurements were quickest, followed by the instrument-end method, then by the plastic ruler. CONCLUSIONS: This report describes a novel structured light technique for laparoscopic measurement of intracorporeal targets capable of producing results superior to those of current techniques.

Intraabdominal abscess following open and laparoscopic appendectomy in the pediatric population.

BACKGROUND: Studies comparing intraabdominal abscess (IAA) rates following laparoscopic appendectomy (LA) and open appendectomy (OA) have shown conflicting results. METHODS: The charts of 324 children undergoing appendectomy were reviewed retrospectively to examine the incidence of IAA. RESULTS: Of the 324 appendectomies, 204 (63.0%) were completed laparoscopically and 119 (36.7%) were performed open. The conversion rate was 0.2% (1/324). Of the 15 (4.6%) IAAs, 7 occurred in the LA group (3.4%) and 8 occurred in the OA group (6.7%) [p = not significant (NS)]. The incidence of IAA for perforated appendicitis for LA was 15% (7/46) and that for OA was 10% (7/70) (p = NS). CONCLUSION: This study demonstrates no statistically significant difference in the rate of IAA among children following LA and OA. LA can be performed for perforated appendicitis without increasing the risk of IAA.

Interactions of aphid herbivory and nitrogen availability on the total foliar glycoalkaloid content of potato plants.

In plant growth room (PGR) and open-air pot (OAP) experiments, potato cvs King Edward and Maris Piper were grown under two nitrogen levels or two different nitrogen release patterns. Plants were subjected to infestation by peach potato aphids Myzus persicae (Homoptera: Aphididae). Total glycoalkaloid (GA) levels were measured in the foliage of both infested and non-infested plants, before, during and after aphid infestation. In the PGR experiment, aphid infestation reduced the amounts of total GAs in both cultivars. This reduction is attributed to the sugar deficiency induced in the plants owing to the dense aphid colonization. Results from the OAP experiment showed a temporal increase of GAs produced by potato cv. King Edward plants subjected to aphid infestation. Elevated amounts of nitrogen in the nutrient solutions (PGR experiment) reduced total GAs, while no differences were observed between manure and fertilizer treated plants (OAP experiment). It is concluded that the source of available nitrogen does not affect foliar GA synthesis in potatoes, and as a consequence, does not affect its endogenous chemical defense against insect herbivory. The case for insect-induced chemical defense mechanisms as triggered by low rates of aphid infestation is discussed.