The Personal Medical Services (PMS) pilot sites, launched in England in 1997 by the Secretary of State for the then Conservative government, introduced a local contract for primary care, aimed at promoting flexibility, innovation and policy participation. As part of the National Evaluation of PMS, this paper considers the professional and organisational relationships established between service providers working in those PMS sites which specifically set out to address inequalities in access to primary care for vulnerable populations. The introduction of PMS enabled a change of cultural values in primary care, particularly regarding GPs' relationships with nurses and practice staff. However, PMS has not necessarily led to equal partnerships within primary care teams. Rather,in the selected sites evaluated new interprofessional relationships emerged. There was evidence of intra and interprofessional partnerships being forged, providing the basis for further improved intersectoral collaboration. There was also evidence that the GP based medical model made way for a community oriented/public health model with emphasis on health maintenance for the vulnerable.
The role of skin irritation and other factors on the tumorigenic activity of petroleum middle distillates (PMDs) in mice was examined in a comprehensive research program. The program culminated in a 2-year dermal carcinogenicity study which compared the effects of equal weekly doses of irritating and nonirritating PMDs. Modified Ames mutagenicity studies and three- to seven-ring polycyclic aromatic compound (PAC) analyses indicated that the mutagenic activity of PMDs was correlated to PAC content. In subchronic and subacute studies, PMDs produced marked skin irritation which was ameliorated if the test samples were diluted in mineral oil. The reduction in irritation level was not a result of reduced dermal absorption. Straight-run kerosine (SRK), straight-run gas oil (SRGO), and catalytically cracked light cycle oil (LCO) were evaluated in the dermal carcinogenicity study. Test materials were applied either undiluted (2x/week) or as 28.5% (7x/week) or 50% (4x/week) concentrations in mineral oil for a total weekly dose of 100 microliters PMD per animal. All three materials produced moderate to marked skin irritation and increased tumor frequency when applied undiluted. When diluted, the irritant effects of SRK and SRGO, which contain low levels of PACs, were ameliorated, and there were no significant increases in tumors relative to controls. LCO, containing 8.7% three- to seven-ring PACs, increased tumor frequency when diluted, even when skin irritation was limited. These data indicate that the tumorigenic activity of straight-run MDs is likely a consequence of a nongenotoxic process, associated with frequent cell damage and repair. PMDs which contain low levels of three- to seven-ring PACs are unlikely to cause tumors in the absence of prolonged skin irritation. In addition, genotoxic mechanisms may also contribute to tumor formation for other PMDs containing higher levels of PACs, e.g., products blended with cracked stocks.
When assessing cancer hazard and risk associated with a complex petroleum substance, like bitumen emissions, there are often conflicting results related to human, animal and mechanistic studies. Validation of the complex composition to assure that it matches real-world exposures and control of confounders are pivotal factors in study design to allow the necessary read-across during assessments. Several key studies on bitumen emissions in two-year dermal cancer assays reported variable outcomes ranging from high cancer incidence to no cancer incidence. Here, we synthesize findings from published studies to explain the differences and discuss critical factors in cancer hazard evaluation for complex petroleum substances. Using these critical factors, we reviewed relevant human genetic toxicity, mammalian toxicity and mechanistic studies with bitumen to understand the divergence in results. We assess the most reliable and scientifically supported information on the potential carcinogenic hazards of bitumen emissions and comment on quality and completeness of data. Human hazard data are typically considered highest priority because they eliminate the need for interspecies extrapolation and reduce the range of high -to low-dose extrapolation during the risk assessment process. Finally, two well-conducted comprehensive animal studies are discussed that have well-defined test material, exposure concentration and composition representative of worker exposure, evidence of systemic uptake, no confounding exposures and provide consistency across all elements within both studies. Studies that allow effective read-across from human, animal and mechanistic components, control for confounders and are well-validated analytically against workplace exposures, provide the strongest evidence base for evaluating cancer hazard. ARTICLE HISTORY
The United Nations Conference on Environment and Development (UNCED) has developed criteria for a globally harmonised system of classification and labelling of chemicals (GHS). With regard to carcinogenicity, GHS distinguishes between Category 1 ('known or presumed human carcinogens') and Category 2 ('suspected human carcinogens'). Category 1 carcinogens are divided into Category 1A ('known to have carcinogenic potential for humans'), based largely on human evidence, and 1B ('presumed to have carcinogenic potential for humans'), based largely on experimental animal data. Concerns have been raised that the criteria for applying these carcinogenicity classifications are not sufficiently well defined and potentially allow different conclusions to be drawn. The current document describes an attempt to reduce the potential for diverse conclusions resulting from the GHS classification system through the application of a series of questions during the evaluation of data from experiments with rodents; epidemiological data, which could lead to Category 1A, have not been considered. Answers to each question can lead either to a classification decision or to the next question, but this process should only be implemented in an environment of informed scientific opinion. The scheme is illustrated with five case studies. These questions are: (1) Has a relevant form of the substance been tested? (2) Is the study design relevant to human exposure? (3) Is there a substance-related response? (4) Is the target tissue exposure relevant to humans? (5) Can a mode of action be established? (6) Is the mode of action relevant to humans? (7) What is the potency?
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