Cocktails of pharmaceuticals are released in the environment after human consumption and due to the incomplete removal at the wastewater treatment plants. Pharmaceuticals are considered as contaminants of emerging concern and, a plethora of journal articles addressing their possible adverse effects have been published during the past 20 years. The emphasis during the early years of research within this field, was on the assessment of acute effects of pharmaceuticals applied singly, leading to results regarding their environmental risk, potentially not realistic or relevant to the actual environmental conditions. Only recently has the focus been shifted to chronic exposure and to the assessment of cocktail effects. To this end, this review provides an up-to-date compilation of 57 environmental and human toxicology studies published during 2000-2014 dealing with the adverse effects of pharmaceutical mixtures. The main challenges regarding the design of experiments and the analysis of the results regarding the effects of pharmaceutical mixtures to different biological systems are presented and discussed herein. The gaps of knowledge are critically reviewed highlighting specific future research needs and perspectives.

Objective. Inflammatory disease activity in patients with systemic lupus erythematosus (SLE) may affect the development of atherosclerosis, contributing to their increased risk of cardiovascular disease (CVD). This process may be mediated by anti-apolipoprotein A-I (anti-Apo A-I), anti-high-density lipoprotein (anti-HDL), and anti-C-reactive protein (anti-CRP) autoantibodies. We undertook this study to examine whether levels of these antibodies rise in association with increased SLE disease activity.Methods. IgG anti-Apo A-I, anti-HDL, and anti-CRP levels were measured in serum from the following groups: 39 patients with persistently high disease activity (British Isles Lupus Assessment Group [BILAG] A or B score) over the previous 2 years, 42 patients with persistently low disease activity (no BILAG A or B scores) over the previous 2 years, 34 healthy controls, 25 individual patients from whom paired samples (at time of disease flare and quiescence) were obtained and compared, 16 patients with newly diagnosed lupus nephritis from whom multiple samples were obtained and who were followed up prospectively for up to 2 years, and 24 patients with SLE who had experienced CVD events.Results. Serum levels of IgG anti-Apo A-I, anti-HDL, and anti-CRP were higher in patients with SLE than in controls. Anti-Apo A-I and anti-HDL levels, but not anti-CRP levels, were higher in patients with persistently high disease activity than in those with low disease activity. Mean levels of the 3 autoantibodies in patients who had experienced CVD events lay between the mean levels in the high and low disease activity groups. Only levels of anti-Apo A-I were significantly higher in samples obtained from individual patients during disease flares than in samples obtained during disease quiescence. In the lupus nephritis patients, anti-Apo A-I and anti-HDL levels correlated with serum levels of high avidity IgG anti-double-stranded DNA.Conclusion. Persistent disease activity is associated with a significant increase in IgG anti-Apo A-I and anti-HDL in patients with SLE.

A major mechanism of hypercoagulability in the antiphospholipid syndrome (APS) is antiphospholipid antibody (aPL)-mediated up-regulation of tissue factor (TF) on monocytes via activation of toll-like receptors (TLR), p38 mitogen activated protein kinase (MAPK) and nuclear factor (NF) κB pathways. We examined whether monocyte signalling pathways are differentially activated by IgG from patients with vascular thrombosis (VT) alone compared with IgG from patients with pregnancy morbidity (PM) alone. We purified IgG from 49 subjects. A human monocyte cell line and ex vivo healthy monocytes were treated with 100μg/ml IgG for 6 hours and cell extracts examined by immunoblot using antibodies to p38MAPK and NFκB. To further investigate intracellular signalling pathways induced by these IgG, specific inhibitors of p38MAPK, NFκB, TLR4 and TLR2 were used to determine their effect on TF activity. Only IgG from patients with VT but no PM (VT+/PM−) caused phosphorylation of NFκB, p38MAPK and up-regulation of TF activity in monocytes. These effects were not seen with IgG from patients with PM alone (VT−/PM+), aPL-positive patients without APS or healthy controls. TF up-regulation caused by the VT+/PM− samples was reduced by inhibitors of p38MAPK, NFkB, and TLR4. The effects of VT+/PM− IgG on signalling and TF up-regulation were concentrated in the fraction that bound b-2-glycoprotein I. Our findings demonstrate that IgG from patients with diverse clinical manifestations of APS have differential effects upon phosphorylation of NFkB, p38MAPK and TF activity which may be mediated by differential activation of TLR4.