Bisphenol A in the Canadian environment: A multimedia analysis.

Bisphenol A (BPA) is an industrial chemical that has been identified by some jurisdictions as an environmental concern. In 2010, Canada concluded that this substance posed a risk to the environment and human health, and implemented actions to reduce its concentrations in the environment. To support these activities, a multimedia analysis of BPA in the Canadian environment was conducted to evaluate spatial and temporal trends, and to infer mechanisms influencing the patterns. BPA was consistently detected in wastewater and biosolids across Canadian wastewater treatment plants (WWTPs) and in landfill leachate. In addition, BPA concentrations were significantly higher in surface water downstream compared to upstream of WWTPs in three of five urban areas evaluated. However, application of biosolids to Canadian agricultural fields did not contribute to elevated BPA concentrations in soil, earthworms, and European Starling (Sturnus vulgaris) plasma one and two years post-treatment. Spatial trends of BPA concentrations in surface water and sediment are influenced by human activity, with higher concentrations typically found downstream of industrial sources and WWTPs in urban areas. BPA was detected in bird plasma at locations impacted by WWTPs and landfills. However, spatial trends in birds were less clear and may have been confounded by metabolic biotransformation. In terms of temporal trends, BPA concentrations in surface water decreased significantly at 10 of 16 monitoring sites evaluated between 2008 and 2018. In contrast, recent temporal trends of BPA in six sediment cores were variable, which may be a result of biotransformation of the flame retardant tetrabromobisphenol A to BPA. Overall, our study provides evidence that Government of Canada actions have been generally successful in reducing BPA concentrations in the Canadian environment. Our results indicate that long-term monitoring programs using surface water are more effective than other media for tracking and understanding future environmental trends of BPA.

Recruitment, retention, and adherence in a clinical trial: The Pediatric Heart Network's Marfan Trial experience.

BACKGROUND/AIMS: The Pediatric Heart Network Marfan Trial was a randomized trial comparing atenolol versus losartan on aortic root dilation in 608 children and young adults with Marfan syndrome. Barriers to enrollment included a limited pool of eligible participants, restrictive entry criteria, and a diverse age range that required pediatric and adult expertise. Retention was complicated by a 3-year commitment to a complex study and medication regimen. The Network partnered with the Marfan Foundation, bridging the community with the research. The aims of this study are to report protocol and medication adherence and associated predictive factors, and to describe recruitment and retention strategies. METHODS: Recruitment, retention, and adherence to protocol activities related to the primary outcome were measured. Retention was measured by percentage of enrolled participants with 3-year outcome data. Protocol adherence was calculated by completion rates of study visits, ambulatory electrocardiography (Holter monitoring), and quarterly calls. Medication adherence was assessed by the number of tablets or the amount of liquid in bottles returned. Centers were ranked according to adherence (high, medium, and low tertiles). Recruitment, retention, and adherence questionnaires were completed by sites. Descriptive statistics summarized recruitment, retention, and adherence, as well as questionnaire results. Regression modeling assessed predictors of adherence. RESULTS: Completion rates for visits, Holter monitors, and quarterly calls were 99%, 94%, and 96%, respectively. Primary outcome data at 3 years were obtained for 88% of participants. The mean percentage of medication taken was estimated at 89%. Site and age were associated with all measures of adherence. Young adult and African American participants had lower levels of adherence. Higher adherence sites employed more strategies; had more staffing resources, less key staff turnover, and more collaboration with referring providers; utilized the Foundation's resources; and used a greater number of strategies to recruit, retain, and promote protocol and medication adherence. CONCLUSION: Overall adherence was excellent for this trial conducted within a National Institutes of Health-funded clinical trial network. Strategies specifically targeted to young adults and African Americans may have been beneficial. Many strategies employed by higher adherence sites are ones that any site could easily use, such as greeting families at non-study hospital visits, asking for family feedback, providing calendars for tracking schedules, and recommending apps for medication reminders. Additional key learnings include adherence differences by age, race, and site, the value of collaborative learning, and the importance of partnerships with patient advocacy groups. These lessons could shape recruitment, retention, and adherence to improve the quality of future complex trials involving rare conditions.

The nuanced negative: Meanings of a negative diagnostic result in clinical exome sequencing.

Genomic sequencing technology is moving rapidly from the research setting into clinical medicine but significant technological and interpretive challenges remain. Exome sequencing (ES) in its recent clinical application provides a genetic diagnosis in about 25 per cent of cases (Berg 2014). While this diagnostic yield is substantial, it also indicates that in a majority of cases, patients are receiving negative results (i.e. no explanatory genetic variant found) from this technology. There are a number of uncertainties regarding the meaning of a negative result in the current context of ES. A negative result may be due to current technological limitations that hinder detection of disease-causing variants or to gaps in the knowledge base that prohibit accurate interpretation of their pathogenicity; or it may indicate that there is not a genetic etiology for the disorder. In this paper we examine the uncertainties and nuances of the negative result from genome sequencing and how both clinicians and patients make meaning of it as revealed in ethnographic observations of the clinic session where results are returned, and in interviews with patients. We find that clinicians and patients construct the meaning of a negative result in ways that are uncertain, contingent, and multivalent; but invested with optimism, promise, and potentiality.

Perfluoroalkyl acids in the Canadian environment: multi-media assessment of current status and trends.

In Canada, perfluoroalkyl acids (PFAAs) have been the focus of several monitoring programs and research and surveillance studies. Here, we integrate recent data and perform a multi-media assessment to examine the current status and ongoing trends of PFAAs in Canada. Concentrations of perfluorooctane sulfonate (PFOS), perfluorooctanoate (PFOA), and other long-chain perfluorocarboxylates (PFCAs) in air, water, sediment, fish, and birds across Canada are generally related to urbanization, with elevated concentrations observed around cities, especially in southern Ontario. PFOS levels in water, fish tissue, and bird eggs were below their respective Draft Federal Environmental Quality Guidelines, suggesting there is low potential for adverse effects to the environment/organisms examined. However, PFOS in fish and bird eggs tended to exceed guidelines for the protection of mammalian and avian consumers, suggesting a potential risk to their wildlife predators, although wildlife population health assessments are needed to determine whether negative impacts are actually occurring. Long-term temporal trends of PFOS in suspended sediment, sediment cores, Lake Trout (Salvelinus namaycush), and Herring Gull (Larus argentatus) eggs collected from Lake Ontario increased consistently from the start of data collection until the 1990s. However, after this time, the trends varied by media, with concentrations stabilizing in Lake Trout and Herring Gull eggs, and decreasing and increasing in suspended sediment and the sediment cores, respectively. For PFCAs, concentrations in suspended sediment, sediment cores, and Herring Gulls generally increased from the start of data collection until present and concentrations in Lake Trout increased until the late 1990s and subsequently stabilized. A multimedia comparison of PFAA profiles provided evidence that unexpected patterns in biota of some of the lakes were due to unique source patterns rather than internal lake processes. High concentrations of PFAAs in the leachate and air of landfill sites, in the wastewater influent/effluent, biosolids, and air at wastewater treatment plants, and in indoor air and dust highlight the waste sector and current-use products (used primarily indoors) as ongoing sources of PFAAs to the Canadian environment. The results of this study demonstrate the utility of integrating data from different media. Simultaneous evaluation of spatial and temporal trends in multiple media allows inferences that would be impossible with data on only one medium. As such, more co-ordination among monitoring sites for different media is suggested for future sampling, especially at the northern sites. We emphasize the importance of continued monitoring of multiple-media for determining future responses of environmental PFAA concentrations to voluntary and regulatory actions.

Health reform: special report. Health reform turns two: after passage of the Affordable Care Act, the work--and the criticisms--persist.

UNLABELLED: NCSL tracks state actions on federal health reform closely. You can learn more about federal regulations, state legislation, Medicaid, insurance reform and more at www.ncsl.org/healthreform. Several NCSL health staff contributed to this package of stories related to the two-year anniversary of the Affordable Care Act. Contributors: Exchanges: job no. 1--Martha Salazar. Big changes for insurers--Richard Cauchi. Sharp divisions persist over law's future--Richard Cauchi. Transforming Medicaid--Melissa Hansen. States decided essential benefits--Richard Cauchi. PREVENTION: more than an ounce--Amy Winerfeld. Help wanted: doctors and nurses--Laura Tobler.

Hurdles of health care reform.

The obstacles are enormous, and so are the stakes. But there are some new ideas for reining in health care costs and keeping Americans healthy.