Occurrence and fate of trace organic contaminants in onsite wastewater treatment systems and implications for water quality management

March 2009.Includes bibliographical references

Evaluating a Prioritization Framework for Monitoring Chemicals of Emerging Concern in the Salish Sea Based on Lessons Learned from Western States Programs

We are now approaching a tipping point where priority pollutants may no longer be the primary driver of environmental impairment. Contaminants of Emerging Concern (CECs) present a challenge to environmental monitoring and management programs because the rapidly emerging state of the knowledge requires an adaptive and transparent prioritization framework. The state of the science, treatment technologies, and regulatory policies are not well understood, CEC quantification is challenging and expensive, and the management approach is not simply a concentration based criteria, but may include biological end-points. The need for a shared responsibility and leveraging across many programs was evaluated through a series of webinars with other programs studying CECs including Columbia River Toxics Program, Washington Department of Ecology, Oregon Department of Environmental Quality, Southern California Coastal Waters Research Project, and San Francisco Bay Regional Monitoring Program. The lessons learned were articulated into a 10-step prioritization framework. The critical lesson learned included: 1) Develop clear objectives, definitions of CECs, and target audience; 2) Identify conceptual models to provide a clear target for the appropriate media to monitor for various chemicals and at what frequency; 3) Define the chemical characteristics in terms of usage, persistence, bioaccumulation, and toxicity; 4) Develop a target CEC analyte list; 5) Screen and rank the CEC analyte list based on chemical characteristics, environmental concentrations, and state of the science; 6) Create a transparent prioritization process to include input from key stakeholders and end users that builds consensus during development; 7) Prioritize the chemical categories by using specific metrics such as available data, status of analytical methods, available thresholds, costs, programmatic concerns and opportunities for leveraging with other programs; 8) Identify potential biological end-points and other indicators; 9) Create a formal review process to support data and knowledge sharing, adaptively manage prioritization to include new science and critical research gaps; and 10) Develop a working group to facilitate leveraging of funds across many programs

Improving access to emergent spinal care through knowledge translation : an ethnographic study

Background: For patients and family members, access to timely specialty medical care for emergent spinal conditions is a significant stressor to an already serious condition. Timing to surgical care for emergent spinal conditions such as spinal trauma is an important predictor of outcome. However, few studies have explored ethnographically the views of surgeons and other key stakeholders on issues related to patient access and care for emergent spine conditions. The primary study objective was to determine the challenges to the provision of timely care as well as to identify areas of opportunities to enhance care delivery. Methods: An ethnographic study of key administrative and clinical care providers involved in the triage and care of patients referred through CritiCall Ontario was undertaken utilizing standard methods of qualitative inquiry. This comprised 21 interviews with people involved in varying capacities with the provision of emergent spinal care, as well as qualitative observations on an orthopaedic/neurosurgical ward, in operating theatres, and at CritiCall Ontario’s call centre. Results: Several themes were identified and organized into categories that range from inter-professional collaboration through to issues of hospital-level resources and the role of relationships between hospitals and external organizations at the provincial level. Underlying many of these issues is the nature of the medically complex emergent spine patient and the scientific evidentiary base upon which best practice care is delivered. Through the implementation of knowledge translation strategies facilitated from this research, a reduction of patient transfers out of province was observed in the one-year period following program implementation. Conclusions: Our findings suggest that competing priorities at both the hospital and provincial level create challenges in the delivery of spinal care. Key stakeholders recognized spinal care as aligning with multiple priorities such as emergent/critical care, medical through surgical, acute through rehabilitative, disease-based (i.e. trauma, cancer), and wait times initiatives. However, despite newly implemented strategies, there continues to be increasing trends over time in the number of spinal CritiCall Ontario referrals. This reinforces the need for ongoing inter-professional efforts in care delivery that take into account the institutional contexts that may constrain individual or team efforts

Intentional and unintentional medication non-adherence in psoriasis: The role of patients’ medication beliefs and habit strength

Medication non-adherence is a missed opportunity for therapeutic benefit. We assessed “real-world” levels of self-reported non-adherence to conventional and biologic systemic therapies used for psoriasis and evaluated psychological and biomedical factors associated with non-adherence using multivariable analyses. Latent profile analysis was used to investigate whether patients can be categorized into groups with similar medication beliefs. Latent profile analysis categorizes individuals with similar profiles on a set of continuous variables into discrete groups represented by a categorical latent variable. Eight hundred and eleven patients enrolled in the British Association of Dermatologists Biologic Interventions Register were included. Six hundred and seventeen patients were using a self-administered systemic therapy; 22.4% were classified as “non-adherent” (12% intentionally and 10.9% unintentionally). Patients using an oral conventional systemic agent were more likely to be non-adherent compared to those using etanercept or adalimumab (29.2% vs. 16.4%; P ≤ 0.001). Latent profile analysis supported a three-group model; all groups held strong beliefs about their need for systemic therapy but differed in levels of medication concerns. Group 1 (26.4% of the sample) reported the strongest concerns, followed by Group 2 (61%), with Group 3 (12.6%) reporting the weakest concerns. Group 1 membership was associated with intentional non-adherence (odds ratio = 2.27, 95% confidence interval = 1.16−4.47) and weaker medication-taking routine or habit strength was associated with unintentional non-adherence (odds ratio = 0.92, 95% confidence interval = 0.89−0.96). Medication beliefs and habit strength are modifiable targets for strategies to improve adherence in psoriasis

Multiple novel prostate cancer susceptibility signals identified by fine-mapping of known risk loci among Europeans

Genome-wide association studies (GWAS) have identified numerous common prostate cancer (PrCa) susceptibility loci. We have fine-mapped 64 GWAS regions known at the conclusion of the iCOGS study using large-scale genotyping and imputation in 25 723 PrCa cases and 26 274 controls of European ancestry. We detected evidence for multiple independent signals at 16 regions, 12 of which contained additional newly identified significant associations. A single signal comprising a spectrum of correlated variation was observed at 39 regions; 35 of which are now described by a novel more significantly associated lead SNP, while the originally reported variant remained as the lead SNP only in 4 regions. We also confirmed two association signals in Europeans that had been previously reported only in East-Asian GWAS. Based on statistical evidence and linkage disequilibrium (LD) structure, we have curated and narrowed down the list of the most likely candidate causal variants for each region. Functional annotation using data from ENCODE filtered for PrCa cell lines and eQTL analysis demonstrated significant enrichment for overlap with bio-features within this set. By incorporating the novel risk variants identified here alongside the refined data for existing association signals, we estimate that these loci now explain ∼38.9% of the familial relative risk of PrCa, an 8.9% improvement over the previously reported GWAS tag SNPs. This suggests that a significant fraction of the heritability of PrCa may have been hidden during the discovery phase of GWAS, in particular due to the presence of multiple independent signals within the same regio

AI is a viable alternative to high throughput screening: a 318-target study

: High throughput screening (HTS) is routinely used to identify bioactive small molecules. This requires physical compounds, which limits coverage of accessible chemical space. Computational approaches combined with vast on-demand chemical libraries can access far greater chemical space, provided that the predictive accuracy is sufficient to identify useful molecules. Through the largest and most diverse virtual HTS campaign reported to date, comprising 318 individual projects, we demonstrate that our AtomNet® convolutional neural network successfully finds novel hits across every major therapeutic area and protein class. We address historical limitations of computational screening by demonstrating success for target proteins without known binders, high-quality X-ray crystal structures, or manual cherry-picking of compounds. We show that the molecules selected by the AtomNet® model are novel drug-like scaffolds rather than minor modifications to known bioactive compounds. Our empirical results suggest that computational methods can substantially replace HTS as the first step of small-molecule drug discovery

Disengaged : a qualitative study of communication and collaboration between physicians and other professions on general internal medicine wards

BACKGROUND: Poor interprofessional communication in hospital is deemed to cause significant patient harm. Although recognition of this issue is growing, protocols are being implemented to solve this problem without empirical research on the interprofessional communication interactions that directly underpin patient care. We report here the first large qualitative study of directly-observed talk amongst professions in general internal medicine wards, describing the content and usual conversation partners, with the aim of understanding the mechanisms by which current patterns of interprofessional communications may impact on patient care. METHODS: Qualitative study with 155 hours of data-collection, including observation and one-on-one shadowing, ethnographic and semi-structured interviews with physicians, nurses, and allied health professionals in the General Internal Medicine (GIM) wards of two urban teaching hospitals in Canada. Data were coded and analysed thematically with a focus on collaborative interactions between health professionals in both interprofessional and intraprofessional contexts. RESULTS: Physicians in GIM wards communicated with other professions mainly in structured rounds. Physicians' communications were terse, consisting of reports, requests for information, or patient-related orders. Non-physician observations were often overlooked and interprofessional discussion was rare. Intraprofessional interactions among allied health professions, and between nursing, as well as interprofessional interactions between nursing and allied health were frequent and deliberative in character, but very few such discussions involved physicians, whose deliberative interactions were almost entirely with other physicians. CONCLUSION: Without interprofessional problem identification and discussion, physician decisions take place in isolation. While this might be suited to protocol-driven care for patients whose conditions were simple and courses predictable, it may fail complex patients in GIM who often need tailored, interprofessional decisions on their care.Interpersonal communication training to increase interprofessional deliberation may improve efficiency, patient-centredness and outcomes of care in hospitals. Also, electronic communications tools which reduce cognitive burden and facilitate the sharing of clinical observations and orders could help physicians to engage more in non-medical deliberation. Such interventions should take into account real-world power differentials between physicians and other health professions

Update from CDC's Public Health Surveillance & Informatics Program Office (PHSIPO)

OBJECTIVE: To provide updates on current activities and future directions for the National Notifiable Diseases Surveillance System (NNDSS), BioSense 2.0, and the Behavioral Risk Factor Surveillance System (BRFSS) and on the role of PHSIPO as the “home” at CDC for addressing cross-cutting issues in surveillance and informatics practice. INTRODUCTION: The practice of public health surveillance is evolving as electronic health records (EHRs) and automated laboratory information systems are increasing adopted, as new approaches for health information exchange are employed, and as new health information standards affect the entire cascade of surveillance information flow. These trends have been accelerated by the Federal program to promote the Meaningful Use of electronic health records, which includes explicit population health objectives. The growing use of Internet “cloud” technology provides new opportunities for improving information sharing and for reducing surveillance costs. Potential benefits include not only faster and more complete surveillance but also new opportunities for providing population health information back to clinicians. For public health surveys, new Internet-based sampling and survey methods hold the promise of complementing existing telephone-based surveys, which have been plagued by declining response rates despite the addition of cell-phone sampling. While new technologies hold promise for improving surveillance practice, there are multiple challenges, including constraints on public health budgets and the workforce. This panel will explore how PHSIPO is addressing these opportunities and challenges. METHODS: Panelists will provide updates on 1) PHSIPO’s role in engaging health departments, the organizations that represent them, and CDC programs in shaping national policies for implementing the Meaningful Use program, 2) how the BioSense 2.0 program is supporting growth in syndromic surveillance capacity, including its partnership with ISDS in developing standards for syndromic surveillance as part of Meaningful Use, 3) improvements that are underway in strengthening the NNDSS, including efforts to improve CDC’s support for health department disease reporting systems and to develop a “shared services” approach that could provide a platform for streamlining the exchange of information between health departments and CDC, 4) pilot development of Internet-based panels of survey volunteers to supplement existing telephone-based sampling in the BRFSS and of approaches to extend BRFSS survey information through consent-based linkage of survey responses to selected measures recorded in respondents’ EHRs. RESULTS: Potential questions or discussion points that might arise include: What can or should be done to assure that the population health objectives of Meaningful Use are fulfilled? What are the lessons learned to date in leveraging investments in the Meaningful Use of EHRs to improve disease reporting and syndromic surveillance systems? What are the next steps in developing BioSense 2.0 to assure that it leads to strengthened surveillance capacity at both state/local and regional/national levels? How can insights from the BioSense redesign be applied to improve case reporting and other surveillance capacities? What is CDC doing to address states’ concerns about the growing number of CDC surveillance systems? How will national discussions about the future of public health affect the future surveillance practice? What can be done to assure the ongoing representativeness of population health surveys? Is it feasible to link BRFSS responses to information obtained from EHRs? How can data from surveillance become part of the real-time evidence base for clinical decision making? CONCLUSIONS: The intended outcome of the panel is to foster a conversation between the panelists and the audience, to inform the audience about recent developments in PHSIPO, to obtain insights from the audience about innovations and ideas arising from their experience, and to generate new ideas for approaches to meeting the needs of public health for surveillance information

Loading estimates of PCBs from upstream sources transported by the Green-Duwamish River, WA to the Lower Duwamish Waterway

The sediments in the Lower Duwamish Waterway (LDW) in Seattle, Washington are contaminated with polychlorinated biphenyls (PCBs) from decades of intense industrial, commercial, and residential activities. Previous studies predicted that greater than 99 percent of new sediment entering the LDW will originate from upstream sources. The U.S. Geological Survey (USGS) is conducting field monitoring to estimate sediment loads and sediment-associated toxic chemical loads from upstream sources in the watershed that are transported by the Green-Duwamish River to the LDW. Two new real-time stream gaging stations in tidally-influenced reaches of the Green-Duwamish River upstream of the LDW were installed (at River Mile, RM, 5 and 10). Each station utilizes an Acoustic Doppler Velocity Meter and turbidity sensor to provide continuous, publicly-available discharge and turbidity data. During a range of hydrological conditions representing seasonal, storm-, and dam-related variations in flow and/or turbidity, the USGS is collecting representative samples of water, suspended sediment and bed sediment from the upstream station (RM 10) for analysis of a broad suite of contaminants including PCB Aroclors and 209 congeners. Concurrent with the chemistry sampling, the USGS is measuring discharge, suspended sediment concentration and particle size distribution, and general water quality parameters. The resulting data is being used to develop regression relations between discrete samples and continuous turbidity and discharge to improve estimates of event, seasonal, and annual sediment loading and sediment-associated chemical loading from the Green-Duwamish River to the LDW. During a spring 2013 storm event with peak flows of 5000 cubic feet per second, a suspended sediment-associated loading of approximately 200 mg/hr of PCBs was estimated, which was more than 50 times higher than low-flow loading estimates. This presentation will provide preliminary results from the first phase of the study and describe current monitoring activities

Update from CDC's Public Health Surveillance & Informatics Program Office (PHSIPO)

The growing automation of healthcare information affects surveillance systems that depend on information arising from healthcare use. Changing communications technologies and styles affect population health surveys. CDC's Public Health Surveillance & Informatics Program Office (PHSIPO) manages the National Notifiable Diseases Surveillance System, BioSense 2.0, and the Behavioral Risk Factor Surveillance System (BRFSS) and serves as the 'home' at CDC for addressing cross-cutting issues in surveillance and informatics practice. This panel will discuss how PHSIPO is supporting health departments in adapting to the changing public health landscape and will provide opportunities to hear from audience members