Multidisciplinary approach to evaluation of rectovaginal fistulas.

Thorough evaluation of a rectovaginal fistula is essential to optimize surgical repair. The underlying cause should be addressed and treated, which can affect the timing and the approach to repair. It is imperative to be well prepared because the highest chance of successful closure occurs during the initial repair attempt. Our objective was to demonstrate how multidisciplinary colorectal surgery and urogynecology teams use specific methods during the examination under anesthesia to evaluate a complex rectovaginal fistula and to optimize the surgical approach to repair. Anesthesia may be provided with monitored anesthesia care and a posterior perineal block. This pain control allows for a wide range of techniques to evaluate the fistula using anoscopy, fistula probe, hydrogen peroxide, and sigmoidoscopy. In addition, the teams show how curettage and subsequent seton placement can encourage closure by secondary intention and decrease the risk of abscess formation, respectively.

Validation of Lower Urinary Tract Symptom Questionnaire in the Transmasculine Population.

INTRODUCTION AND HYPOTHESIS: Transgender men and transmasculine individuals report a variety of lower urinary tract symptoms (LUTS), but little is known about LUTS in this population. One of the obstacles is the lack of validated questionnaires. This study was aimed at validating the International Consultation on Incontinence Questionnaire-Lower Urinary Tract Symptoms (ICIQ-LUTS), which measures filling, voiding, and incontinence symptoms, in transmasculine individuals. METHODS: This is an observational validation study that included transmasculine individuals receiving care within a single tertiary care hospital system. Construct validity was assessed by comparing the ICIQ-LUTS with severity of LUTS as measured by the Urinary Distress Inventory-Short Form (UDI-6), and concurrent validity by the association between ICIQ-LUTS and the Patient Perception of Bladder Condition (PPBC). Discriminant validity was determined by comparing ICIQ-LUTS scores in those with and those without self-reported LUTS. Spearman correlation, t test, and Kruskal-Wallis test were used for data analysis. RESULTS: A total of 131 respondents were included in the analysis. Only two individuals (1.5%) reported prior vaginectomy and/or phalloplasty. Concurrent validity was demonstrated by a significant association between ICIQ-LUTS subscales and PPBC (filling p < 0.001, voiding p < 0.001, incontinence p < 0.001). Construct validity was demonstrated by a significant correlation between ICIQ-LUTS and UDI-6 (filling ρ = 0.76, p < 0.001; voiding ρ = 0.48, p < 0.001; incontinence ρ = 0.61, p < 0.001). For discriminant validity, those with at least one self-reported LUTS had significantly higher (worse) ICIQ-LUTS subscale scores than those without self-reported LUTS. CONCLUSIONS: The ICIQ-LUTS is valid for measurement of LUTS severity in transmasculine individuals. This will be an important tool to use in future research to learn more about LUTS in this population.

Feasibility and user-experience of a virtual environment for social connection and education after stroke: A pilot study.

OBJECTIVES: To evaluate the feasibility and usability of stroke survivor participation in an 8-week virtual environment intervention that provides opportunities for social support exchanges, social network interactions, and recovery education. MATERIALS AND METHODS: A single-group, pre- and post-test measure design was used. Descriptive statistics were used to examine enrollment and retention rates, proportion of questionnaires completed, and virtual environment process data (e.g., number of log-ins) and usability scores. Changes in pre- and post-intervention questionnaire (e.g., usability, social support, depression, anxiety, loneliness, and self-efficacy) scores were explored using Wilcoxon signed-rank tests and paired t-test. RESULTS: Fifteen (65 %) of the eligible stroke survivors enrolled (60 % white, 27 % black), 12 (80 %) had an ischemic stroke, ages ranged from 33 to 74 years (mean 44 years), and mean months since stroke was 33 ± 23. Retention and questionnaire completion rates were both 93 % (n = 14). Survivors logged into the virtual environment a total of 122 times, logged an average of 49 min/log-in, and 12 (80 %) attended support groups and social activities. Median usability score indicated lower than average usability. Improvement trends in social support, loneliness, and depressive symptoms were found, but significant changes in mean questionnaire scores were not found. CONCLUSIONS: Overall, the results suggest that using a virtual environment to foster social support exchanges, social network interactions, and recovery education after stroke is feasible. Similar to other chronic disease populations, stroke survivor adoption of a virtual environment likely requires ongoing technical assistance, repetition of instructions, and opportunities for practice to reinforce engagement. TRIAL REGISTRATION: NCT05487144.

Does preoperative resting genital hiatus size predict surgical outcomes?

AIM: To determine whether preoperative genital hiatus at rest is predictive of medium-term prolapse recurrence. METHODS: We conducted a retrospective study of women who underwent native tissue prolapse surgery from 2002 to 2017 with pelvic organ prolapse quantification data including resting genital hiatus at one of three time points: preoperatively, 6 weeks, and ≥1 year postoperatively. Demographics and clinical data were abstracted from the chart. Prolapse recurrence was defined by anatomic outcomes (Ba > 0, Bp > 0, and/or C ≥ -4) or retreatment. Descriptive statistics, bivariate analyses, and logistic regression analyses were performed. RESULTS: Of the 165 women included, 36 (21.8%) had prolapse recurrence at an average of 1.5 years after surgery. Preoperative resting genital hiatus did not differ between women with surgical success versus recurrence (3.5 cm [interquartile range, IQR 2.25, 4.0) vs 3.5 cm (IQR 3.0, 4.0), p = 0.71). Point Bp was greater in the recurrence group at every time point. Preoperative Bp (odds ratio [OR] 1.24, confidence interval [CI] [1.06-1.45], p = 0.01) and days from surgery (OR 1.001, CI [1.000-1.001], p < 0.01) were independently associated with recurrence. Preoperative genital hiatus at rest and strain were significantly larger among women who underwent a colpoperineorrhaphy (rest: 4.0 [3.0, 4.5] cm vs 3.5 [3.0, 4.0] cm, p < 0.01; strain: 6.0 [4.0, 6.5] cm vs 5.0 [4.0, 6.0] cm, p = 0.01). CONCLUSIONS: Preoperative genital hiatus at rest was not associated with prolapse recurrence when the majority of women underwent colpoperineorrhaphy. Preoperative Bp was more predictive of short-term prolapse recurrence. For every 1 cm increase in point Bp, there is a 24% increased odds of recurrence.

Indications for surgical intervention in a postpartum pelvic floor specialty clinic.

OBJECTIVE: To determine the prevalence and type of surgical procedures undergone by postpartum women seen in a specialty postpartum pelvic floor clinic over 11 years. METHODS: This study was a retrospective chart review of patients requiring surgical intervention within a 1-year period after their initial visit to the Michigan Healthy Healing After Delivery (MHHAD) clinic at the University of Michigan from July 2007 through January 2019. Chart review was performed to abstract demographics, obstetric data, indication for postpartum clinic visit, primary and secondary indications for surgery, and procedures performed. Descriptive analyses were used to describe the cohort. RESULTS: Of the 1138 new MHHAD patients seen during the study period, 9.1% (n = 103) underwent surgical management. Anal incontinence was the primary or secondary indication for surgery in 51.5% (n = 53) of women. The most common surgical interventions were anal sphincteroplasty (37.9%, n = 39), perineal laceration revision (33.0%, n = 34), and rectovaginal fistula repair/fistulotomy (19.4%, n = 20). Of the women who had a sphincteroplasty, 61.5% (24/39) had a prior fourth-degree perineal laceration. CONCLUSIONS: Anal sphincteroplasty was the most common surgical intervention undergone by women seen in a postpartum pelvic floor specialty clinic. Postpartum pelvic floor clinics, such as the Michigan Healthy Healing After Delivery Clinic, provide the expertise and specialized resources required to ensure the early diagnosis and treatment of pelvic floor conditions related to childbirth thus improving women's quality of life and preventing potential life-long sequelae.

Air concentrations of volatile compounds near oil and gas production: a community-based exploratory study.

BACKGROUND: Horizontal drilling, hydraulic fracturing, and other drilling and well stimulation technologies are now used widely in the United States and increasingly in other countries. They enable increases in oil and gas production, but there has been inadequate attention to human health impacts. Air quality near oil and gas operations is an underexplored human health concern for five reasons: (1) prior focus on threats to water quality; (2) an evolving understanding of contributions of certain oil and gas production processes to air quality; (3) limited state air quality monitoring networks; (4) significant variability in air emissions and concentrations; and (5) air quality research that misses impacts important to residents. Preliminary research suggests that volatile compounds, including hazardous air pollutants, are of potential concern. This study differs from prior research in its use of a community-based process to identify sampling locations. Through this approach, we determine concentrations of volatile compounds in air near operations that reflect community concerns and point to the need for more fine-grained and frequent monitoring at points along the production life cycle. METHODS: Grab and passive air samples were collected by trained volunteers at locations identified through systematic observation of industrial operations and air impacts over the course of resident daily routines. A total of 75 volatile organics were measured using EPA Method TO-15 or TO-3 by gas chromatography/mass spectrometry. Formaldehyde levels were determined using UMEx 100 Passive Samplers. RESULTS: Levels of eight volatile chemicals exceeded federal guidelines under several operational circumstances. Benzene, formaldehyde, and hydrogen sulfide were the most common compounds to exceed acute and other health-based risk levels. CONCLUSIONS: Air concentrations of potentially dangerous compounds and chemical mixtures are frequently present near oil and gas production sites. Community-based research can provide an important supplement to state air quality monitoring programs.

Forever Pesticides: A Growing Source of PFAS Contamination in the Environment.

BACKGROUND: Environmental contamination by fluorinated chemicals, in particular chemicals from the per- and polyfluoroalkyl substances (PFAS) class, has raised concerns around the globe because of documented adverse impacts on human health, wildlife, and ecosystem quality. Recent studies have indicated that pesticide products may contain a variety of chemicals that meet the PFAS definition, including the active pesticide ingredients themselves. Given that pesticides are some of the most widely distributed pollutants across the world, the legacy impacts of PFAS addition into pesticide products could be widespread and have wide-ranging implications on agriculture and food and water contamination, as well as the presence of PFAS in rural environments. OBJECTIVES: The purpose of this commentary is to explore different ways that PFAS can be introduced into pesticide products, the extent of PFAS contamination of pesticide products, and the implications this could have for human and environmental health. METHODS: We submitted multiple public records requests to state and federal agencies in the United States and Canada and extracted relevant data from those records. We also compiled data from publicly accessible databases for our analyses. DISCUSSION: We found that the biggest contributor to PFAS in pesticide products was active ingredients and their degradates. Nearly a quarter of all US conventional pesticide active ingredients were organofluorines and 14% were PFAS, and for active ingredients approved in the last 10 y, this had increased to 61% organofluorines and 30% PFAS. Another major contributing source was through PFAS leaching from fluorinated containers into pesticide products. Fluorination of adjuvant products and "inert" ingredients appeared to be limited, although this represents a major knowledge gap. We explored aspects of immunotoxicity, persistence, water contamination, and total fluorine load in the environment and conclude that the recent trend of using fluorinated active ingredients in pesticides may be having effects on chemical toxicity and persistence that are not given adequate oversight in the United States. We recommend a more stringent risk assessment approach for fluorinated pesticides, transparent disclosure of "inert" ingredients on pesticide labels, a complete phase-out of post-mold fluorination of plastic containers, and greater monitoring in the United States. https://doi.org/10.1289/EHP13954.

Utility of Abbreviated Small Bowel Follow Through Study in the Management of Small Bowel Obstruction.

INTRODUCTION: Small bowel obstruction is a common surgical complaint. Most small bowel obstructions are managed successfully nonoperatively. Unanimous guidelines for nonoperative management of small bowel obstruction do not exist. METHODS: A standardized protocol for water-soluble contrast administration and abbreviated small bowel follow through imaging was implemented in January of 2021. A retrospective chart review identified 111 patients admitted for SBO from 6/2019 to 9/2019 for a control group. A planned follow-up review identified 158 patients managed according to the new protocol from 3/2021 to 10/2021. The primary outcome was in-hospital length of stay. Standard statistical analyses were performed and pre-specified. RESULTS: Before implementation of the standardized protocol patients that were managed strictly nonoperatively, the mean length of stay (LOS) was 8.3 days. After implementation, the average LOS was 4.8 (P < .0001). Comparatively, patients admitted after protocol implementation were more likely to undergo CT scan with PO contrast on admission (98.1% vs 90.1%; P < .005), undergo NG tube decompression (84.7% vs 68.5%; P < .005), and undergo water-soluble contrast with abbreviated or formal SBFT (75.3% vs 37.8%; P < .0001). CONCLUSION: Implementation of a standardized protocol utilizing abbreviated SBFT with water-soluble contrast for the management of SBO at our institution resulted in a decrease in the average length of stay for patients definitively managed in a nonoperative fashion.

Health, Pesticide Adjuvants, and Inert Ingredients: California Case Study Illustrates Need for Data Access.

BACKGROUND: Many pesticide products are mixtures of multiple chemicals. These include active ingredients intended to kill pests, and so-called inert ingredients intended to improve the physical characteristics of the product. In addition, shortly before applying a pesticide product, applicators often mix adjuvants into the sprayer tank. Adjuvants are products designed to improve the performance or physical properties of a pesticide spray mixture. Manufacturers may use a particular chemical compound both as an inert ingredient within pesticide products and as a component of adjuvant products. Nonetheless, regulations dictate that data on use are publicly available only for the portion used in adjuvants. Adjuvants are exempt from federal registration, but are defined as pesticides in California. Based on that definition, California has identified α-(p-nonylphenyl)-ω-hydroxypoly(oxyethylene) (APNOHO) as the most widely used pesticide in the state, applied to more than 10 million acres annually. That quantified use includes only agricultural acres treated with adjuvants containing APNOHO. Total APNOHO use is likely higher because manufacturers also use the chemical as an inert ingredient within pesticide products, although data on such use are shielded by regulation. OBJECTIVES: We use APNOHO as a case study to demonstrate that the use of adjuvants and inert ingredients is difficult to track because relevant information is not publicly available. We synthesize information that suggests widespread agricultural use of alkylphenol ethoxylates, such as APNOHO, may pose significant human and environmental health risks. We then make recommendations for future research and policy. METHODS: We used information from California's pesticide use reporting system and the U.S. Environmental Protection Agency (EPA) to estimate use of APNOHO. We used U.S. EPA and European databases, as well as published research, to identify human and environmental health hazards of APNOHO. We focused on research showing that APNOHO is an endocrine-disrupting chemical. DISCUSSION: Within California, APNOHO is applied in more than 150 adjuvant products. Nationwide, it is used as an inert ingredient in at least 650 pesticide products. Exposure to APNOHO is associated with endocrine disruption, birth defects, and aquatic toxicity. We suggest that the case of APNOHO illustrates the larger problem of a lack of publicly available data on use and toxicity of many adjuvants and pesticide inert ingredients. We recommend that researchers and regulators include adjuvants and inert ingredients when evaluating pesticide hazards, including endocrine disruption. We also recommend regulatory requirements to identify all ingredients on product labels. https://doi.org/10.1289/EHP10634.

Antibiotic use during repair of obstetrical anal sphincter injury: a quality improvement initiative.

OBJECTIVE: To evaluate the effects of a quality improvement initiative regarding the administration of antibiotics at the time of obstetric anal sphincter injury (OASIS) repair. METHODS: At University of Michigan-a tertiary care center in Ann Arbor, MI, USA, we implemented a quality improvement intervention aimed at administering a single dose of broad-spectrum antibiotics at the time of OASIS repair. Best practice recommendations and reminders were presented to the department. Cefazolin plus metronidazole or clindamycin plus gentamycin were the recommended antibiotics. The effects of this intervention were assessed based on a chart review of deliveries between January 4, 2014 and February 13, 2019, which included patient data both pre-initiative and post-initiative to compare the prevalence of antibiotic use at the time of OASIS repair. RESULTS: Recommended antibiotic use increased from 0.3% (1/372) pre-initiative to 75.7% (106/140) post-initiative (P < 0.001), and any antibiotic use increased from 6.5% (24/372) to 82.9% (116/140, P < 0.001). The proportion of cases complicated by wound infection/breakdown decreased by 55% after the quality improvement intervention (3.2% pre-intervention vs 1.4% post-intervention, P = 0.22). CONCLUSION: Following a departmental quality improvement intervention aimed at increasing antibiotic administration at the time of OASIS repair, antibiotic use increased 13-fold. Although underpowered to detect a significant difference in wound complications, our study showed a clinically meaningful decrease in wound infection/breakdown with antibiotic administration.

Stigma Associated With Pelvic Floor Disorders.

OBJECTIVES: Although the impact of stigma is known for women with urinary incontinence, it has not been well studied among the full spectrum of pelvic floor disorders. This study quantifies the level of stigma among women presenting for urogynecologic care and tests the hypothesis that stigma related to pelvic floor disorders results in a delay in care seeking for these problems. METHODS: Women presenting for new patient visits (N = 523) in university medical center-based urogynecology clinics completed 2 anonymous questionnaires (Stigma Scale for Chronic Illnesses 8-item version and Pelvic Floor Bother Questionnaire) before their visit. The Kruskal-Wallis test was used to compare the distributions of stigma scores. Logistic regression was used to model factors associated with a delay in seeking care. Spearman correlation was used to determine whether there was an association between stigma and bother scores. RESULTS: Median stigma score was significantly higher for those presenting with complaints of urine leakage (P = 0.015), accidental bowel leakage (P < 0.001), and constipation (P < 0.001) compared with women without these symptoms. Women presenting with accidental bowel leakage had the highest median stigma score, and those presenting with pelvic organ prolapse had the lowest. Total stigma score had a moderately positive correlation (r = 0.5, P < 0.001) with bother score. In a logistic regression model, higher stigma score was associated with a decreased likelihood of waiting 1 year or more to seek care (odds ratio = 0.92, 95% confidence interval = 0.86-0.98). CONCLUSIONS: Pelvic floor disorders carry varying levels of stigma. Women who feel more stigmatized by pelvic floor disorders seem to seek care earlier.

Genome-Wide Association Study of Pelvic Organ Prolapse Using the Michigan Genomics Initiative.

OBJECTIVES: The aim of this study was to (1) replicate previously identified genetic variants significantly associated with pelvic organ prolapse and (2) identify new genetic variants associated with pelvic organ prolapse using a genome-wide association study. METHODS: Using our institution's database linking genetic and clinical data, we identified 1,329 women of European ancestry with an International Classification of Diseases, Ninth Revision (ICD-9)/ICD-10 code for prolapse, 767 of whom also had Current Procedural Terminology (CPT)/ICD-9/ICD-10 procedure codes for prolapse surgery, and 16,383 women of European ancestry older than 40 years without a prolapse diagnosis code as controls. Patients were genotyped using the Illumina HumanCoreExome chip and imputed to the Haplotype Reference Consortium. We tested 20 million single nucleotide polymorphisms (SNPs) for association with pelvic organ prolapse adjusting for relatedness, age, chip version, and 4 principal components. We compared our results with 18 previously identified genome-wide significant SNPs from the UK Biobank, Commun Biol (2020;3:129), and Obstet Gynecol (2011;118:1345-1353). RESULTS: No variants achieved genome-wide significance (P = 5 × 10-8). However, we replicated 4 SNPs with biologic plausibility at nominal significance (P ≤ 0.05): rs12325192 (P = 0.002), rs9306894 (P = 0.05), rs1920568 (P = 0.034), and rs1247943 (P = 0.041), which were all intergenic and nearest the genes SALL1, GDF7, TBX5, and TBX5, respectively. CONCLUSIONS: Our replication of 4 biologically plausible previously reported SNPs provides further evidence for a genetic contribution to prolapse, specifically that rs12325192, rs9306894, rs1920568, and rs1247943 may contribute to susceptibility for prolapse. These and previously reported associations that have not yet been replicated should be further explored in larger, more diverse cohorts, perhaps through meta-analysis.

Review of Malpractice Litigations Involving Vesicovaginal and Rectovaginal Fistulas Following Elective Hysterectomy for Benign Indications in the United States From 1970 to 2020.

OBJECTIVE: The aims of this study were to review malpractice litigations involving vesicovaginal and rectovaginal fistulas after elective hysterectomy for benign indications in the United States and identify the most common themes in allegations by the plaintiffs and defenses by the defendants. METHODS: Using the Lexis Nexis legal database, we searched for and reviewed all U.S. malpractice litigations pertinent to this question between 1970 and 2020. RESULTS: Out of 82 cases that were identified and reviewed, 17 cases met our inclusion and exclusion criteria. These cases were decided between 1973 and 2019. Nine cases involved total abdominal hysterectomies, 1 involved total laparoscopic hysterectomy (TLH), 1 involved total vaginal hysterectomy (TVH), and the rest were not specified. Fifteen cases involved vesicovaginal fistulas and 2 involved rectovaginal fistulas. Three cases were ruled in favor of the plaintiffs, with monetary compensation ranging from $250,000 to $753,722 (approximately $364,120 to $1.8 million when adjusted for inflation), whereas 14 cases were ruled in favor of the defending surgeons. Common allegations were negligence in 15 cases and lack of informed consent in 2 cases. Factors that strengthened the defendants' arguments were thorough documentation, informed consent, and prompt referral to specialists. Intraoperative cystoscopy may have benefited in some cases. CONCLUSIONS: Thorough documentation, informed consent, and prompt referral to specialists strengthened the defendants' legal arguments. Intraoperative cystoscopy may also be beneficial.

Reduction in the prevalence of lead-containing jewelry in California following litigation and legislation.

Exposure to lead-containing jewelry has been identified as one cause of elevated blood lead levels. Because of the significant health effects of lead exposure, litigation and legislation in California set standards for lead content of children's and adult jewelry. We measured compliance with these standards for jewelry sold at 42 major retailers statewide. During a one-year period, we purchased over 1500 pieces of jewelry and used a two-step process (X-ray fluorescence analysis followed by laboratory verification) to identify noncompliant jewelry. About 4% of the jewelry we purchased did not comply with California lead standards, dramatically less jewelry with high lead content than has been measured in the past in California and in other states. We identified violations at 26 retailers. The violations were not restricted to particular types of jewelry or a particular price range. Most violations exceeded state standards by at least 2x. The most common violation was the "lobster-claw" clasp often used on necklaces. Litigation and legislation have been effective tools for reducing the prevalence of jewelry with high lead content in California. We are continuing our monitoring for at least another year with a goal of reducing the frequency of jewelry in violation of California lead standards to near zero.

Pesticide risk indicators: unidentified inert ingredients compromise their integrity and utility.

Pesticide Risk Indicators (PRIs) are widely used to evaluate and compare the potential health and environmental risks of pesticide use and to guide pest control policies and practices. They are applied to agricultural, landscape and structural pest management by governmental agencies, private institutions and individuals. PRIs typically assess only the potential risks associated with the active ingredients because, with few exceptions, pesticide manufacturers disclose only the identity of the active ingredients which generally comprise only a minor portion of pesticide products. We show that when inert ingredients are identified and assessed by the same process as the active ingredient, the product specific risk can be much greater than that calculated for the active ingredient alone. To maintain transparency in risk assessment, all those who develop and apply PRIs or make decisions based on their output, should clearly disclose and discuss the limitations of the method.

Neurodevelopmental and neurological effects of chemicals associated with unconventional oil and natural gas operations and their potential effects on infants and children.

Heavy metals (arsenic and manganese), particulate matter (PM), benzene, toluene, ethylbenzene, xylenes (BTEX), polycyclic aromatic hydrocarbons (PAHs) and endocrine disrupting chemicals (EDCs) have been linked to significant neurodevelopmental health problems in infants, children and young adults. These substances are widely used in, or become byproducts of unconventional oil and natural gas (UOG) development and operations. Every stage of the UOG lifecycle, from well construction to extraction, operations, transportation and distribution can lead to air and water contamination. Residents near UOG operations can suffer from increased exposure to elevated concentrations of air and water pollutants. Here we focus on five air and water pollutants that have been associated with potentially permanent learning and neuropsychological deficits, neurodevelopmental disorders and neurological birth defects. Given the profound sensitivity of the developing brain and central nervous system, it is reasonable to conclude that young children who experience frequent exposure to these pollutants are at particularly high risk for chronic neurological diseases. More research is needed to understand the extent of these concerns in the context of UOG, but since UOG development has expanded rapidly in recent years, the need for public health prevention techniques, well-designed studies and stronger state and national regulatory standards is becoming increasingly apparent.

Lobectomy for treatment of differentiated thyroid cancer: can patients avoid postoperative thyroid hormone supplementation and be compliant with the American Thyroid Association guidelines?

BACKGROUND: The American Thyroid Association recommended thyroid lobectomy as an alternative for low-risk differentiated thyroid cancer. One hypothetical benefit includes avoiding lifelong thyroid hormone supplementation; however, guidelines recommend maintaining the thyroid-stimulating hormone <2 mIU/L postoperatively in low-risk patients. Our hypothesis is that most patients will require hormone supplementation to maintain thyroid-stimulating hormone <2 mIU/L, minimizing this advantage of lobectomy. The goal of this study is to determine how often patients have thyroid-stimulating hormone <2 mIU/L after lobectomy without thyroid hormone supplementation. METHODS: A retrospective review of 555 consecutive patients who underwent thyroid lobectomy was performed. Thyroid hormone supplementation was documented, along with thyroid-stimulating hormone levels preoperatively, 7 to 10 days, and 2 to 12 months postoperatively. RESULTS: In the study, 478/555 (86%) patients did not take thyroid hormone before thyroidectomy; 394/478 (82%) had thyroid-stimulating hormone levels available at 7 to 10 days postoperatively, and of these, 218 (55%) had thyroid-stimulating hormone >2 mIU/L. From 2 to 12 months postoperatively, of the 225 patients who continued to remain off thyroid hormone supplementation, 132 (59%) experienced a thyroid-stimulating hormone increase to >2 mIU/L; therefore, 350/478 (73%) patients after thyroid lobectomy had thyroid-stimulating hormone levels >2 mIU/L within a year. CONCLUSION: It is important to counsel patients that to be compliant with the American Thyroid Association guidelines for differentiated thyroid cancer, the majority of patients undergoing thyroid lobectomy may require thyroid hormone supplementation to maintain a thyroid-stimulating hormone level <2 m IU/L.

Unidentified inert ingredients in pesticides: implications for human and environmental health.

BACKGROUND: By statute or regulation in the United States and elsewhere, pesticide ingredients are divided into two categories: active and inert (sometimes referred to as other ingredients, adjuvants, or coformulants). Despite their name, inert ingredients may be biologically or chemically active and are labeled inert only because of their function in the formulated product. Most of the tests required to register a pesticide are performed with the active ingredient alone, not the full pesticide formulation. Inert ingredients are generally not identified on product labels and are often claimed to be confidential business information. OBJECTIVES: In this commentary, we describe the shortcomings of the current procedures for assessing the hazards of pesticide formulations and demonstrate that inert ingredients can increase the toxicity of and potential exposure to pesticide formulations. DISCUSSION: Inert ingredients can increase the ability of pesticide formulations to affect significant toxicologic end points, including developmental neurotoxicity, genotoxicity, and disruption of hormone function. They can also increase exposure by increasing dermal absorption, decreasing the efficacy of protective clothing, and increasing environmental mobility and persistence. Inert ingredients can increase the phytotoxicity of pesticide formulations as well as the toxicity to fish, amphibians, and microorganisms. CONCLUSIONS: Pesticide registration should require full assessment of formulations. Evaluations of pesticides under the National Environmental Policy Act, the Endangered Species Act, and similar statutes should include impact assessment of formulations. Environmental monitoring for pesticides should include inert ingredients. To enable independent research and risk assessment, inert ingredients should be identified on product labels.

Potential hazards of air pollutant emissions from unconventional oil and natural gas operations on the respiratory health of children and infants.

Research on air pollutant emissions associated with unconventional oil and gas (UOG) development has grown significantly in recent years. Empirical investigations have focused on the identification and measurement of oil and gas air pollutants [e.g. volatile organic compounds (VOCs), particulate matter (PM), methane] and the influence of UOG on local and regional ambient air quality (e.g. tropospheric ozone). While more studies to better characterize spatial and temporal trends in exposure among children and newborns near UOG sites are needed, existing research suggests that exposure to air pollutants emitted during lifecycle operations can potentially lead to adverse respiratory outcomes in this population. Children are known to be at a greater risk from exposure to air pollutants, which can impair lung function and neurodevelopment, or exacerbate existing conditions, such as asthma, because the respiratory system is particularly vulnerable during development in-utero, the postnatal period, and early childhood. In this article, we review the literature relevant to respiratory risks of UOG on infants and children. Existing epidemiology studies document the impact of air pollutant exposure on children in other contexts and suggest impacts near UOG. Research is sparse on long-term health risks associated with frequent acute exposures - especially in children - hence our interpretation of these findings may be conservative. Many data gaps remain, but existing data support precautionary measures to protect the health of infants and children.