Prevalence and determinants of multimorbidity in the Canadian population.

Multimorbidity, which is defined as having at least two or more chronic diseases concurrently, has been a rising public health issue in recent years in Canada and worldwide. The increasing prevalence of multimorbidity has posed a burden on the current health care system and quality of life for the Canadian population. There is a lack of up-to-date research on determinants of multimorbidity in the Canadian population, which is necessary to better understand and prevent multimorbidity. This study aims to determine the prevalence and risk factors of multimorbidity in the middle-aged and older Canadian adult population. Multivariable logistic regression analyses incorporating survey weights and biologically plausible interactions were conducted to examine the determinants of multimorbidity using data from the 2017/2018 Canadian Community Health Survey (CCHS). Of the 113,290 CCHS participants, 82,508 subjects who were aged 35 years and above were included in the study. The prevalence of multimorbidity was 22.20% (95% CI: 21.74%, 22.67%) and was greater for females. Multimorbidity was more likely in subjects who were obese, abstaining from alcohol, inactive, had a lower education level, widowed, divorced, or separated and was less likely among subjects living in Quebec. The protective effect of household income on multimorbidity decreased with age. Current smokers who reported extreme stress were more likely to have multimorbidity. Multimorbidity is associated with various determinants that need to be considered in chronic disease control and prevention. These results suggest that future research should focus not only on these determinants but also on the relationships between them. A future longitudinal study is required to provide causal evidence for the study findings.

Should we screen aging physicians for cognitive decline?

OBJECTIVES: To synthesize evidence relevant for informed decisions concerning cognitive testing of older physicians. METHODS: Relevant literature was systematically searched in Medline, EMBASE, PsycInfo, and ERIC, with key findings abstracted and synthesized. RESULTS: Cognitive abilities of physicians may decline in an age range where they are still practicing. Physician competence and clinical performance may also decline with age. Cognitive scores are lower in physicians referred for assessment because of competency or performance concerns. Many physicians do not accurately self-assess and continue to practice despite declining quality of care; however, perceived cognitive decline, although not an accurate indicator of ability, may accelerate physicians' decision to retire. Physicians are reluctant to report colleagues' cognitive problems. Several issues should be considered in implementing cognitive screening. Most cognitive assessment tools lack normative data for physicians. Scientific evidence linking cognitive test results with physician performance is limited. There is no known level of cognitive decline at which a doctor is no longer fit to practice. Finally, relevant domains of cognitive ability vary across medical specialties. CONCLUSION: Physician cognitive decline may impact clinical performance. If cognitive assessment of older physicians is to be implemented, it should consider challenges of cognitive test result interpretation.

Mortality among Canadian population with multimorbidity: A retrospective cohort study.

Objective: The aim of this study was to examine the effect of multimorbidity and the joint effect of chronic diseases on all-cause mortality among subjects aged 35 years and above. Study Design: Population-based retrospective cohort study. Methods: Multimorbidity was defined by the respondent's self-report of having two or more chronic diseases of the nine considered. The Canadian Community Health Surveys conducted in 2003/2004, 2005/2006 and 2007 to 2014 were linked with the Canadian Vital Statistics Death Database to examine the association between multimorbidity and all-cause mortality in subjects aged 35 years and above. Cox's proportional hazards models were used to estimate risk of multimorbidity on death after adjusting for the confounders in three age groups. Results: Multimorbidity had an increased risk of death in all three age groups with the youngest having the highest risk after adjusting for potential confounders (35 to 54 years: hazard ratio (HR) = 3.77, 95% CI: 3.04, 4.67; 55 to 64 years: HR = 2.64, 95% CI: 2.36, 2.95; 65 years and above: HR = 1.71; 95% CI:1.63,1.80). Subjects with cancer had the highest risk of death in the three age groups. When the interactions between chronic diseases were considered, subjects with COPD and diabetes had a significantly increased risk of death in comparison to those without COPD or diabetes in the 55 to 64 years. (HR = 2.59, 95% CI: 2.01, 3.34). Conclusions: Prevention of multimorbidity should be targeted not only in the older population but also in the younger populations. Synergistic effects of chronic diseases should be considered in the management of multimorbidities.

Sex-specific characteristics for the coexistence of asthma and COPD in the Canadian population: a cross-sectional analysis of CLSA data.

Objective: The coexistence of asthma and COPD (asthma + COPD) is a condition found among patients who present with clinical features of both asthma and COPD. Epidemiological evidence points to an increasingly disproportionate burden of asthma + COPD and COPD in females. The objective of this cross-sectional study is to identify female and male-specific epidemiological and clinical characteristics associated with asthma + COPD.Methods: Baseline data from the comprehensive cohort of Canadian Longitudinal Study on Aging (CLSA) were used in this cross-sectional study which included 30,097 subjects between the ages of 45- and 85-years Participants were categorized into four mutually exclusive groups: asthma + COPD, COPD-only, asthma-only and neither asthma nor COPD.Results: The prevalence was significantly greater in females than males for asthma + COPD (2.71% vs. 1.41%; p < 0.001), COPD-only (3.22% vs. 2.87%; p < 0.001) and asthma-only (13.31% vs. 10.11%; p < 0.001). The association between smoking and asthma + COPD was modified by age in females. Osteoporosis and underactive thyroid disease were significantly more prevalent in females than in males in asthma + COPD, COPD-only and asthma-only groups. In asthma + COPD group, a greater proportion of respiratory symptoms associated with asthma was observed in females whereas a greater proportion of respiratory symptoms associated with COPD was observed in males. Severity of airway obstruction determined by spirometry measurements was greater in males than females.Conclusions: In the Canadian adult population, several epidemiological and clinical characteristics in asthma + COPD varied between females and males. The findings in this study will help healthcare professional in the recognition and management of coexisting asthma and COPD in females and males.

Sports-Related Concussions in Adults Presenting to Canadian Emergency Departments.

OBJECTIVE: To document the occurrence and recovery outcomes of sports-related concussions (SRCs) presenting to the Emergency Department (ED) in a community-based sample. DESIGN: A prospective observational cohort study was conducted in 3 Canadian hospitals. SETTING: Emergency Department. PATIENTS: Adults (≥17 years) presenting with a concussion to participating EDs with a Glasgow Coma Scale score ≥13 were recruited. INTERVENTIONS: Patient demographics (eg, age and sex), clinical characteristics (eg, history of depression or anxiety), injury characteristics (eg, injury mechanisms and loss of consciousness and duration), and ED management and outcomes (eg, imaging, consultations, and ED length of stay) were collected. MAIN OUTCOME MEASURES: Patients' self-reported persistent concussion symptoms, return to physical activity status, and health-related quality of life at 30 and 90 days after ED discharge. RESULTS: Overall, 248 patients were enrolled, and 25% had a SRC. Patients with SRCs were younger and reported more physical activity before the event. Although most of the patients with SRCs returned to their normal physical activities at 30 days, postconcussive symptoms persisted in 40% at 90 days of follow-up. After adjustment, there was no significant association between SRCs and persistent symptoms; however, patients with concussion from motor vehicle collisions were more likely to have persistent symptoms. CONCLUSION: Although physically active individuals may recover faster after a concussion, patients returning to their physical activities before full resolution of symptoms are at higher risk of persistent symptoms and further injury. Patient-clinician communications and tailored recommendations should be encouraged to guide appropriate acute management of concussions.

Pregnancy Outcome in Women Exposed to Metal Fume in Welding: A Canadian Cohort Study.

OBJECTIVES: Welding is a physically demanding job that entails exposure to metal fume and particles. There is little information on the effect of welding exposures on the outcome of a pregnancy conceived during a period when a woman was employed as a welder. METHODS: Women welders recruited to the Workers Health in Apprenticeship Trades-Metal and Electrical (WHAT-ME) study were followed-up every 6 months for up to 5 years (January 2011-August 2018), and every pregnancy recorded. At the first 6-month follow-up, a detailed questionnaire was completed for the most recent day in welding, and this information was collected again at each follow-up and also from questionnaires completed during pregnancy. The date of conception was estimated for each pregnancy and the job at that date identified. Exposures to ergonomic factors, work schedule and perceptions of noise, heat and cold were extracted for the job at conception. Exposures to metals (aluminum, chromium, manganese, and nickel) and particles in welding fume were estimated from previously validated exposure algorithms reflecting the welding process, base metal and consumables of the job at the conception date. The effects of exposures were estimated in multilevel multivariable models allowing for confounding. RESULTS: There were 242 pregnancies conceived by a welder working in her trade, 87 were before the first follow-up, 3 were after first follow-up but detailed information was not collected, 22 of those potentially included in the assessment group were in-trade but not welding leaving 122 pregnancies in 90 welders for analysis. Of these 91 resulted in a live birth and 31 in a fetal loss (27 miscarriages and 4 stillbirths). Mean birth weight for live births was 3365 g and gestation 39.4 weeks. Final models showed that risk of fetal loss increased with manipulating heavy objects [odds ratio (OR) = 5.13, 95% confidence interval (CI) 2.04-12.92], whole-body vibration (OR = 5.86, 95% CI 1.81-18.92), a higher rating for noise exposure intensity (OR = 1.52, 95% CI 1.24-1.85), and decreased with use of local exhaust ventilation (OR = 0.20, 95% CI 0.03-1.18). Gestation decreased with perceived heat intensity (ß = -0.15, 95% CI -0.29 to -0.02) and number of previous pregnancies (ß = -0.35, 95% CI -0.65 to -0.05). Birth weight was lower in those reporting whole-body vibration (ß = -596 g, 95% CI -924 to -267) and increased with the welder's body mass index (ß = 36 g, 95% CI 12-61). Estimates of exposure to metals and particles were unrelated to gestation or birth weight. In a bivariate analysis, allowing for the same welder reporting >1 pregnancy, estimated airborne aluminum exposure (and to a lesser degree exposure to nickel and particles) was related to greater risk of fetal loss (OR = 1.52, 95% CI 1.04-2.24) but neither aluminum nor the other estimated elements of welding fume added to the final model. CONCLUSIONS: In this group of women actively engaged in welding during the time surrounding conception, the outcome of pregnancy was strongly related to work exposures, particularly vibration (reported in grinding tasks), manipulation of heavy objects, and perceived intensity of noise and heat. The study was unable to show an independent effect of exposure to metal fume constituents.

Urinary Metals as a Marker of Exposure in Men and Women in the Welding and Electrical Trades: A Canadian Cohort Study.

OBJECTIVES: Men and women working in the welding trades undergo the same apprenticeship training but it is unknown whether, once in the trade, their exposures differ. Comparison of urinary metal concentrations, having adjusted for estimated airborne exposure, may provide an answer. METHODS: Men and women were recruited to a cohort study of workers in the welding and electrical trades (the Workers Health in Apprenticeship Trades-Metal working and Electrical [WHAT-ME study]). They completed a recruitment questionnaire and further questionnaires every 6 months for up to 5 years. At each follow-up, they gave details on employment and, if welding, answered trade-specific questionnaires. Urine samples were collected by mail. Welding exposure matrices were developed to estimate metal exposures from welding process, base metal, and consumables. Urinary metal concentrations, determined by ICP-MS, were compared by trade (welding or electrical). Within welding, the relation of urinary concentrations to estimated airborne exposure was examined, with adjustment for potential confounders including sex, use of respiratory protective equipment (RPE), and time spent outdoors. Natural logarithms were taken of exposure estimates and urinary concentrations, to reduce skew. All regression analyses included creatinine concentration. RESULTS: Urinary metal concentrations were analysed for 12 metals in 794 samples. Antimony, arsenic, lead, and mercury had a high proportion of samples with no metal detected and were not considered further. The urinary concentrations of aluminum, cadmium, chromium, cobalt, copper, manganese, nickel, and zinc were compared for welders (434 samples) and electrical workers (360). After adjustment for potential confounders, welders had higher urinary concentrations for aluminum (ß = 0.13 95%CI 0.03-0.24) and chromium (ß = 0.66 95%CI 0.55-0.77). Of 434 welder urines, 334 could be matched securely to detailed information about the most recent day welding. For these, an estimate of airborne exposure was made for aluminum, chromium, manganese, and nickel. Male welders were estimated to have higher airborne exposure to chromium and nickel than women welders. No difference was seen in the estimated exposures for aluminum or manganese (or total dust). Regression analyses of the relation of urinary metals to estimated exposure showed a good concordance for aluminum (ß = 0.09 95%CI 0.04-0.15 (P < 0.001) and chromium (ß = 0.11 95%CI 0.05-0.17 P < 0.001). The concordance for manganese and nickel was positive, but much weaker. Urinary concentrations of aluminum and nickel were somewhat lower with increasing time wearing RPE and, for chromium and nickel, with time working outdoors. Having adjusted for estimated exposure, creatinine and other confounders, male welders had lower urine concentrations of aluminum (ß = -0.35 95%CI -0.51 to -0.19 P < 0.001) chromium (ß = -0.38 95%CI -0.57 to -0.19 P < 0.001) and manganese (ß = -0.36 95%CI -0.49 to -0.23 P < 0.001) than female welders. CONCLUSION: Welders had higher urinary concentrations of aluminum and chromium than electrical workers. Exposure estimates of aluminum and chromium for welders were a valid representation of the airborne exposures to these metals. Although male welders were estimated to have higher exposures of chrome and nickel than female welders, the higher urinary metal concentrations in women welders is of concern, particularly for women who may conceive while in the trade.

Ergonomic demands and fetal loss in women in welding and electrical trades: A Canadian cohort study.

OBJECTIVES: To determine the relationship between ergonomic demands of the job at conception and fetal loss (miscarriage or stillbirth). METHODS: Women with a welding or electrical trade apprenticeship were identified across Canada for the Women's Health in Apprenticeship Trades-Metal and Electrical study. They completed a reproductive and employment history at recruitment and every 6 months for up to 5 years to provide details on pregnancies and work demands. Job at conception was identified and fetal loss examined in relation to ergonomic exposures/demands, allowing for potential confounders. RESULTS: A total of 885 women were recruited; 447 in welding and 438 in electrical trades. Of these, 574 reported at least one pregnancy. Analysis of 756 pregnancies since the woman started in her trade suggested no increased risk of fetal loss in those choosing welding rather than electrical work. Among 506 pregnancies conceived during a period working in a trade, 148 (29.2%) ended in fetal loss: 31.2% (73/234) in welding, and 27.6% (75/272) in electrical work. Detailed exposure information was available for 59% (299/506) of these pregnancies. In welders, the risk of fetal loss was increased with whole-body vibration (prevalence ratio [PR] = 2.14; 95% confidence interval [CI] 1.39-3.31) and hand-arm vibration for > 1 hour/day (PR = 2.15; 95% CI 1.33-3.49). In electrical workers risk increased with more than 8 days working without a rest day (PR = 2.29; 95% CI 1.25-4.17). Local exhaust ventilation reduced risk in welders. CONCLUSIONS: There was no significant increase in fetal loss in welding trades compared to electrical work. Vibration, largely from grinding, and extended work rotations appear to be potentially modifiable factors of some importance.

Sex-based differences in outcomes for adult patients presenting to the emergency department with a concussion.

OBJECTIVE: Patients with concussion frequently present to the emergency department (ED). Studies of athletes and children indicate that concussion symptoms are often more severe and prolonged in females compared with males. Given infrequent study of concussion symptoms in the general adult population, the authors conducted a sex-based comparison of patients with concussion. METHODS: Adults (≥ 17 years of age) presenting with concussion to one of three urban Canadian EDs were recruited. Discharged patients were contacted by telephone 30 and 90 days later to capture the extent of persistent postconcussion symptoms using the Rivermead Post Concussion Symptoms Questionnaire (RPQ). A multivariate logistic regression model for persistent symptoms that included biological sex was developed. RESULTS: Overall, 250 patients were included; 131 (52%) were women, and the median age of women was significantly higher than that of men (40 vs 32 years). Women had higher RPQ scores at baseline (p < 0.001) and the 30-day follow-up (p = 0.001); this difference resolved by 90 days. The multivariate logistic regression identified that women, patients having a history of sleep disorder, and those presenting to the ED with concussions after a motor vehicle collision were more likely to experience persistent symptoms. CONCLUSIONS: In a community concussion sample, inconsequential demographic differences existed between adult women and men on ED presentation. Based on self-reported and objective outcomes, work and daily activities may be more affected by concussion and persistent postconcussion symptoms for women than men. Further analysis of these differences is required to identify different treatment options and ensure adequate care and management of injury.

The Health of Firefighters Deployed to the Fort McMurray Fire: Lessons Learnt.

Introduction: Firefighters were working in exceptionally difficult conditions during the Fort McMurray/Horse River fire in May 2016. Methods: From mid-May, we recruited firefighters from 13 fire services as they returned from the fire. In October 2016 we extended recruitment to all Alberta-based firefighters deployed to the fire. In December 2017-May 2018 we sent a first online follow-up: this concentrated on mental health supports. The second follow-up, in October 2018-January 2019, included screening scales for respiratory ill-health and PTSD. All three contacts included visual analogue scales for chest symptoms and the Hospital Anxiety and Depression Scale. We estimated exposure to PM2.5, and calculated an exposure mitigation index from reports of respiratory protective equipment (RPE). Results: We recruited 1,234 firefighters and examined the relation of respiratory symptoms to estimated particulate exposure. The relation was strong immediately post fire but weakened over time. We found less chest tightness and cough in those whose RPE in the first week mitigated exposure by at least 10%. We examined the relation between particulate exposure and mental ill-health from screening questionnaires and found those with high exposure (reflecting the ferocity of the fire) had poorer mental health scores. Firefighters reporting their "worst moment during the fire" was life threatening were more anxious at second follow-up. Overall both anxiety and depression scores increased at successive contacts, more so in those with mental ill-health recorded in physician billing records before the fire. Discussion: The results from this study overall suggest on-going fire-related health effects in a substantial minority of firefighters, similar to those reported in the longitudinal follow-up of firefighters after the collapse of the World Trade Centre. Self-reports of both respiratory symptoms and mental ill-health were strongly related, soon after the fire, to estimated particulate exposures. Anxiety increased over time since the fire in those who felt their life or safety had been threatened, underlining the need for ongoing support. Our conclusions about the benefits of rapid research relate particularly to the collection of biomarkers of exposure as quickly and widely as possible, and the establishment of a nominal list of participants before they are too widely dispersed.

Respiratory Outcomes of Firefighter Exposures in the Fort McMurray Fire: A Cohort Study From Alberta Canada.

OBJECTIVE: Determine effects on respiratory health of firefighters attending a catastrophic wildfire. METHODS: Within the Alberta Administrative Health Database, we identified five community-based controls for each firefighter in a cohort of 1234 deployed to the 2016 Fort McMurray fire. Spirometry records were identified and a stratified sample assessed clinically. We estimated PM2.5 particles exposure. RESULTS: Firefighters had an increased risk of asthma consultation post-fire (OR new onset asthma = 2.56; 95%CI 1.75 to 3.74). Spirometry showed decreased FEV1 and FVC with increasing exposure. In the clinical assessment, 20% had a positive MCT and 21% BWT. Those with ongoing fire-related symptoms had a higher concurrence of positive MCT and BWT (OR = 4.35; 95%CI 1.11 to 17.12). Lower diffusion capacity related to higher exposure. CONCLUSIONS: Massive exposures during a wildfire are associated with non-resolving airways damage.

Effects of tumor necrosis factor (TNF) gene polymorphisms on the association between smoking and lung function among workers in swine operations.

Workers in swine operations may be at increased risk of developing respiratory problems. These respiratory conditions are more prevalent among workers who are smokers. Tumor necrosis factor (TNF) genes play an important role in human immune responses to various respiratory hazards. This study aimed to investigate whether polymorphisms in TNF genes might alter the effects of smoking on lung function among workers in swine operations. Three hundred and seventy-four full-time workers from large swine operations and 411 non-farming rural dwellers in Saskatchewan were included in this study. Information on demographic and lifestyle characteristics, pulmonary function, and blood samples were obtained. Multiple linear regression analyses were used in the statistical analysis. Three promoter polymorphisms (rs1799724, rs361525, and rs1800629) in the TNF gene were investigated. Only the interaction term between smoking status and rs1799724 was significant in the multiple regression models. Among workers with the rs1799724 polymorphism (TT+TC), current smokers exhibited significantly lower lung function than nonsmokers. These associations were not observed among workers with the wild-type (CC). These findings were not observed among non-farming rural dwellers. Data demonstrated the possible involvement of TNF gene in (1) development of adverse respiratory conditions among workers who are smokers, (2) importance of smoking cessation among workers, especially those with polymorphisms in the TNF gene, and (3) potential implications in treatment, screening, and prevention.

Are Inflammatory Markers an Indicator of Exposure or Effect in Firefighters Fighting a Devastating Wildfire? Follow-up of a Cohort in Alberta, Canada.

OBJECTIVES: The Fort McMurray fire in Alberta, Canada, devastated the townsite in May 2016. First responders were heavily exposed to smoke particles. Blood samples taken from firefighters in May and August/September 2016 were used to measure concentrations of inflammatory markers in plasma and the relation of these markers to exposures and respiratory ill-health. METHODS: Blood samples were drawn from firefighters from two fire services, who also completed questionnaires about tasks and exposures during their deployment to the fire and about respiratory symptoms. Plasma was analysed for 42 inflammatory markers in a multiplex assay. At Service A, samples were collected twice, within 19 days of the start of the fire (early sample) and again 14-18 weeks later (late sample). At Service B, only late samples were collected, at 16-20 weeks. Principal component (PC) scores were extracted from markers in plasma from the early and late samples and, at both time periods, the first two components retained. PC scores were examined against estimated cumulative exposures to PM2.5 particles, self-rated physical stressors during the fire, and time since the last deployment to an active fire. The relation of component scores and exposure estimates to respiratory health were examined, using self-ratings at the time of the blood draw, a validated respiratory screening questionnaire (the European Community Respiratory Health Survey [ECRHS]) some 30 months after the fire, and clinical assessments in 2019-2020. RESULTS: Repeat blood samples were available for 68 non-smoking first responders from Service A and late samples from 160 non-smokers from both services. In the 68 with two samples, marker concentrations decreased from early to late samples for all but 3 of the 42 markers, significantly so (P < 0.05) for 25. The first component extracted from the early samples (C1E) was unrelated to respiratory symptoms but the second (C2E) was weakly related to increased cough (P = 0.079) and breathlessness (P = 0.068) and a lower forced expiratory volume in one second/forced expiratory capacity (FEV1/FVC)(ß = -1.63, 95% CI -3.11 to -0.14) P = 0.032. The first PC at 14-20 weeks (C1L) was unrelated to exposure or respiratory health but the second PC (C2L) from these late samples, drawn from both fire services, related to cumulative PM2.5 exposure. In a multivariate model, clustered within fire service, cumulative exposure (ß = 0.19, 95% CI 0.09-0.30), dehydration (ß = 0.65, 95% CI 0.04-1.27) and time since last deployed to a fire (ß = -0.04, 95% CI -0.06 to -0.01) were all related to the C2L score. This score was also associated with respiratory symptoms of wheezing, chest tightness, and breathlessness at the time of the blood draw but not to symptoms at later follow-up. However, apart from the lower FEV1/FVC at 15-19 days, the marker scores did not add to regression models that also included estimated cumulative PM2.5 exposure. CONCLUSIONS: Concentrations of persisting inflammatory markers in the plasma of firefighters deployed to a devastating fire decreased with time and were related to estimates of exposure. Although not a powerful independent predictor of later respiratory ill-health, they may serve as an indicator of previous high exposure in the absence of contemporary exposure estimates.

The effectiveness of removal from exposure and reduction of exposure for managing occupational asthma: Summary of an updated Cochrane systematic review.

BACKGROUND: The objective was to update the 2011 Cochrane systematic review on the effectiveness of workplace interventions for the treatment of occupational asthma. METHODS: A systematic review was conducted with the selection of articles and reports through 2019. The quality of extracted data was evaluated, and meta-analyses were conducted using techniques recommended by the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: Data were extracted from 26 nonrandomized controlled before-and-after studies. The mean number of participants per study was 62 and the mean follow-up time was 4.5 years. Compared with continued exposure, removal from exposure had an increased likelihood of improved symptoms and change in spirometry. Reduction of exposure also had more favorable results for symptom improvement than continued exposure, but no difference for change in spirometry. Comparing exposure removal to reduction revealed an advantage for removal with both symptom improvement and change in spirometry for the larger group of patients exposed to low-molecular-weight agents. Also, the risk of unemployment was greater for exposure removal versus reduction. CONCLUSIONS: Exposure removal and reduction had better outcomes than continued exposure. Removal from exposure was more likely to improve symptoms and spirometry than reduction among patients exposed to low-molecular-weight agents. The potential benefits associated with exposure removal versus reduction need to be weighed against the potential for unemployment that is more likely with removal from exposure. The findings are based on data graded as very low quality, and additional studies are needed to generate higher quality data.

Sarcoidosis: a prospective observational cohort from Northern Alberta.

INTRODUCTION: Sarcoidosis is a multi-system disease reported to occur with a higher incidence in Alberta than many other health jurisdictions within and outside of Canada. The reasons for this higher incidence are currently not known. Exposure to beryllium can result in a clinically and radiologically identical disease to sarcoidosis. The purpose of our study was to identify patterns with potential occupational or environmental exposures to beryllium amongst individuals with sarcoidosis in Alberta through a tertiary referral center. METHODS: A prospective observational study was carried out at the University of Alberta Hospital. Patients with confirmed sarcoidosis (stages 0-4) were recruited from subspecialty clinics (Respirology, Cardiology, Neurology and Occupational Health). A predetermined list of industries thought to involve potentially relevant exposures for the development of sarcoidosis was used to capture current and previous exposure history. Results were entered into a database and where possible verified by comparing with existing electronic medical records (including histories, physical examination, diagnostic imaging and physiology). RESULTS: A total of 45 patients were recruited, 25 men and 20 women. Of these, 84% of participants reported working in or being exposed to an industry/environment suspected of contributing to development of sarcoidosis over their lifetime. The most frequently reported exposures were within farming and agriculture (27%), oil and gas (20%), metalworking and handling animals (18%). CONCLUSIONS: Amongst this cohort, a high proportion reported working with a potentially relevant exposure. Individuals being assessed for sarcoidosis should have their most responsible physician elicit a detailed work and environmental history. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (4): e2020014).

Workplace interventions for treatment of occupational asthma.

BACKGROUND: The impact of workplace interventions on the outcome of occupational asthma is not well understood. OBJECTIVES: To evaluate the effectiveness of workplace interventions on occupational asthma. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (PubMed); EMBASE(Ovid); NIOSHTIC-2; and CISILO (CCOHS) up to July 31, 2019. SELECTION CRITERIA: We included all eligible randomized controlled trials, controlled before and after studies and interrupted time-series of workplace interventions for occupational asthma. DATA COLLECTION AND ANALYSIS: Two authors independently assessed study eligibility and risk of bias, and extracted data. MAIN RESULTS: We included 26 non-randomized controlled before and after studies with 1,695 participants that reported on three comparisons: complete removal from exposure and reduced exposure compared to continued exposure, and complete removal from exposure compared to reduced exposure. Reduction of exposure was achieved by limiting use of the agent, improving ventilation, or using protective equipment in the same job; by changing to another job with intermittent exposure; or by implementing education programs. For continued exposure, 56 per 1000 workers reported absence of symptoms at follow-up, the decrease in forced expiratory volume in one second as a percentage of a reference value (FEV1 %) was 5.4% during follow-up, and the standardized change in non-specific bronchial hyperreactivity (NSBH) was -0.18.In 18 studies, authors compared removal from exposure to continued exposure. Removal may increase the likelihood of reporting absence of asthma symptoms, with risk ratio (RR) 4.80 (95% confidence interval (CI) 1.67 to 13.86), and it may improve asthma symptoms, with RR 2.47 (95% CI 1.26 to 4.84), compared to continued exposure. Change in FEV1 % may be better with removal from exposure, with a mean difference (MD) of 4.23 % (95% CI 1.14 to 7.31) compared to continued exposure. NSBH may improve with removal from exposure, with standardized mean difference (SMD) 0.43 (95% CI 0.03 to 0.82).In seven studies, authors compared reduction of exposure to continued exposure. Reduction of exposure may increase the likelihood of reporting absence of symptoms, with RR 2.65 (95% CI 1.24 to 5.68). There may be no considerable difference in FEV1 % between reduction and continued exposure, with MD 2.76 % (95% CI -1.53 to 7.04) . No studies reported or enabled calculation of change in NSBH.In ten studies, authors compared removal from exposure to reduction of exposure. Following removal from exposure there may be no increase in the likelihood of reporting absence of symptoms, with RR 6.05 (95% CI 0.86 to 42.34), and improvement in symptoms, with RR 1.11 (95% CI 0.84 to 1.47), as well as no considerable change in FEV1 %, with MD 2.58 % (95% CI -3.02 to 8.17). However, with all three outcomes, there may be improved results for removal from exposure in the subset of patients exposed to low molecular weight agents. No studies reported or enabled calculation of change in NSBH.In two studies, authors reported that the risk of unemployment after removal from exposure may increase compared with reduction of exposure, with RR 14.28 (95% CI 2.06 to 99.16). Four studies reported a decrease in income of 20% to 50% after removal from exposure.The quality of the evidence is very low for all outcomes. AUTHORS' CONCLUSIONS: Both removal from exposure and reduction of exposure may improve asthma symptoms compared with continued exposure. Removal from exposure, but not reduction of exposure, may improve lung function compared to continued exposure. When we compared removal from exposure directly to reduction of exposure, the former may improve symptoms and lung function more among patients exposed to low molecular weight agents. Removal from exposure may also increase the risk of unemployment. Care providers should balance the potential clinical benefits of removal from exposure or reduction of exposure with potential detrimental effects of unemployment. Additional high-quality studies are needed to evaluate the effectiveness of workplace interventions for occupational asthma.

Dental microwear texture analysis of Homo sapiens sapiens: Foragers, farmers, and pastoralists.

OBJECTIVES: The current study seeks to determine if a sample of foragers, farmers, and pastoralists are distinguishable based on their dental microwear texture signatures. MATERIALS AND METHODS: The study included a sample of 719 individuals from 51 archeological sites (450 farmers, 192 foragers, 77 pastoralists). All were over age 12 and sexes were pooled. Using a Sensofar® white-light confocal profiler we collected dental microwear texture analysis (DMTA) data from a single first or second molar from each individual. We leveled and cleaned data clouds following standard procedures and analyzed the data with Sfrax® and Toothfrax® software. The DMTA variables were complexity and anisotropy. Statistics included ANOVA with partial eta squared and Hedges's g. We also performed a follow-up K-means cluster analysis. RESULTS: We found significant differences between foragers and farmers and pastoralists for complexity and anisotropy, with foragers having greater complexity than either the farmers or the pastoralists. The farmers and pastoralists had greater anisotropy than the foragers. The Old World foragers had significantly higher anisotropy values than New World foragers. Old and New World farmers did not differ. Among the Old World farmers, those dating from the Neolithic through the Late Bronze Age had higher complexity values than those from the Iron Age through the medieval period. The cluster analysis discerned foragers and farmers but also indicated similarity between hard food foragers and hard food farmers. DISCUSSION: Our findings reaffirm that DMTA is capable of distinguishing human diets. We found that foragers and farmers, in particular, differ in their microwear signatures across the globe. There are some exceptions, but nothing that would be unexpected given the range of human diets and food preparation techniques. This study indicates that in general DMTA is an efficacious means of paleodietary reconstruction in humans.

Urinary 1-hydroxypyrene and Skin Contamination in Firefighters Deployed to the Fort McMurray Fire.

BACKGROUND: In May 2016, firefighters from the province of Alberta, Canada deployed to a fire that engulfed the urban area of Fort McMurray. During the first days of the fire, firefighters experienced heavy smoke exposures during greatly extended work shifts. Urinary samples were collected post-deployment from three fire services for estimation of 1-hydroxypyrene (1-HP) concentration, reflecting exposure to polycyclic aromatic hydrocarbons (PAHs), to determine the effects of respiratory protective equipment (RPE) and skin hygiene in reducing internal dose. METHODS: Urine samples from one fire service (n = 62) were analyzed for 1-HP by two laboratories, using different assays (LC-MS/MS: GC-MS): remaining samples were analyzed just by LC-MS/MS. A Skin Exposure Mitigation Index (SEMI) was computed from questions on opportunities for changing clothing, showering, and washing during breaks. Regression analyses, using 1-HP ng/g creatinine as the dependent variable, assessed the effect of RPE and skin factors on PAH absorption, allowing for environmental exposure and potential confounders. Stratification identified key groups with equal delay in sample collection. RESULTS: 1-HP was detected in 71.0% of 62 samples by LC-MS/MS and 98.4% by GC-MS, with good mutual agreement between the methods. In 171 post-fire samples, 1-HP corrected for creatinine was related to current cigarette smoking and recent barbeque. Among those with samples collected within 48 h, urinary 1-HP was correlated with estimated exposure(r = 0.53, P < 0.001). In those with only one rotation before urine sample collection, no effect was seen of RPE use but I-HP was significantly lower (P = 0.003) in those with those with a high score on the SEMI scale, indicating better access to factors mitigating skin absorption. CONCLUSION: Skin exposure to PAHs is an important route of absorption in firefighters, which can be mitigated by good skin hygiene.

Characteristics of asthma and COPD overlap syndrome (ACOS) in the Canadian population.

Objective: Asthma is a chronic disease affecting both children and adults, whereas chronic obstructive pulmonary disease (COPD) is a respiratory disease most commonly related to smoking and is usually seen in adults. When the airway disease shares features of both asthma and COPD, the phenotype is referred to as asthma and COPD overlap syndrome (ACOS). The objective of this cross-sectional study is to characterize ACOS in the Canadian population. Methods: Data from the first three cycles of the Canadian Health Measures Survey (CHMS) were used in this study. The study included 9059 subjects aged 30 years and above. The CHMS included a detailed interviewer-administered questionnaire and spirometry measurements. Based on the self-report, subjects were categorized into control, ACOS, COPD only and asthma only groups. Results: The prevalence of ACOS, COPD and asthma groups was 1.59%, 2.21% and 6.65%, respectively. The proportion of females was significantly greater than males in the ACOS group. The proportion of wheeze was highest in the ACOS group (64.93%) whereas the prevalence of shortness of breath was the highest in the COPD group (46.25%). Heart disease, cancer, arthritis and liver disease were more prevalent in the ACOS group than in COPD, asthma and control groups. Severity of airway obstruction was the highest in the ACOS group and was followed by COPD, asthma and control groups, respectively. Conclusions: Characteristics of ACOS in the Canadian population were similar to those observed in the developed countries and longitudinal studies are required to determine the incidence and risk factors of ACOS.

Psychiatric co-morbidity and asthma: A pilot study utilizing a free use tool to improve asthma care.

PURPOSE: To assess the prevalence of co-morbid psychiatric disorders in asthmatic patients in a Western Canadian Regional Severe Asthma Center. METHODS: A prospective study was completed of patients evaluated through the Edmonton Regional Severe Asthma Clinic (ERSAC). A standardised evaluation, the Mini International Neuropsychiatric Interview (MINI) screen was used to identify possible psychiatric disorders. RESULTS: Twenty-four individuals with moderate to severe asthma, who presented for treatment at ERSAC, were recruited and underwent assessment with the MINI screen. The average patient age was 48 years (range 18-81 years). Nine patients were male and fifteen were female. Twenty subjects (83%) screened positive for a possible psychiatric co-morbidity using the MINI screen. The most common psychiatric co-morbidities identified were post-traumatic stress disorder (50% of the sampled population), depressive episode or persistent depressive disorder (42%), substance/alcohol abuse (33%), generalized anxiety disorder (335), manic episode (25%), agoraphobia (21%), panic disorder (21%) and obsessive-compulsive disorder (17%). Some individuals had more than one concomitant possible psychiatric co-morbidity identified by the MINI screen. CONCLUSIONS: Psychiatric co-morbidity was confirmed to be common in patients with moderate-severe asthma. In individuals with asthma, the MINI screen appeared to be a simple and useful clinical tool to screen for untreated/sub-optimally-managed psychiatric co-morbidities that may impact management.