Climate Change Imperils Pediatric Health: Child Advocacy Through Fossil Fuel Divestment.

Climate change poses an existential threat to children's health. Divestment of ownership stakes in fossil fuel companies is one tool available to pediatricians to address climate change. Pediatricians are trusted messengers regarding children's health and therefore bear a unique responsibility to advocate for climate and health policies that affect children. Among the impacts of climate change on pediatric patients are allergic rhinitis and asthma; heat-related illnesses; premature birth; injuries from severe storms and fires; vector-borne diseases; and mental illnesses. Children are disproportionately affected as well by climate-related displacement of populations, drought, water shortages, and famine. The human-generated burning of fossil fuels emits greenhouse gases (GHG) such as carbon dioxide, which trap heat in the atmosphere and cause global warming. The US healthcare industry is responsible for 8.5% of the nation's entire greenhouse gases and toxic air pollutants. In this perspectives piece we review the principle of divestment as a strategy for improving childhood health. Healthcare professionals can help combat climate change by embracing divestment in their personal investment portfolios and by their universities, healthcare systems, and professional organizations. We encourage this collaborative organizational effort to reduce greenhouse gas emissions.

The Role of Physician Advocacy in Supporting Policy Change That Reduces Leaded Aviation Gasoline Emissions.

BACKGROUND: Leaded aviation gasoline (AvGas) accounts for 70%, or 935,082 pounds, of total lead emissions in the United States and has been repeatedly linked to elevated blood lead levels (BLLs) in those living in the vicinity of airports using AvGas. The well-established link between lead exposure and adverse health outcomes provided a platform ripe for environmental health advocates and pediatric health experts to assist a local environmental health organization in addressing lead waste from a local airport, Montgomery-Gibbs Executive Airport (MYF). METHOD: We detail the steps we took, as a physician clean-air advocacy group. We provide a qualitative analysis of our efforts in addressing leaded air pollution through targeted and creative environmental health advocacy through three main avenues: government, public awareness, and academia. OBJECTIVES: Our actions were taken to ensure the City of San Diego installed an unleaded fuel tank at MYF to reduce leaded aviation gasoline usage and subsequently lead air pollution in the surrounding area. DISCUSSION: Ultimately, the identified objective of an unleaded fuel tank was added to the San Diego City budget and scheduled for construction. We hope our actions can serve as a framework to provide concrete steps for clinicians and other advocates to enact change in their communities.

Using exterior housing conditions to predict elevated pediatric blood lead levels.

Housing-based lead paint dust is the most common source of lead exposure for US-born children. Although year of housing construction is a critical indicator of the lead hazard to US children, not all housing of the same age poses the same risk to children. Additional information about housing condition is required to differentiate the housing-based lead risk at the parcel level. This study aimed to identify and assess a method for gathering and using observations of exterior housing conditions to identify active housing-based lead hazards at the parcel level. We used a dataset of pediatric blood lead observations (sample years 2000-2013, ages 6-72 months, n = 6,589) to assess associations between observations of exterior housing conditions and housing-based lead risk. We used graphical and Lasso regression methods to estimate the likelihood of an elevated blood lead observation (≥3.5 µg/dL). Our methods estimate a monotonic increase in the likelihood of an elevated blood lead observation as housing conditions deteriorate with the largest changes associated with homes in the greatest disrepair. Additionally we estimate that age of home construction works in consort with housing conditions to amplify risks among those houses built before 1952. Our analysis indicates that a survey of external housing conditions can be used in combination with age of housing in the identification process, at the parcel level, of homes that pose a housing-based lead hazard to children.

Historic racism in Kansas City affects Today's pediatric asthma burden.

Asthma morbidity is unequally distributed across populations throughout the United States, and reasons remain unclear. To assess how historical structural racism correlates with current day asthma disparities, we conducted a retrospective cohort study of 10,736 pediatric patients, ages 3-19 years, with two or more asthma encounters between October 2017-October 2019. Patient addresses were matched with historic Home Owners' Loan Corporation (HOLC) maps - which provide a measure of historic structural racism. Residential proximity to pollution sources served as an additional exposure measure. Healthcare utilization and asthma severity were studied against age, race, SES, geographic proximity to pollution, and HOLC grades. Patients living in historically divested neighborhoods and BIPOC patients were likely to require more acute care for asthma, even when adjusting for present day SES and residential proximity to pollution sources. This supports the assertion that historic structural racism influences present-day health.

Microsurgical Management of Early Onset Alveolar Soft Part Sarcoma of the Oral Tongue: Case Report and Review of the Literature.

OBJECTIVES: Alveolar soft part sarcoma is a rare subset of soft tissue sarcomas, typically presenting in subjects 15 to 35 years of age. Usual presentation sites are the trunk, extremities, and the head and neck. Subjects younger than 5 years are rarely affected. METHODS: In this retrospective case report, we present a 16-month old male with a rapidly growing soft tissue mass of the anterior and posterior tongue, found to be alveolar soft part sarcoma. RESULTS: The subject was treated with primary surgical resection and the resulting defect was reconstructed with a radial forearm free flap. CONCLUSIONS: To our knowledge, this is the youngest subject to have been diagnosed with alveolar soft part sarcoma. Surgical extirpation and microvascular reconstruction were successful, and the patient remains disease free 4 years post-operatively.

The legacy of weapons grade plutonium production: Health status of Hanford complex workers who manage the waste.

The extent and etiology of health effects in workers who maintain underground storage tanks at the Hanford Nuclear Reservation (Hanford) have been subjects of controversy and concern for several decades. Hanford is a decommissioned nuclear production complex managed by the US Department of Energy in southeast Washington State. This integration-of-evidence review evaluates the relationship between exposure to vapors from mixed chemical and radioactive waste stored in underground storage tanks at Hanford and worker health. Hanford workers' health information was gathered from technical reports, media reports, and published literature, including the systematic search of seven databases. This review describes the health status and health concerns of Hanford tank farm workers based on the integration of the available health effects data from disparate sources. In interviews with external groups, Hanford workers reported both irritant-type symptoms and diseases that they believe are attributable to tank farm vapors. However, the results of this integration-of-evidence review indicated that no pervasive pattern of occupational disease was identified that can be associated with exposure to tank farm vapors. Inhalation exposure to asbestos and beryllium is associated with lung disease from various types of nuclear industry work but not from work on tank farms. This review concluded that while irritant-type symptoms and isolated cases of occupational disease are plausible under certain conditions, the currently available data do not support a pervasive pattern of occupational disease associated with vapor exposure.

A comparison of depth of necrosis among adjuvant therapies used for the treatment of benign bone tumors.

BACKGROUND AND OBJECTIVES: Benign bone tumors are often treated with extended curettage utilizing an adjuvant therapy to eliminate any remaining tumor cells. The purpose of this study was to explore and compare the histologic depth of necrosis created by various adjuvant therapies used in the treatment of benign bone tumors. METHODS: A high-speed burr was utilized to create cortical defects within porcine humeri and femora. Phenol, polymethyl methacrylate (PMMA), argon beam coagulation (ABC), liquid nitrogen, and the Bipolar Hemostatic Sealer (BHS) were each applied to five defects, with an additional five defects left untreated as a control. The maximal depth of necrosis was determined under microscopic examination. RESULTS: The phenol, PMMA, ABC, liquid nitrogen, and BHS demonstrated an average histologic depth of necrosis of 0.30, 0.78, 2.54, 2.54, and 0.92 mm, respectively, each of which was significantly increased compared to the control group (p = .001, .003, .003, .01, and  <.001). Their respective variances, a measure of reproducibility, were 0.01, 0.09, 0.96, 1.93, and 0.03 mm2 . CONCLUSION: This study confirms, through histologic analysis, adjuvant therapies create a rim of cellular necrosis beyond that of burring during extended curettage, supporting their use in the treatment of benign bone tumors. Furthermore, it provides a head-to-head comparison.

Hemorrhagic Synovitis of the First Metatarsophalangeal Joint: A Case Report.

CASE: A 69-year-old woman presented with a painful mass at her first metatarsophalangeal joint. Further evaluation was concerning for a neoplastic process, leading to surgical intervention. Pathological examination demonstrated hemosiderotic synovitis, and hematologic evaluation led to a new diagnosis of von Willebrand disease. CONCLUSION: Hemorrhagic synovitis, involving mostly larger joints, has been well described. However, a literature search demonstrates no cases of this in the foot or toes. Presentation of hemarthroses and underlying coagulopathies can be subtle and must be considered in patients presenting with soft-tissue masses or pseudotumors, despite having no previous diagnosis.

Residential proximity to greenhouse agriculture and neurobehavioral performance in Ecuadorian children.

BACKGROUND: Children living near greenhouse agriculture may have an increased risk of pesticide exposure due to drift or direct contact with pesticide-treated areas. However, little is known about whether this increased potential for chronic exposure may impair their neurodevelopment. METHODS: We examined 307 children aged 4-9 years, living in agricultural communities in Ecuador (ESPINA study). The two exposures calculated were residential distance from the nearest flower plantation perimeter and flower plantation surface area within 100 m of homes. Five neurobehavioral domains were assessed: Attention/Inhibitory Control, Memory/Learning, Visuospatial processing and Sensorimotor (higher values reflect better performance). Low scores were defined according to the test's cut-offs. Models were adjusted for demographic, socio-economic and growth variables. RESULTS: The mean (SD) residential distance to the nearest flower plantation was 446 m (344). Living 100 m closer to crops was associated with increased odds (OR [95% CI]) of low scores in the domains of Memory/Learning (1.24 [1.05, 1.46]) and Language (1.09 [1.00, 1.19]). Associations were strongest among children living within 50 m, having significantly lower scores in Language (-1.28 which is ~50% of a SD [-2.50, -0.06]), Attention/Inhibitory Control (-1.24 units, [-2.45, -0.04]), and Memory/Learning (-0.91, [-1.99, 0.17]), compared to children living farther than 500 m. Analyses of areas of flower crops near homes concurred with these findings. CONCLUSIONS: Close residential proximity to greenhouse floricultural crops was associated with adverse neurobehavioral performance in Attention/Inhibitory Control, Language and Memory/Learning among children. This highlights the importance of reducing pesticide drift from plantations to nearby homes.

Ornithine decarboxylase as a therapeutic target for endometrial cancer.

Ornithine Decarboxylase (ODC) a key enzyme in polyamine biosynthesis is often overexpressed in cancers and contributes to polyamine-induced cell proliferation. We noted ubiquitous expression of ODC1 in our published endometrial cancer gene array data and confirmed this in the cancer genome atlas (TCGA) with highest expression in non-endometrioid, high grade, and copy number high cancers, which have the worst clinical outcomes. ODC1 expression was associated with worse overall survival and increased recurrence in three endometrial cancer gene expression datasets. Importantly, we confirmed these findings using quantitative real-time polymerase chain reaction (qRT-PCR) in a validation cohort of 60 endometrial cancers and found that endometrial cancers with elevated ODC1 had significantly shorter recurrence-free intervals (KM log-rank p = 0.0312, Wald test p = 5.59e-05). Difluoromethylornithine (DFMO) a specific inhibitor of ODC significantly reduced cell proliferation, cell viability, and colony formation in cell line models derived from undifferentiated, endometrioid, serous, carcinosarcoma (mixed mesodermal tumor; MMT) and clear cell endometrial cancers. DFMO also significantly reduced human endometrial cancer ACI-98 tumor burden in mice compared to controls (p = 0.0023). ODC-regulated polyamines (putrescine [Put] and/or spermidine [Spd]) known activators of cell proliferation were strongly decreased in response to DFMO, in both tumor tissue ([Put] (p = 0.0006), [Spd] (p<0.0001)) and blood plasma ([Put] (p<0.0001), [Spd] (p = 0.0049)) of treated mice. Our study indicates that some endometrial cancers appear particularly sensitive to DFMO and that the polyamine pathway in endometrial cancers in general and specifically those most likely to suffer adverse clinical outcomes could be targeted for effective treatment, chemoprevention or chemoprevention of recurrence.

Training on Exercise is Medicine® Within an Integrative Medicine Curriculum.

Physicians are increasingly approached by individuals seeking integrative approaches to health care and well-being. Many integrative modalities include a physical activity component. Patients seek guidance from primary and specialty care providers on the safe and effective incorporation of these modalities into their lifestyle. Physicians and other health professionals receive very limited training in the clinical applications of exercise science. This paper reports on a curriculum designed to teach health professionals key exercise constructs for application to clinical practice for prevention and management of lifestyle-related disease, and incorporating the curriculum into a preventive medicine residency training program. The course was developed in 2012-2013, data collected in 2013-2015, and analysis was done in 2015. Six modules were developed as part of a 24-hour course. Each module included didactic, laboratory, and case examples. The modules included energetics, exercise and cardiorespiratory health, bone health, obesity and sarcopenia, balance and fall prevention, and behavior change and the use of technologies. The delivery was found feasible for all three components, delivered in 2-4-hour segments. The incorporation into the residency curriculum was feasible, efficacious, well received, and easily incorporated into the existing curriculum. This comprehensive curriculum has the potential to close the gap in medical school, residency, graduate, nursing, and integrative curricula on this important topic. Current practitioners would benefit in primary care and geriatric settings. This curriculum would also be useful for cross-disciplinary researchers, including public health, health behaviors, and integrative medicine practitioners.

Danio rerio in K-12 classrooms: sparking interest in the new generation of scientists.

Zebrafish are ideal for experimental studies in the classroom because, in contrast to chicks or mammals, fish embryos are relatively easy and inexpensive to maintain, and embryonic development can be observed with common classroom equipment. The eight student-developed laboratory exercises described here have been used by students in Neuroscience Research at Sidwell Friends School. This course uses zebrafish as a vertebrate model to study genetics, development, behavior, neurobiology, regeneration, learning, and memory. The students develop protocols through collaboration with the teacher and scientists in specific fields. Through individual research, students develop and perform their own experiments, formulate and test hypotheses, learn basic laboratory and microscopy techniques, collect and analyze data, read original scientific literature, and collaborate with prominent zebrafish researchers.

The effect of statin therapy on allergic patients with asthma.

BACKGROUND: 3-Hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors have significantly improved outcomes in coronary artery disease. They have anti-inflammatory and cholesterol-lowering effects. Statins alter the production of T(H)1 cytokines and thus promote a T(H)2 response. This immune alteration would promote allergic diseases such as asthma. OBJECTIVE: To ascertain whether statin use adversely affects the clinical course of asthma. METHODS: We retrospectively reviewed 759 medical records of consecutive patients with asthma to identify patients with extrinsic asthma who had at least 4 physician visits over 1 year. We compared patients who started receiving statins after their initial asthma evaluation with patients who never received statins. Baseline characteristics; change in forced expiratory volume in 1 second from baseline at 3, 6, 12, and 24 months; and a need for increases in medication and acute asthma visits were compared between the statin and control groups. RESULTS: We identified 24 patients who started statin therapy and 26 control patients. There was a statistically significant 3% to 5% median worsening of forced expiratory volume in 1 second at all time points for the statin group compared with the controls. At 6 months, more patients in the statin group needed increased maintenance medication (16 [67%] vs 7 [27%]; P = .005), used albuterol more frequently (18 [75%] vs 3 [12%]; P < .001), had more nocturnal awakenings (8 [33%] vs 0 [0%]; P < .001), and were seen more frequently at office visits for acute asthma (9 [38%] vs 1 [4%]; P = .003). CONCLUSIONS: This preliminary study demonstrated that patients with asthma who received statins had a worse clinical course than controls. Given the prevalence of both statin use and asthma, further research is needed.