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Transdisciplinary solutions are needed to achieve the sustainability of ecosystem services for future generations. We propose a framework to identify the causes of ecosystem function loss and to forecast the future of ecosystem services under different climate and pollution scenarios. The framework (i) applies an artificial intelligence (AI) time-series analysis to identify relationships among environmental change, biodiversity dynamics and ecosystem functions; (ii) validates relationships between loss of biodiversity and environmental change in fabricated ecosystems; and (iii) forecasts the likely future of ecosystem services and their socioeconomic impact under different pollution and climate scenarios. We illustrate the framework by applying it to watersheds, and provide system-level approaches that enable natural capital restoration by associating multidecadal biodiversity changes to chemical pollution.

The Earth’s biodiversity and the ecosystem services it provides are declining rapidly because of an increasing use of natural (finite) resources to meet human needs and environmental change affecting biodiversity dynamics. Truly trans-disciplinary solutions are needed for a sustainable development of ecosystem services. Collaboration and knowledge transfer across paleo biology, climatology, global ecology, evolution, biogeography, water sciences, computer science, statistics, and economics has to be mustered for scientists, resources managers and policy makers to counter ecosystem function collapse and ecosystem services loss. We propose a novel framework that closes the implementation gap, in which long-term dynamics of biodiversity, abiotic properties, and ecosystem functions are reconstructed using an unprecedented integration of biochemical and environmental fingerprinting of biological archives spanning centuries. The long-term dynamics obtained from this fingerprinting are then placed in a machine learning pipeline to identify cause-effect relations between environmental change and biodiversity dynamics. Predictive models are tested by hindcasting, and then used to accurately forecast the future of ecosystem services and their socio-economic impact under different climate change scenarios. The framework provides accessible tools to practitioners to translate cutting-edge research into practical solutions for environmental management and practice.

In the present study, both bioanalytical and instrumental tools were employed to examine the endocrine-disruptive potentials of water samples, cyanobloom samples, and sediment samples collected from in the northern region of Taihu Lake (China) during cyanobloom season. Results from cell-based bioassays suggested the occurrence of estrogenic, anti-estrogenic, anti-androgenic, and anti-glucocorticogenic activities, while no androgenic and glucocorticogenic activities were observed in the collected samples. Using an UPLC-MS/MS system, 29 endocrine disrupting compounds including seven estrogens, seven androgens, six progestogens, and five adrenocortical hormones and four industrial pollutants were simultaneously detected. 17, 20 and 12 chemicals were detected at least in one of the water samples, cyanobloom samples and sediment samples, respectively. Since both agonistic and antagonistic endocrine-disruptive activities were detected in the present study, commonly used receptor-based in vitro bioassays resulted in net effects, suggesting that the hormone receptor agonistic potentials might be underestimated with this practice. The EDCs detected in cyanobloom samples also highlight the necessity to consider the phytoplankton matrix for understanding the mass fluxes of endocrine disruptors in eutrophic freshwaters and to consider it in monitoring strategies.

Lake ecosystems are sensitive recorders of environmental changes that provide continuous archives at annual to decadal resolution over thousands of years. The systematic investigation of land use changes and emission of pollutants archived in Holocene lake sediments as well as the reconstruction of contamination, background conditions, and sensitivity of lake systems offer an ideal opportunity to study environmental dynamics and consequences of anthropogenic impact that increasingly pose risks to human well-being. This paper discusses the use of sediment and other lines of evidence in providing a record of historical and current contamination in lake ecosystems. We present a novel approach to investigate impacts from human activities using chemical-analytical, bioanalytical, ecological, paleolimnological, paleoecotoxicological, archeological as well as modeling techniques. This multi-time slice weight-of-evidence (WOE) approach will generate knowledge on conditions prior to anthropogenic influence and provide knowledge to (i) create a better understanding of the effects of anthropogenic disturbances on biodiversity, (ii) assess water quality by using quantitative data on historical pollution and persistence of pollutants archived over thousands of years in sediments, and (iii) define environmental threshold values using modeling methods. This technique may be applied in order to gain insights into reference conditions of surface and ground waters in catchments with a long history of land use and human impact, which is still a major need that is currently not yet addressed within the context of the European Water Framework Directive.

While it is well recognized that the frequency and intensity of flood events are increasing worldwide, the environmental, economic, and societal consequences of remobilization and distribution of pollutants during flood events are not widely recognized. Loss of life, damage to infrastructure, and monetary cleanup costs associated with floods are important direct effects. However, there is a lack of attention towards the indirect effects of pollutants that are remobilized and redistributed during such catastrophic flood events, particularly considering the known toxic effects of substances present in flood-prone areas. The global examination of floods caused by a range of extreme events (e.g., heavy rainfall, tsunamis, extra- and tropical storms) and subsequent distribution of sediment-bound pollutants are needed to improve interdisciplinary investigations. Such examinations will aid in the remediation and management action plans necessary to tackle issues of environmental pollution from flooding. River basin-wide and coastal lowland action plans need to balance the opposing goals of flood retention, catchment conservation, and economical use of water.

Assessment of uranium (U)-contaminated sediment is often hindered by the inability to accurately account for the physicochemical properties of sediment that modify U bioavailability. The present goal was to determine whether sediment-associated U bioavailability could be predicted over a wide range of conditions and sediment properties using simple regressions and a geochemical speciation model, the Windermere Humic Aqueous Model (WHAM7). Data from a U-contaminated field sediment bioaccumulation test, along with previously published bioaccumulation studies with U-spiked field and formulated sediments, were used to examine the models. Observed U concentrations in Chironomus dilutus larvae exposed to U-spiked and U-contaminated sediments correlated well (r2 > 0.74, p

Uranium (U) can enter aquatic environments from natural and anthropogenic processes, accumulating in sediments to concentrations that could, if bioavailable, adversely affect benthic organisms. To better predict the sorption and mobility of U in aquatic ecosystems, we investigated the sediment-solution partition coefficients ( K d ) of U for nine uncontaminated freshwater sediments with a wide range of physicochemical characteristics over an environmentally relevant pH range. Test solutions were reconstituted to mimic water quality conditions and U(VI) concentrations (0.023–2.3 mg U/L) found downstream of Canadian U mines. Adsorption of U(VI) to each sediment was greatest at pH 6 and 7, and significantly reduced at pH 8. There were significant differences in pH-dependent sorption among sediments with different physicochemical properties, with sorption increasing up until thresholds of 12% total organic carbon, 37% fine fraction (≤50 μm), and 29 g/kg of iron content. The K d values for U(VI) were predicted using the Windermere Humic Aqueous Model (WHAM) using total U(VI) concentrations, and water and sediment physicochemical parameters. Predicted K d -U values were generally within a factor of three of the observed values. These results improve the understanding and assessment of U sorption to field sediment, and quantify the relationship with sediment properties that may influence the bioavailability and ecological risk of U-contaminated sediments.

The partitioning of metals between dissolved and solid phases directly affects metal bioavailability to benthic invertebrates and is influenced by metal-binding properties of sediment phases. Little research has been done examining the effects of sediment properties on the bioavailability of uranium (U) to freshwater benthic invertebrates. In the present study, 18 field sediments with a wide range of properties (total organic carbon, fine fraction, cation exchange capacity, and iron content) were amended with the same concentrations of U to characterize the effects of these sediment properties on U bioavailability to freshwater midge, Chironomus dilutus. Bioaccumulation of U by C. dilutus larvae varied by over an order of magnitude when exposed to sediments spiked with 50 mg U kg(-1) d.w. (5-69 mg U kg(-1) d.w.) and 500 mg U kg(-1) d.w. (20-452 mg U kg(-1) d.w.), depending on the type of sediment. Variance in U bioaccumulation was best explained by differences in the cation exchange capacity, fine fraction (≤50 μm particle size), and Fe content of U-spiked sediment, with generated regression equations predicting observed bioaccumulation within a factor of two. The presented regression equations offer an easy-to-apply method for accounting for the influence of sediment properties on U bioavailability in freshwater sediment, with fine fraction being the single most practical variable. This research strongly supports that risk assessments and guidelines for U-contaminated sediments should not ignore the influence of sediment properties that can result in substantial differences in the bioaccumulation of U in benthic invertebrates.

Metabolism has to be considered during the toxicological assessment of chemical and environmental samples because it is an important process in the mammalian liver. It can be assessed in vitro via liver homogenates called S9-fractions, an external metabolic activation system. However, the external metabolic activation systems can vary greatly in their composition due to biological variations among individual animals and animal strains that the S9-fraction are derived as well as the differences in the production treatment. To gain more insight into these variances, three different but commonly used rat-derived S9-fractions were compared in the present study for their variance and performance with a reference compound in the Ames fluctuation assay with Salmonella typhimurium strains TA 98 and TA 100 according to ISO 11350. Severe shortcomings of conventional rat-derived S9-fractions were observed in the present study, such that S9-fractions differed significantly within the same rat strain and for different types of induction procedures in regards to the metabolic capability. An intrinsic mutagenic potential of the three rat-derived S9-fractions were identified in the Ames fluctuation assay with varying S9-fraction concentrations. To address some of the shortcomings of the animal-derived S9-fraction, the present study investigated the use and performance of a biotechnological, animal-free alternative, ewoS9R, in comparison to one of the rat-derived S9-fraction as the others showed a mutagenic potential themselves. Specifically, 12 different chemicals were used as a reference to determine if ewoS9R could serve as an adequate and more consistent replacement of traditional rat-derived metabolic activation systems: 8 pro-mutagenic compounds (i.e., require metabolic activation to show a mutagenic potential), one pro-mutagenic compound but not in the tested strains, one mutagenic compound without metabolic activation and two compounds that are equivocal in the literature. EwoS9R was evaluated as a promising approach in the Ames fluctuation assay with 5 compounds observed to have similar results with both rat-derived S9-fraction and ewoS9R (41%), for 3 compounds ewoS9R was a better metabolization system than the rat-derived S9-fraction (16%). Further research is necessary to determine the full potential of ewoS9R in comparison to rat-derived S9-fractions.

Numerous environmental pollutants have the potential to accumulate in sediments, and among them are endocrine-disrupting chemicals (EDCs). It is well documented that water-borne exposure concentrations of some potent EDCs, more specifically estrogenic- active compounds (ECs), can impair the reproduction of fish. In contrast, little is known about the bioavailability and effects of sediment-associated ECs on fish. Particularly, when sediments are disturbed, e.g., during flood events, chemicals may be released from the sediment and become bioavailable. The main objectives of this study were to evaluate a) whether ECs from the sediment become bioavailable to fish when the sediment is suspended, and b) whether such exposure leads to endocrine responses in fish. Juvenile rainbow trout (Oncorhynchus mykiss) were exposed over 21 days to constantly suspended sediments in the following treatments: i) a contaminated sediment from the Luppe River, representing a "hotspot" for EC accumulation, ii) a reference sediment (exhibiting only background contamination), iii) three dilutions, 2-, 4- and 8-fold of Luppe sediment diluted with the reference sediment, and iv) a water-only control. Measured estrogenic activity using in vitro bioassays as well as target analysis of nonylphenol and estrone via LC-MS/MS in sediment, water, fish plasma, as well as bile samples, confirmed that ECs became bioavailable from the sediment during suspension. ECs were dissolved in the water phase, as indicated by passive samplers, and were readily taken up by the exposed trout. An estrogenic response of fish to Luppe sediment was indicated by increased abundance of transcripts of typical estrogen responsive genes, i.e. vitelline envelope protein α in the liver and vitellogenin induction in the skin mucus. Altered gene expression profiles of trout in response to suspended sediment from the Luppe River suggest that in addition to ECs a number of other contaminants such as dioxins, polychlorinated biphenyls (PCBs) and heavy metals were remobilized during suspension. The results of the present study demonstrated that sediments not only function as a sink for ECs but can turn into a significant source of pollution when sediments are resuspended as during flood-events. This highlights the need for sediment quality criteria considering bioavailability sediment-bound contaminants in context of flood events.

This study presents a high-throughput (HTP) micronucleus assay in multi-well plates with an automated evaluation for risk assessment applications. The evaluation of genotoxicity via the micronucleus assays according to international guidelines ISO 21427-2 with Chinese hamster (Cricetulus griseus) V79 cells was the starting point to develop our methodology. A drawback of this assay is that it is very time consuming and cost intensive. Our HTP micronucleus assay in a 48-well plate format allows for the simultaneous assessment of five different sample-concentrations with additional positive, negative and solvent controls with six technical replicates each within a quarter of the time required for the equivalent evaluation using the traditional slide method. In accordance with the 3R principle, animal compounds should be replaced with animal-free alternatives. However, traditional cell culture-based methods still require animal derived compounds like rat-liver derived S9-fraction, which is used to simulate the mammalian metabolism in in vitro assays that do show intrinsic metabolization capabilities. In the present study, a recently developed animal-free biotechnological alternative (ewoS9R) was investigated in the new high-throughput micronucleus assay. In total, 12 different mutagenic or genotoxic chemicals were investigated to assess the potential use of the animal-free metabolization system (ewoS9R) in comparison to a common rat-derived product. Out of the 12 compounds, one compound did not induce micronuclei in any treatment and 2 substances showed a genotoxic potential without the need for a metabolization system. EwoS9R demonstrated promising potential for future applications as it shows comparable results to the rat-derived S9 for 6 of the 9 pro-genotoxic substances tested. The remaining 3 substances (2-Acetamidofluorene, Benzo[a]pyrene, Cyclophosphamide) were only metabolized by rat-derived S9. A potential explanation is that ewoS9R was investigated with an approx. 10-fold lower enzyme concentration and was only optimized for CYP1A metabolization that may be improved with a modified production procedure. Future applications of ewoS9R go beyond the micronucleus assay, but further research is necessary.

Studies worldwide have demonstrated through in vitro bioassays and chemical analysis that endocrine-disrupting chemicals (EDCs) can accumulate in river sediments. However, remobilization of sediment-bound EDCs due to bioturbation or re-suspension during flood events remains poorly understood. The aim of this study was to evaluate the bioavailability of EDCs, more specifically estrogenic compounds (EC), from sediment under turbulent conditions using a passive sampling approach. Sediment was sampled along the Luppe River, Germany, previously described as a “hotspot” for ECs. The concentration of target ECs and estrogenic activity were investigated using chemical analysis (LC MS/MS) in addition to a novel screening tool (planar Yeast Estrogen Screen; p-YES) that utilizes high performance thin-layer chromatography plates in combination with an in vitro bioassay (YES). Estrone (50%, E1) and nonylphenol (35%, NP) accounted for the majority of estrogenic activity reported of up to 20 ± 2.4 μg E2 equivalents per kg dry weight in the Luppe sediments. Two types of passive samplers (polar organic chemical integrative sampler (POCIS) and Chemcatcher) were used to investigate the bioavailability of ECs from suspended sediment under laboratory conditions. NP, E1, E2 and ethynylestradiol (EE2) were remobilized from Luppe sediment when subjected to turbulent conditions, such as in a flood event, and were readily bioavailable at ecotoxicologically relevant concentrations (NP 18 μg/L, E1 14 ng/L, E2 0.2 ng/L, EE2 0.5 ng/L).

Microplastics have become one of the most pervasive emerging pollutants in the marine environment because of their wide occurrence and high sorption ability for hydrophobic organic contaminants (HOCs). Among the associated HOCs, dioxin-like chemicals (DLCs) can pose severe health risks; however, information on effects of microplastics bound DLCs is lacking. To fill this knowledge gap, this study integrated chemical analysis and in vitro bioassays to elucidate the potential dioxin-like effects of microplastics bound DLCs. Chemical analysis results demonstrated that styrofoams possessed significantly greater DLCs than other coastal or open ocean plastic particles. This was probably due to the presence of additives and greater sorption ability of expanded polystyrene. However, styrofoams did not show as strong dioxin-like effects as predicted by the bioanalysis equivalent model in bioassays. This could be attributed to the decreased DLC bioavailability and increased competition with the presence of styrene oligomers. Besides, bioassay results also demonstrated that aging increased the associated DLC concentrations, since extra sorption from surrounding environment occurred during prolonged retention periods. Finally, it was estimated that the leaching of DLCs could induce dioxin-like effects in marine organisms under 100% (11/11) and 18% (2/11) scenarios for aged pellets and styrofoams through aqueous or dietary exposures.

Purpose To present a case series of patients who were unable to lie flat for cataract surgery. Setting University teaching hospital, district hospital, and private practice, Norwich, United Kingdom. Design Prospective case series. Methods All patients had phacoemulsification using face-to-face upright seated positioning. The patient sits upright or semi-recumbent, and the surgeon sits or stands, facing the patient. The microscope is rotated forward, and surgery is done via an incision in the lower half of the cornea, using topical intracameral anesthesia. All 240 face-to-face cases, performed by the same surgeon, were prospectively recorded. The database included reasons for positioning difficulty, position adopted, and per-operative complications. Data on full systemic monitoring of 34 patients and satisfaction data on 90 patients were also recorded. Results In 13 years, 240 eyes (179 patients) had face-to-face surgery. Common diagnoses were severe kyphosis, orthopnea, or both. No patient was refused face-to-face surgery since the service was started. The rate of vitreous loss was 12 (5%) of 240 cases. However, all patients (100%) received a posterior chamber intraocular lens. No patient had any systemic adverse event, and vital signs remained stable during surgery. All respondents stated that they would be happy to have face-to-face positioning again. Conclusions Face-to-face positioning, in the hands of an experienced surgeon, was an acceptably safe approach for patients unable to lie flat for cataract surgery. It might be the only option for some patients. However, all patients should be counseled regarding the increased risk for operative complications.

Cyanobacterial blooms are of global concern due to the multiple harmful risks they pose towards aquatic ecosystem and human health. However, information on the fate of organic pollutants mediated by cyanobacterial blooms in eutrophic water remains elusive. In the present study, endocrine disruptive potentials of phytoplankton samples were evaluated throughout a year-long surveillance in a large and eutrophic freshwater lake. Severe cyanobacterial blooms persisted during our sampling campaigns. Estrogenic agonistic, anti-estrogenic, anti-androgenic, and anti-glucocorticogenic effects were observed in the phytoplankton samples using in vitro reporter gene bioassays. 27 endocrine disrupting chemicals (EDCs) of different modes of action were detected in the samples via UPLC-MS/MS system. Results from mass balance analysis indicated that the measured estrogenic activities were greater than the predicted estrogenic potencies from chemical analysis, demonstrating that chemical analysis of targeted EDCs is unable to fully explain the compounds responsible for the observed estrogenicities. Results from Spearman's correlation analysis concluded that the concentrations of ten EDCs in phytoplankton samples were negatively correlated with cyanobacterial biomass, suggesting the potential occurrence of biomass bio-dilution effects of EDCs due to the huge biomass of cyanobacteria during bloom seasons. The present study provided complementary information about the potential endocrine disruptive risks of cyanobacterial blooms, which is important for understanding and regulating EDCs in eutrophic lakes.

Effect-based methods including cell-based bioassays, reporter gene assays and whole-organism assays have been applied for decades in water quality monitoring and testing of enriched solid-phase extracts. There is no common EU-wide agreement on what level of bioassay response in water extracts is acceptable. At present, bioassay results are only benchmarked against each other but not against a consented measure of chemical water quality. The EU environmental quality standards (EQS) differentiate between acceptable and unacceptable surface water concentrations for individual chemicals but cannot capture the thousands of chemicals in water and their biological action as mixtures. We developed a method that reads across from existing EQS and includes additional mixture considerations with the goal that the derived effect-based trigger values (EBT) indicate acceptable risk for complex mixtures as they occur in surface water. Advantages and limitations of various approaches to read across from EQS are discussed and distilled to an algorithm that translates EQS into their corresponding bioanalytical equivalent concentrations (BEQ). The proposed EBT derivation method was applied to 48 in vitro bioassays with 32 of them having sufficient information to yield preliminary EBTs. To assess the practicability and robustness of the proposed approach, we compared the tentative EBTs with observed environmental effects. The proposed method only gives guidance on how to derive EBTs but does not propose final EBTs for implementation. The EBTs for some bioassays such as those for estrogenicity are already mature and could be implemented into regulation in the near future, while for others it will still take a few iterations until we can be confident of the power of the proposed EBTs to differentiate good from poor water quality with respect to chemical contamination.

Assessment of uranium (U)-contaminated sediment is often hindered by the inability to accurately account for the physicochemical properties of sediment that modify U bioavailability. The present goal was to determine whether sediment-associated U bioavailability could be predicted over a wide range of conditions and sediment properties using simple regressions and a geochemical speciation model, the Windermere Humic Aqueous Model (WHAM7). Data from a U-contaminated field sediment bioaccumulation test, along with previously published bioaccumulation studies with U-spiked field and formulated sediments, were used to examine the models. Observed U concentrations in Chironomus dilutus larvae exposed to U-spiked and U-contaminated sediments correlated well (r

Jakarta, the capital of Indonesia, is one of the rapidly growing coastal megacities in Asia. The implementation of the urban wastewater infrastructure is not keeping up with the rapid expansion of the city, leading to a severe deterioration of water and sediment quality in the metropolitan area. The present study aimed to assess sediment contamination with organic pollutants in Jakarta rivers and the related risks to the coastal ecosystem. To this end, the site-specific and most harmful organic pollutants in the sediments were quantified, and the obtained chemical data were compared to reported sediment toxicity thresholds for an impact assessment on the benthic community. The detected pollutant spectrum included several compounds, such as the detergent residues nonylphenols and the insect repellent DEET (N,N-diethyl-m-toluamide), that were previously reported as contaminants in industrialized countries but have been banned or partly substituted. The risk of sediment contamination for benthic macroinvertebrates was associated with PAHs (polycyclic aromatic hydrocarbons), DDT (bis(chlorophenyl)dichloroethane), nonylphenols and a synthetic fragrance. High concentrations of paper manufacturing educts, a compound class that was recently reported in industrialized areas with a flourishing paper industry, were found in Jakarta sediments. However, sediment quality guidelines or sediment toxicity thresholds for these compounds are not available, which limited the ecotoxicological risk assessment. More studies on sediment toxicities considering emerging industrial pollutants and test species from all climate regions are urgently required, as a prerequisite for an adequate impact assessment of sediment contamination.

Sensitivity of white sturgeon (Acipenser transmontanus) to copper (Cu) or cadmium (Cd) has been shown to significantly differ as a function of life-stage. This study investigated oxidative stress, metal homeostasis, and associated compensatory responses as potential mechanisms of this sensitivity pattern in three early life-stages. Sturgeon were most sensitive to Cu at 15 days post hatch (dph), which was accompanied by a significant increase in lipid peroxidation (LPO). Genes involved with amelioration of oxidative stress were significantly less inducible at this stage than in older, less sensitive fry. At 48 dph, acute lethality of sturgeon exposed to Cd was greatest and body LPO was significantly induced by 3.5-fold at 5 μg Cd/L. Moreover, there was a small but significant increase in antioxidative responses. At 139 dph, sturgeon were most tolerant to Cu and Cd and accumulation of these metals was least. Also, expression of metallothionein (MT) and apoptotic genes were greatest while expression of metal transporters was reduced and concentration of LPO was not different from controls. Our results suggest that life-stage specific sensitivity of white sturgeon to metals is complex, encompassing differences in the ability to mount compensatory responses important for metal homeostasis and combating oxidative stress and concomitant damages.

It is well established that bioavailability influences metal toxicity in aquatic ecosystems. However, the factors and mechanisms that influence uranium (U) bioavailability and toxicity in sediment have not been thoroughly evaluated, despite evidence that suggests different sediment components can influence the sorption and interaction of some metals. Given that dissolved U is generally accepted as being the primary bioavailable fraction of U, it is hypothesized that adsorption and interaction of U with different sediment components will influence the bioavailability of U in sediment. We investigated the effects of key sediment physicochemical properties on the bioavailability of U to a model freshwater benthic invertebrate, Chironomus dilutus. Several 10-day spiked sediment bioaccumulation experiments were performed, exposing C. dilutus larvae to a variety of formulated sediments spiked with different concentrations of U (5, 50 and/or 200 mg U/kg d.w.). Mean accumulation of U in C. dilutus larvae decreased significantly from 1195 to 10 mg U/kg d.w. as kaolin clay content increased from 0% to 60% in sediment spiked with 50 mg U/kg d.w. Similarly, higher organic matter content also resulted in a significant reduction of U bioaccumulation in C. dilutus larvae, indicating a reduction in U bioavailability. Concentrations of U in both the overlying water and sediment pore water displayed a strong positive relationship to U bioaccumulation in C. dilutus larvae (r(2) = 0.77, p

This article reports a patient with acquired haemophilia who presented with life-threatening haemorrhage. Acquired haemophilia A is a rare autoimmune disorder caused by the development of an autoantibody to endogenous factor VIII. The diagnosis and management of the condition are reviewed. A high index of suspicion is essential for the accurate and prompt diagnosis of acquired haemophilia A, when the patient is bleeding and has an isolated abnormality in APTT.