The postfinasteride syndrome; an overview

As a 5-α reductase inhibitor, Finasteride has proven effective in ameliorating two conditions documented to be androgen dependent, namely male androgenic alopecia and benign prostatic hyperplasia. Therapeutic results are maintained as long as the drug is administered, with treatment cessation generally leading to the return of symptomatology for each condition. In addition, during the therapeutic phase, several adverse effects have been reported, some of which persist long or indefinitely after treatment cessation, known as “post-finasteride syndrome.” Herein we present and discuss the most common finasteride side effects, along with a psycho-neuroendocrine rationale that could explain the persistence of many adverse effects after treatment cessation. Moreover, we argue that finasteride adverse effects occurring during finasteride administration should be delineated from postfinasteride side effects (encountered after treatment cessation), suggesting the need to be addressed separately within a therapeutic perspective. Until a tailored therapeutic approach of postfinasteride syndrome becomes available, we have noted that hand preference and sexual orientation seem to be useful as possible predicting factors for finasteride side effects and postfinasteride syndrome. Finally, even though finasteride administration is considered relatively safe, literature data urges prudence. Specifically, recent studies report that some subjects receiving finasteride develop severe depressive episodes including suicidal thoughts, in part due to persistent sexual side effects

INNOVATIVE IN-SITU REMEDIATION OF CONTAMINATED SEDIMENTS FOR SIMULTANEOUS CONTROL OF CONTAMINATION AND EROSION

New technologies are needed that neutralize contaminant toxicity and control physical transport mechanisms that mobilize sediment contaminants. The last 12 months of this comprehensive project investigated the use of combinations of sequestering agents to develop in situ active sediment caps that stabilize mixtures of contaminants and act as a barrier to mechanical disturbance under a broad range of environmental conditions. Efforts focused on the selection of effective sequestering agents for use in active caps, the composition of active caps, and the effects of active cap components on contaminant bioavailability and retention. Results from this project showed that phosphate amendments, some organoclays, and the biopolymer, chitosan, were very effective at removing metals from both fresh and salt water. These amendments also exhibited high retention (80% or more) of most metals indicating reduced potential for remobilization to the water column. Experiments on metal speciation and retention in contaminated sediment showed that apatite and organoclay can immobilize a broad range of metals under both reduced and oxidized conditions. These studies were followed by sequential extractions to evaluate the bioavailability and retention of metals in treated sediments. Metal fractions recovered in early extraction steps are more likely to be bioavailable and were termed the Potentially Mobile Fraction (PMF). Less bioavailable fractions collected in later extraction steps were termed the Recalcitrant Factor (RF). Apatite and organoclay reduced the PMF and increased the RF for several elements, especially Pb, Zn, Ni, Cr, and Cd. Empirically determined partitioning coefficients and modeling studies were used to assess the retention of organic contaminants on selected sequestering agents. Organoclays exhibited exceptionally high sorption of polycyclic aromatic hydrocarbons as indicated by a comparison of K{sub d} values among 12 amendments. These results suggested that organoclays have high potential for controlling organic contaminants. Measured partitioning coefficients were used to model the time required for a contaminant to penetrate sediment caps composed of organoclay. The results showed that a thin layer of highly sorptive organoclay can lead to very long migration times, perhaps longer than the expected lifetime of the contaminant in the sediment environment. A one-dimensional numerical model was used to examine the diffusion of metals through several cap material based on measured and assumed material and transport properties. These studies showed that active caps composed of apatite or organoclay have the potential to delay contaminant breakthrough due to diffusion by hundreds of years or more compared with passive caps composed of sand. Advectively dominated column experiments are currently underway to define effective sorption related retardation factors in promising amendments for various hydrophobic organic compounds. Upon completion of these experiments, advection transient models will be used to estimate the time required for the breakthrough of various contaminants in caps composed of different experimental materials. Biopolymer products for inclusion in active caps were evaluated on the basis of resistance to biodegradation, sorption capacity for organic and inorganic contaminants, and potential for erosion control. More than 20 biopolymer products were evaluated resulting in the selection of chitosan/guar gum cross-linked with borax and xanthan/chitosan cross-linked with calcium chloride for inclusion in active caps to produce a barrier that resists mechanical disturbance. A process was developed for coating sand with cross-linked biopolymers to provide a means for delivery to the sediment surface. Properties of biopolymer coated sand such as carbon fraction (indicating biopolymer coverage), porosity, bulk density, and biodegradability have been evaluated, and experiments are currently underway to assess the resistance of biopolymer coated sand to erosion. Although the ability of active cap materials to remediate contaminants has been emphasized in this study, it is also important to ensure that these materials do not have deleterious effects on the environment. Therefore, promising amendments were evaluated for toxicity using 10 day sediment toxicity tests, the standardized Toxicity Characteristic Leaching Procedure (TCLP), and measurement of metal concentrations in aqueous extracts from the amendments. Metal concentrations were below TCLP limits, EPA ambient water quality criteria, and other ecological screening values These results showed that apatite, organoclay, and biopolymer coated sand do not release metals. The sediment toxicity tests indicated that apatite and biopolymer coated sand are unlikely to adversely affect benthic organisms, even when used in high concentrations

SEQUESTERING AGENTS FOR ACTIVE CAPS - REMEDIATION OF METALS AND ORGANICS

This research evaluated organoclays, zeolites, phosphates, and a biopolymer as sequestering agents for inorganic and organic contaminants. Batch experiments were conducted to identify amendments and mixtures of amendments for metal and organic contaminants removal and retention. Contaminant removal was evaluated by calculating partitioning coefficients. Metal retention was evaluated by desorption studies in which residue from the removal studies was extracted with 1 M MgCl{sub 2} solution. The results indicated that phosphate amendments, some organoclays, and the biopolymer, chitosan, were very effective sequestering agents for metals in fresh and salt water. Organoclays were very effective sorbents for phenanthrene, pyrene, and benzo(a)pyrene. Partitioning coefficients for the organoclays were 3000-3500 ml g{sup -1} for benzo(a)pyrene, 400-450 ml g{sup -1} for pyrene, and 50-70 ml g{sup -1} for phenanthrene. Remediation of sites with a mixture of contaminants is more difficult than sites with a single contaminant because metals and organic contaminants have different fate and transport mechanisms in sediment and water. Mixtures of amendments (e.g., organoclay and rock phosphate) have high potential for remediating both organic and inorganic contaminants under a broad range of environmental conditions, and have promise as components in active caps for sediment remediation

Microbial forensics

Burlington, US

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

Prospective observational cohort study on grading the severity of postoperative complications in global surgery research

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally

Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries

This was an investigator initiated study funded by Nestle Health Sciences through an unrestricted research grant, and by a National Institute for Health Research (UK) Professorship held by RP. The study was sponsored by Queen Mary University of London

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

© 2017 British Journal of Anaesthesia Background: The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods: Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results: We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32–0.77); P\u3c0.01], but no difference in complication rates [OR 1.02 (0.88–1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62–0.92); P\u3c0.01; I2=87%] and reduced complication rates [OR 0.73 (0.61–0.88); P\u3c0.01; I2=89%). Conclusions: Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine