Medical Specialties Commons^™

The Metreleptin Effectiveness And Safety Registry (Measure): Concept, Design And Challenges, Morey W Haymond, David Araújo-Vilar, John Balser, James H Lewis, Ruth Louzado, Carla Musso, Julia Von Schnurbein, Martin Wabitsch

Faculty, Staff and Students Publications

BACKGROUND: Metreleptin, a recombinant analog of human leptin, is an approved therapy, adjunct to diet, to treat the metabolic complications of leptin deficiency in patients with lipodystrophy - a group of rare diseases characterized by a paucity of adipose tissue. MEASuRE (Metreleptin Effectiveness And Safety Registry) is a post-authorization, voluntary registry that gathers long-term safety and effectiveness data on metreleptin. Here, we present the aims and evolution of MEASuRE.

METHODS: MEASuRE was established to collect data from patients receiving commercially supplied metreleptin in the United States (US) and European Union (EU). MEASuRE aims to determine the incidence and severity of …

Commencement, South Georgia (2023), Philadelphia College Of Osteopathic Medicine

Commencements

South Georgia Campus Commencement Program, 2023. Degrees include Doctor of Osteopathic Medicine and Master of Science in Biomedical Sciences.

Commencement Speaker: Jim Matney, Colquitt Regional Medical Center

A Comparison Of Radiographic Alignment Between Bilateral And Unilateral Interbody Cages In Patients Undergoing Transforaminal Lumbar Interbody Fusion, Mark J. Lambrechts, Jeremy Heard, Nicholas D. D'Antonio, John Bodnar, Gregory Schroeder, Evan Bloom, Jose Canseco, Barrett Woods, Ian David Kaye, Mark Kurd, Jeffrey Rihn, Alan Hilibrand, Gregory D. Schroeder, Alex R. Vaccaro, Christopher Kepler

Rothman Institute Papers

Study Design

Purpose:

Overview of Literature

Methods:

Incidence, Risk Factors, And Outcomes Of Incidental Durotomy During Lumbar Spine Decompression With Or Without Fusion, Gregory Toci, Mark James Lambrechts, Tariq Issa, Brian A. Karamian, Nicholas Siegel, Nicholas D'Antonio, Jose Canseco, Mark Kurd, Barrett Woods, Ian D. Kaye, Alan Hilibrand, Christopher K. Kepler, Alexander Vaccaro, Gregory Schroeder

Rothman Institute Papers

STUDY DESIGN: Retrospective cohort study.

PURPOSE: The primary objective of this study was to determine the incidence and risk factors for incidental durotomies during lumbar decompression surgeries. In addition, we aimed to determine the changes in patient-reported outcome measures (PROMs) based on incidental durotomy status.

OVERVIEW OF LITERATURE: There is limited literature investigating the affect of incidental durotomy on patient reported outcome measures. While the majority of research does not suggest differences in complications, readmission, or revision rates, many studies rely on public databases, and their sensitivity and specificity for identifying incidental durotomies is unknown.

METHODS: Patients undergoing lumbar decompression …

Histological Transformation To Gliosarcoma With Combined Braf/Mek Inhibition In Braf V600e Mutated Glioblastoma, Blessie Elizabeth Nelson, Neha K Reddy, Jason T Huse, Behrang Amini, Mirella Nardo, Mohamed Gouda, Shiao-Pei Weathers, Vivek Subbiah

Faculty, Staff and Student Publications

The identification of BRAF V600 mutation in multiple cancers beyond melanoma and the development of combined BRAF and MEK targeting agents have altered the landscape of tissue-agnostic precision oncology therapies with an impact on survival outcomes. Despite initial efficacy, resistance emerges, and it is pertinent to identify putative resistance mechanisms. We report a case of recurrent glioblastoma (GBM) harboring BRAF V600E alteration who initially responded to combined BRAF + MEK inhibition and subsequently developed treatment resistance by histological transformation to gliosarcoma and acquisition of oncogenic KRAS G12D and an NF1 L1083R mutation. This documented case represents an initial evidence of …

Safety And Indications For Endoscopic Retrograde Cholangiopancreatography In Liver Transplant Patients: An Analysis Of The United States’ National Inpatient Sample Database, Zahid Ijaz Tarar, Umer Farooq, Mustafa Gandhi, Muhammad Usman Zafar, Saad Saleem, Faisal Kamal

Division of Gastroenterology and Hepatology Faculty Papers

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is performed to treat biliary complications after a liver transplantation; however, the previously available literature on the safety of ERCP in liver transplant patients is limited. We aimed to study the safety of ERCP in liver transplant patients.

METHODS: We used a National Inpatient Sample database from 2016-2019 to identify patients who underwent ERCP and had a history of a liver transplantation, using the international classification of diseases, 10

RESULTS: Liver transplant patients who underwent ERCP had a higher rate of post-ERCP pancreatitis and bleeding compared to the general adult population (11.39% vs. 9.19%, 0.83% …

Simple Combination Of Multiple Somatic Variant Callers To Increase Accuracy, Alexander J Trevarton, Jeffrey T Chang, W Fraser Symmans

Faculty, Staff and Student Publications

Publications comparing variant caller algorithms present discordant results with contradictory rankings. Caller performances are inconsistent and wide ranging, and dependent upon input data, application, parameter settings, and evaluation metric. With no single variant caller emerging as a superior standard, combinations or ensembles of variant callers have appeared in the literature. In this study, a whole genome somatic reference standard was used to derive principles to guide strategies for combining variant calls. Then, manually annotated variants called from the whole exome sequencing of a tumor were used to corroborate these general principles. Finally, we examined the ability of these principles to …

Usability And Acceptability Testing Of A Plan Of Safe Care In A Mobile Health Platform, Krystyna R. Isaacs, Elina Bajracharya, Shantae Taylor, Katie Chung, Yukiko Washio, Trenee Parker, David A. Paul, Tony X. Ma

Department of Pediatrics Faculty Papers

Purpose: Women who are pregnant or parenting while recovering from substance use disorder (SUD) are at risk for insufficient recovery support. With the federal mandate, implementation has been left to each state for the Plan of Safe Care (POSC), leading to challenges in providing comprehensive care coordination and meeting federal reporting requirements.

Methods: This research tests the usability and acceptability of a POSC platform, called SAFE4BOTH, which combines a mobile health (mHealth) app for use by mothers with substance use disorder (MSUD) with a web-based case management system for use by stakeholders to reduce the issue of fragmented postnatal maternal …

Deeper Seated Than Skin Deep: Report Of A Rare Case Of Follicular Occlusion Tetrad And A Literature Review, Yilen K. Ng-Wong, Blesset Alexander, Mery Bartl, Christine E. Loftis, Dina Hammad, Emilia C. Dulgheru, Mauricio De La Garza, Aidee C. Nunez

School of Medicine Publications

Follicular occlusion tetrad (FOT) is a clinical syndrome consisting of hidradenitis suppurativa (HS), acne conglobata (AC), dissecting cellulitis of the scalp (DCS), and pilonidal cyst (PC). These entities typically occur independently, but occasionally present simultaneously comprising FOT. The four components share similar pathophysiology affecting the apocrine glands, follicular hyperkeratinization being the hallmark of each entity.Understanding shared similarities of each disease is paramount for the treatment approach as the relapsing and chronic nature of this syndrome can be burdening to patients. We present the case of a 22- year-old obese Hispanic man with a history of tobacco use who presented with …

The Effect Of Perceived Weight Status And Bmi Perception On Food Attitudes And Food Relationships, Sahil K. Patel, Ryan Gericke, Jaime Dougherty, Adarsh Gupta

Rowan-Virtua School of Osteopathic Medicine Departmental Research

CONTEXT: Obesity has been a national epidemic throughout the United States due to the increasingly sedentary western lifestyle, paired with calorically dense abundant low-nutritional food options. Discussing weight necessitates the conversation of not only the numerical value (body mass index [BMI]) associated with obesity but also the perceived weight or how an individual categorizes their weight, irrespective of their calculated BMI classification. Perceived weight can influence food relationships, overall health, and lifestyle habits.

OBJECTIVES: The purpose of this study was to identify differences in dietary habits, lifestyle habits, and food attitudes among three groups: those correctly identifying as "obese" with …

Tapped Twice: A Case Of A Rapidly Re-Accumulating Hepatic Hydrothorax In A Patient With Spontaneous Bacterial Empyema, Amir Khalil, Suma Alzouhayli, Silvia Novakova, Saad Shams, Ahmad Baiyasi, Maria Khalil, Mohammed Uddin, Aryan Shiari, Kareem Bazzy

The University of Louisville Journal of Respiratory Infections

Hepatic hydrothorax (HH) is a complication of decompensated liver cirrhosis that only occurs in about 5–6% of cirrhosis patients, defined as a pleural fluid in the setting of known liver disease, with the absence of any other cardiopulmonary etiology. Infected HH is a rare complication, designated as spontaneous bacterial empyema (SBEM), found in only 13–16% of patients with HH. This case follows a patient with SBEM who developed a recurrent pleural effusion minutes after thoracentesis. Our patient is a 56-year-old female with a history of alcoholic cirrhosis with pleuritic pain found to have right-sided pleural effusion with decompensation. She had …

Transmission Of Mycobacterium Tuberculosis To Healthcare Personnel Resulting From Contaminated Bone Graft Material, United States, June 2021–August 2022, Ruoran Li, Molly Deutsch-Feldman, Tamasin Adams, Michelle Law, Chinpar Biak, Erika Pitcher, Marci Drees, Alfonso C Hernandez-Romieu, Thomas D Filardo, Tracina Cropper, Angelica Martinez, W Wyatt Wilson, Sandy P Althomsons, Sapna Bamrah Morris, Jonathan M Wortham, Isaac Benowitz, Noah G Schwartz, Kelly White, Maryam B Haddad, Janet B Glowicz, Bone Allograft Tuberculosis Investigators

Faculty, Staff and Student Publications

A nationwide tuberculosis outbreak linked to a viable bone allograft product contaminated with Mycobacterium tuberculosis was identified in June 2021. Our subsequent investigation identified 73 healthcare personnel with new latent tuberculosis infection following exposure to the contaminated product, product recipients, surgical instruments, or medical waste.

Single-Compartment Dose Prescriptions For Ablative 90y-Radioembolization Segmentectomy, Srinivas Cheenu Kappadath, Benjamin P Lopez

Faculty, Staff and Student Publications

BACKGROUND: Yttrium-90 (90Y) radioembolization is increasingly being utilized with curative intent. While single-compartment doses with respect to the perfused volume for the complete pathologic necrosis (CPN) of tumors have been reported, the actual doses delivered to the tumor and at-risk margins that leads to CPN have hitherto not been estimated. We present an ablative dosimetry model that calculates the dose distribution for tumors and at-risk margins based on numerical mm-scale dose modeling and the available clinical CPN evidence and report on the necessary dose metrics needed to achieve CPN following 90Y-radioembolization.

METHODS: Three-dimensional (3D) activity distributions (MBq/voxel) simulating spherical tumors …

Gm1 Ganglioside As A Disease-Modifying Therapeutic For Parkinson’S Disease: A Multi-Functional Glycosphingolipid That Targets Multiple Parkinson’S Disease-Relevant Pathogenic Mechanisms, Jay S. Schneider

Department of Pathology, Anatomy, and Cell Biology Faculty Papers

Parkinson’s disease (PD) is a progressive neurodegenerative disorder affecting millions of patients worldwide. Many therapeutics are available for treating PD symptoms but there is no disease-modifying therapeutic that has been unequivocally shown to slow or stop the progression of the disease. There are several factors contributing to the failure of many putative disease-modifying agents in clinical trials and these include the choice of patients and clinical trial designs for disease modification trials. Perhaps more important, however, is the choice of therapeutic, which for the most part, has not taken into account the multiple and complex pathogenic mechanisms and processes involved …

Is There Really A Difference In Outcomes Between Men And Women With Hepatocellular Cancer?, Andrea Fa, Denise M. Danos, Lauren Maniscalco, Yong Yi, Xiao Cheng Wu, Mary A. Maluccio, Quyen D. Chu, John M. Lyons

School of Public Health Faculty Publications

Hepatocellular carcinoma (HCC) is a male-dominated disease. Currently, gender differences remain incompletely defined. Data from the state tumor registry were used to investigate differences in demographics, comorbidities, treatment patterns, and cancer-specific survival (HSS) among HCC patients according to gender. Additional analyses were performed to evaluate racial differences among women with HCC. 2627 patients with HCC were included; 498 (19%) were women. Women were mostly white (58%) or African American (39%)—only 3.8% were of another or unknown race. Women were older (65.1 vs. 61.3 years), more obese (33.7% vs. 24.2%), and diagnosed at an earlier stage (31.7% vs. 28.4%) than men. …

Impact Of The Covid-19 Pandemic On The Education And Procedural Volume Of Fellows In Critical Care Medicine – A Cross-Sectional Survey, Orlando Garner, Kanta Velamuri, Kristen Staggers, Andrea Barbara Braun

Faculty, Staff and Students Publications

BACKGROUND: The COVID-19 pandemic has changed the way medical education is delivered. The purpose of this study was to assess the impact of the COVID-19 pandemic on the education and procedural volume of critical care and pulmonary critical care fellows.

METHODS: We conducted a cross-sectional, internet-based, voluntary, anonymous, national survey of adult critical care fellows and academic attending physicians in critical care and pulmonary critical care fellowship programs in the United States between December 2020 and February 2021. Survey questions covered both didactic and non-didactic aspects of education and procedural volumes. Answers were ranked on a 5-point Likert scale. Survey …

Infective Endocarditis-Related Pseudoaneurysms After Bentall Surgery: The Role Of 3d Printing In Pre-Surgical Planning And Management: Case Report, Abdalla Eltayeb, Shaid Khan, Irene Landi, Mohammed Aladmawi, Olga Vriz

Journal of the Saudi Heart Association

We present a case report of a male patient who underwent modified Bentall surgery with a mechanical valved conduit due to severe aortic regurgitation and ascending aortic aneurysm. Four years later, the patient developed a cascade of events as acute stoke, infective endocarditis due to Brucella abortus complicated by pseudoaneurysms of aortic graft with left ventricular outflow tract communication. A multi-modality approach, included a three-dimensional printing, facilitated the diagnosis and surgical planning. During surgery, the team opted for a salvage approach, and the patient showed continued improvement during follow-up. This case highlights the importance of careful monitoring and detection of …

Commencement, Georgia (2023), Philadelphia College Of Osteopathic Medicine

Commencements

Georgia Campus Commencement Program, 2023. Degrees include Doctor of Osteopathic Medicine, Doctor of Pharmacy, Doctor of Physical Therapy, Master of Science in Biomedical Sciences, Master of Science in Medical Laboratory Science, and Master of Science in Health Sciences - Physician Assistant Studies.

Commencement Speaker: Julie Ginn Moretz, Augusta University Health System

Occupation Based Program Enhancement: Promoting Social And Leisure Participation Post-Stroke, Emma Welch, Amy Lyons-Brown

Spring 2023 Virtual OTD Capstone Symposium

This presentation describes the importance of social and leisure participation for individuals who have had a stroke and explores the role of occupational therapy in promoting this area of occupation for the population.

Cellular And Molecular Mechanisms Of Liver Fibrosis In Patients With Nafld, Jessica I Sanchez, Edwin R Parra, Jingjing Jiao, Luisa M Solis Soto, Debora A Ledesma, Omar A Saldarriaga, Heather L Stevenson, Laura Beretta

Faculty, Staff and Student Publications

The expression of immune- and cancer-related genes was measured in liver biopsies from 107 NAFLD patients. The strongest difference in overall gene expression was between liver fibrosis stages F3 and F4, with 162 cirrhosis-associated genes identified. Strong correlations with fibrosis progression from F1 to F4 were observed for 91 genes, including CCL21, CCL2, CXCL6, and CCL19. In addition, the expression of 21 genes was associated with fast progression to F3/F4 in an independent group of eight NAFLD patients. These included the four chemokines, SPP1, HAMP, CXCL2, and IL-8. A six-gene signature including SOX9, THY-1, and CD3D had the highest performance …

Tet2 Truncating Mutations Predict A Worse Outcome In Blastic Plasmacytoid Dendritic Cell Neoplasm, Hannah Beird, C Cameron Yin, Joseph D Khoury, Sherry Pierce, Hussein A Abbas, Li Zhao, Anna Skwarska, Muzaffar Qazilbash, Marina Konopleva, P Andrew Futreal, Naveen Pemmaraju

Faculty, Staff and Student Publications

No abstract provided.

Publisher Correction: A Randomized Pilot Study Of Oncology Massage To Treat Chemotherapy-Induced Peripheral Neuropathy, Gabriel Lopez, Cathy Eng, Michael Overman, David Ramirez, Wenli Liu, Curtiss Beinhorn, Pamela Sumler, Sarah Prinsloo, Yisheng Li, Minxing Chen, Eduardo Bruera, Lorenzo Cohen

Faculty, Staff and Student Publications

No abstract provided.

Balloon Dilatation In The Management Of Congenital Obstructive Lesions Of The Heart: Review Of Author's Experiences And Observations-Part I, P Syamasundar Rao

Faculty, Staff and Student Publications

Balloon dilatation techniques became available to treat congenital obstructive lesions of the heart in the early/mid-1980s. The purpose of this review is to present the author's experiences and observations on the techniques and outcomes of balloon dilatation of pulmonary stenosis (PS), aortic stenosis (AS) and aortic coarctation (AC), both native and postsurgical re-coarctations. Balloon dilatation resulted in a reduction of peak pressure gradient across the obstructive lesion at the time of the procedure as well as at short-term and long-term follow-ups. Complications such as recurrence of stenosis, valvar insufficiency (for PS and AS cases) and aneurysm formation (for AC cases) …

Sequential Absorption Of Two Photons Creates A Bistable Form Of Rubyacr Responsible For Its Strong Desensitization, Oleg A Sineshchekov, Elena G Govorunova, Hai Li, Yumei Wang, John L Spudich

Faculty, Staff and Student Publications

Channelrhodopsins with red-shifted absorption, rare in nature, are highly desired for optogenetics because light of longer wavelengths more deeply penetrates biological tissue. RubyACRs (Anion ChannelRhodopsins), a group of four closely related anion-conducting channelrhodopsins from thraustochytrid protists, are the most red-shifted channelrhodopsins known with absorption maxima up to 610 nm. Their photocurrents are large, as is typical of blue- and green-absorbing ACRs, but they rapidly decrease during continuous illumination (desensitization) and extremely slowly recover in the dark. Here, we show that long-lasting desensitization of RubyACRs results from photochemistry not observed in any previously studied channelrhodopsins. Absorption of a second photon by …

A Phase 2 Study Of Nivolumab Combined With Ibrutinib In Patients With Diffuse Large B-Cell Richter Transformation Of Cll, Nitin Jain, Jayastu Senapati, Beenu Thakral, Alessandra Ferrajoli, Philip Thompson, Jan Burger, Sreyashi Basu, Tapan Kadia, Naval Daver, Gautam Borthakur, Marina Konopleva, Naveen Pemmaraju, Erin Parry, Catherine J Wu, Joseph Khoury, Carlos Bueso-Ramos, Naveen Garg, Xuemei Wang, Wanda Lopez, Ana Ayala, Susan O'Brien, Hagop Kantarjian, Michael Keating, James Allison, Padmanee Sharma, William Wierda

Faculty, Staff and Student Publications

Richter transformation (RT) is a rare complication of chronic lymphocytic leukemia (CLL) that has dismal outcomes. Upregulation of PD-1/PD-L1 drives immunological evasion in patients with RT. We hypothesized that combining nivolumab, a PD-1 blocking antibody, with the BTK inhibitor (BTKi) ibrutinib could potentiate tumor-cell killing. We conducted an investigator-initiated phase 2 clinical trial to assess the efficacy of combined nivolumab and ibrutinib in patients with diffuse large B-cell lymphoma (DLBCL) RT and CLL. Patients included were ≥18 years of age with adequate hepatic and renal function. Patients received nivolumab every 2 weeks of a 4-week cycle for a maximum of …

Smarcb1 Regulates The Hypoxic Stress Response In Sickle Cell Trait, Melinda Soeung, Luigi Perelli, Ziheng Chen, Eleonora Dondossola, I-Lin Ho, Federica Carbone, Li Zhang, Hania Khan, Courtney N Le, Cihui Zhu, Michael D Peoples, Ningping Feng, Shan Jiang, Niki Millward Zacharias, Rosalba Minelli, Daniel D Shapiro, Angela K Deem, Sisi Gao, Emily H Cheng, Donatella Lucchetti, Cheryl L Walker, Alessandro Carugo, Virginia Giuliani, Timothy P Heffernan, Andrea Viale, Nizar M Tannir, Giulio F Draetta, Pavlos Msaouel, Giannicola Genovese

Faculty, Staff and Student Publications

Renal medullary carcinoma (RMC) is an aggressive kidney cancer that almost exclusively develops in individuals with sickle cell trait (SCT) and is always characterized by loss of the tumor suppressor SMARCB1. Because renal ischemia induced by red blood cell sickling exacerbates chronic renal medullary hypoxia in vivo, we investigated whether the loss of SMARCB1 confers a survival advantage under the setting of SCT. Hypoxic stress, which naturally occurs within the renal medulla, is elevated under the setting of SCT. Our findings showed that hypoxia-induced SMARCB1 degradation protected renal cells from hypoxic stress. SMARCB1 wild-type renal tumors exhibited lower levels …

Membrane Bending And Sphingomyelinase-Associated, Sulfatide-Dependent Hypoxic Adhesion Of Sickle Mature Erythrocytes, Utku Goreke, Erdem Kucukal, Fang Wang, Ran An, Nicole Arnold, Erina Quinn, Charlotte Yuan, Allison Bode, Ailis Hill, Yuncheng Man, Bryan C. Hambley, Robert Schilz, Mahazarin Ginwalla, Umut A. Gurkan, Umut A. Gurkan

Faculty Scholarship

Abnormal erythrocyte adhesion owing to polymerization of sickle hemoglobin is central to the pathophysiology of sickle cell disease (SCD). Mature erythrocytes constitute >80% of all erythrocytes in SCD; however, the relative contributions of erythrocytes to acute and chronic vasculopathy in SCD are not well understood. Here, we showed that bending stress exerted on the erythrocyte plasma membrane by polymerization of sickle hemoglobin under hypoxia, enhances sulfatide-mediated abnormal mature erythrocyte adhesion. We hypothesized that sphingomyelinase (SMase) activity, which is upregulated by accumulated bending energy, leads to elevated membrane sulfatide availability, and thus, hypoxic mature erythrocyte adhesion. We found that mature erythrocyte …

Tau Polarizes An Aging Transcriptional Signature To Excitatory Neurons And Glia, Timothy Wu, Jennifer M Deger, Hui Ye, Caiwei Guo, Justin Dhindsa, Brandon T Pekarek, Rami Al-Ouran, Zhandong Liu, Ismael Al-Ramahi, Juan Botas, Joshua M Shulman

Faculty, Staff and Students Publications

Aging is a major risk factor for Alzheimer’s disease (AD), and cell-type vulnerability underlies its characteristic clinical manifestations. We have performed longitudinal, single-cell RNA-sequencing in Drosophila with pan-neuronal expression of human tau, which forms AD neurofibrillary tangle pathology. Whereas tau- and aging-induced gene expression strongly overlap (93%), they differ in the affected cell types. In contrast to the broad impact of aging, tau-triggered changes are strongly polarized to excitatory neurons and glia. Further, tau can either activate or suppress innate immune gene expression signatures in a cell-type-specific manner. Integration of cellular abundance and gene expression pinpoints nuclear factor kappa B …

Assessing The Effects Of Health Insurance Status On Compliance With Diabetes Care, Sara L. Colosimo, Leann N. Petschonek, Uvina S. Allen, Dominique L. Rogers, Sericea Stallings-Smith

Florida Public Health Review

Background: Diabetes is a chronic disease that affects millions of people in the United States. Compliance with treatment plans is important for preventing life-threatening complications of the disease. However, many diabetics forgo recommended testing and other management standards due to lack of health insurance.

Purpose: This study aims to assess the effect of health insurance status on compliance with diabetes care.

Methods: This study was a secondary analysis using 2005–2018 National Health and Nutrition Examination Survey data. For participants who reported having diabetes, compliance with care was assessed based on insurance status. Compliance indicators included hemoglobin A1C check by …

Stat5 Confers Lactogenic Properties In Breast Tumorigenesis And Restricts Metastatic Potential, Richard S Lampitt, Stephen Fletcher, Matthew Cole, Alice Kloker, Stefan Krause, Fran O'Hara, Peter Ryde, Mahua Saha, Anastasia Voronkova, Adrian Whyle

Faculty, Staff and Student Publications

Progress to reduce plastic pollution has been painfully slow and the consequent damage to the natural environment and to human health is likely to increase further. This has been because the views and ways of working of four distinct stakeholder communities are not sufficiently well integrated. (1) Scientists, (2) industry, (3) society at large and (4) those making policy and legislation must in future find ways to work together.