Low-cost interventions to improve ventilation in long-term care facilities.

Residents of long-term care facilities are particularly vulnerable to communicable diseases. Low-cost interventions to increase air exchange rates (AERs) may be useful in reducing the transmission of airborne communicable diseases between long-term care residents and staff. In this study, carbon dioxide gas was used as a tracer to evaluate the AER associated with the implementation of low-cost ventilation interventions. Under baseline conditions with the room's door closed, the mean AER was 0.67 ACH; while baseline conditions with the door open had a significantly higher mean AER of 3.87 ACH (p < 0.001). Subsequently opening a window with the door open increased mean AER by 1.49 ACH (p = 0.012) and adding a fan in the window further increased mean AER by 1.87 ACH (p < 0.001). Regression analyses indicated that the flow rate of air entering through the window, both passively and through the use of a fan, was significantly associated with an increase in AER (p < 0.001). These results indicate that low-cost interventions that pull outside air into resident rooms were effective in improving the air exchange rates in these facilities. While implementation of these interventions is dependent on facility rules and isolation requirements of residents with airborne communicable diseases, these interventions remain viable options for long-term care facilities to improve resident room ventilation without requiring costly ventilation system upgrades.

Non-ionizing radiation modeling to predict ambient irradiance in work areas at an indoor cannabis farm.

Agricultural workers frequently experience potentially hazardous exposure to non-ionizing radiation from both solar and artificial sources, and measurement of this exposure can be expensive and impractical for large populations. This project develops and evaluates a vegetative radiative transfer model (VRTM) to predict irradiance in a grow room of an indoor cannabis farm. The model uses morphological characteristics of the crop, manufacturer provided lamp emissions data, and dimensional measurements of the grow room and cannabis hedgerows to predict irradiance. A linear regression comparing model predictions with the measurements taken by a visible light spectroradiometer had slopes within 23% of unity and R2 values above 0.88 for visible (400-700 nm), blue (400-500 nm), green (500-600 nm), and red (600-700 nm) wavelength bands. The excellent agreement between the model and the measured irradiance in the cannabis farm grow room supports the potential of using VRTMs to predict irradiance and worker exposure in agricultural settings. Because there is no mechanistic difference between visible and other non-ionizing wavelengths of radiation in regards to mechanisms of radiative transfer, the model developed herein for visible wavelengths of radiation should be generalizable to other radiation bands including infrared and ultraviolet radiation.

Assessing the effectiveness of portable HEPA air cleaners for reducing particulate matter exposure in King County, Washington homeless shelters: Implications for community congregate settings.

Over four thousand portable air cleaners (PACs) with high-efficiency particulate air (HEPA) filters were distributed by Public Health - Seattle & King County to homeless shelters during the COVID-19 pandemic. This study aimed to evaluate the real-world effectiveness of these HEPA PACs in reducing indoor particles and understand the factors that affect their use in homeless shelters. Four rooms across three homeless shelters with varying geographic locations and operating conditions were enrolled in this study. At each shelter, multiple PACs were deployed based on the room volume and PAC's clean air delivery rate rating. The energy consumption of these PACs was measured using energy data loggers at 1-min intervals to allow tracking of their use and fan speed for three two-week sampling rounds, separated by single-week gaps, between February and April 2022. Total optical particle number concentration (OPNC) was measured at 2-min intervals at multiple indoor locations and an outdoor ambient location. The empirical indoor and outdoor total OPNC were compared for each site. Additionally, linear mixed-effects regression models (LMERs) were used to assess the relationship between PAC use time and indoor/outdoor total OPNC ratios (I/OOPNC). Based on the LMER models, a 10 % increase in the hourly, daily, and total time PACs were used significantly reduced I/OOPNC by 0.034 [95 % CI: 0.028, 0.040; p < 0.001], 0.051 [95 % CI: 0.020, 0.078; p < 0.001], and 0.252 [95 % CI: 0.150, 0.328; p < 0.001], respectively, indicating that keeping PACs on resulted in significantly lower I/OOPNC. The survey suggested that keeping PACs on and running was the main challenge when operating them in shelters. These findings suggested that HEPA PACs were an effective short-term strategy to reduce indoor particle levels in community congregate living settings during non-wildfire seasons and the need for formulating practical guidance for using them in such an environment.

Ultraviolet radiation exposure in cannabis-growing facilities.

Cannabis cultivation and processing is becoming an important industry in the United States and Canada. The industry employs over 400,000 workers in the United States and is growing rapidly. Both natural sunlight and artificial lamp-generated radiation are commonly used to grow cannabis plants. These optical sources can contain both visible and ultraviolet radiation (UVR) wavelengths, and overexposure to UVR is associated with negative health effects. The severity of these adverse health effects is governed by the specific wavelengths and exposed dose of UVR, yet worker exposure to UVR within cannabis-growing facilities has not been studied. In this study, worker exposure to UVR was assessed at five cannabis production facilities in Washington State, including indoor, outdoor, and shade house facilities. Lamp emission testing was performed at each facility and worker UVR exposures were measured for 87 work shifts. Observations of worker activities and use of personal protective equipment in association with UVR exposure measurements were recorded. For lamp emission measurements, at 3 feet from the center of the lamp, the average irradiances were 4.09 × 10-4, 6.95 × 10-8, 6.76 × 10-9, 3.96 × 10-9, and 1.98 × 10-9 effective W/cm2 for germicidal lamps, metal halide lamps, high-pressure sodium lamps, fluorescent lamps, and light emitting diodes, respectively. The average measured UVR exposure was 2.91 × 10-3 effective J/cm2 (range: 1.54 × 10-6, 1.57 × 10-2 effective J/cm2). Thirty percent of the work shifts monitored exceeded the American Conference for Governmental Industrial Hygienists (ACGIH®) threshold limit value (TLV®) of 0.003 effective J/cm2. Exposures were highest for workers who spent all or part of the work shift outdoors, and solar radiation was the primary source of worker UVR exposure for most of the work shifts that exceeded the TLVs. Outdoor workers can reduce UVR exposure by applying sunscreen and wearing appropriate personal protective equipment. Although the artificial lighting used in the cannabis production facilities included in this study did not contribute substantially to the measured UV exposures, in many cases the lamp emissions would generate theoretical exposures at 3 feet from the center of the lamp that would exceed the TLV. Therefore, employers should choose low UVR emitting lamps for indoor grow operations and should use engineering controls (e.g., door-interlocks to de-energize lamps) to prevent worker exposure to UVR from germicidal lamps.

What happens in Vegas, stays in your lungs: an assessment of fine particulate matter in casinos that prohibit and allow smoking in Las Vegas, Nevada, USA.

INTRODUCTION: Despite progress in adoption of smoke-free policies, smoking in casinos is allowed in some US states, including Nevada. In 2020, for the first time, a resort-style casino in Las Vegas prohibited smoking voluntarily. This study is the first to assess air quality in this casino and compare results with similar casinos that allow smoking. METHODS: A real-time personal aerosol monitor evaluated particulate matter with a diameter <2.5 µm (PM2.5), a surrogate for secondhand smoke (SHS). PM2.5 was measured at eight Las Vegas casinos, including the smoke-free casino. Each casino was visited twice, and PM2.5 was assessed in smoking-permitted gaming areas and areas where smoking is otherwise prohibited. RESULTS: Average PM2.5 levels were significantly higher in casinos that allow smoking, for both casino gaming areas and areas where smoking is otherwise prohibited (p<0.05). Mean PM2.5 in gaming areas was 164.9 µg/m3 in casinos that allow smoking and 30.5 µg/m3 in the smoke-free casino. Mean PM2.5 in areas where smoking is otherwise prohibited was 83.2 µg/m3 in casinos which allowed smoking in gaming areas, and 48.1 µg/m3 in the smoke-free casino. CONCLUSION: Despite robust evidence about the harms of SHS, tens of thousands of casino employees and tens of millions of tourists are exposed to high levels of SHS in Las Vegas casinos annually, with PM2.5 levels 5.4 times higher in gaming areas when compared with a smoke-free casino. The only way to protect people from SHS exposure is to prohibit smoking in all indoor areas.

Work-Related Issues and Physical and Psychological Burden in Canadian Patients With Axial Spondyloarthritis: Results From the International Map of Axial Spondyloarthritis.

OBJECTIVE: To identify factors associated with work-related issues in Canadian patients with axial spondyloarthritis. METHODS: Data from 542 Canadian patients who participated in the International Map of Axial Spondyloarthritis online survey were analyzed. Participants who were employed, unemployed, or on short-term disability were included in this analysis. Regression analysis was used to study the association between work-related issues, disease activity (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI]), and psychological distress (12-item General Health Questionnaire [GHQ-12]). RESULTS: The mean age of surveyed participants was 44.3 (SD 13.9) years, 81% were university educated, and 52.6% employed. A substantial proportion had high disease activity (BASDAI ≥ 4, 72.1%) and psychological distress (GHQ-12 ≥ 3, 53.1%); 81% had work-related issues. This study analyzed responses from a subset of participants who were either employed, unemployed, or on short-term disability (n = 339). Ninety percent of this subset reported at least 1 work-related issue in the year before questionnaire completion, with the most frequent being absenteeism (49.3%) and missing work for healthcare provider visits (42.5%). Factoring in disability benefits eliminated the association between work-related issues and disease activity for all variables except fatigue (r = 0.217; P = 0.03) and discomfort (r = 0.196; P = 0.047). Difficulty fulfilling working hours (ß 2.342, 95% CI 1.413-3.272) and effect on professional advancement (ß 1.426, 95% CI 0.355-2.497) were associated with psychological distress. In the presence of disability benefits, only the effect on professional advancement remained (ß 2.304, 95% CI 0.082-4.527). CONCLUSION: Work-related issues are associated with worse patient-reported outcomes, both physical and psychological.

Wearable Spectroradiometer for Dosimetry.

Available wearable dosimeters suffer from spectral mismatch during the measurement of broadband UV and visible radiation in environments that receive radiation from multiple sources emitting differing spectra. We observed this type of multi-spectra environment in all five Washington State cannabis farms visited during a field study investigating worker exposure to ultraviolet radiation in 2018. Spectroradiometers do not suffer from spectral mismatch in these environments, however, an extensive literature review conducted at the time of writing did not identify any spectroradiometers that were directly deployable as wearable dosimetry devices. To close this research gap, we developed a microcontroller system and platform that allows for researchers to mount and deploy the Ocean Insight Flame-S Spectroradiometer as a wearable device for measurement of UV and visible wavelengths (300 to 700 nm). The platform validation consisted of comparing measurements taken under platform control with measurements taken with the spectrometer controlled by a personal computer running the software provided by the spectroradiometer manufacturer. Three Mann-Whitney U-Tests (two-tailed, 95% CI), one for each intensity condition, compared the central tendency between the total spectral power (TSP), the integral of a spectrum measurement, measured under both control schemas. An additional analysis of per pixel agreement and overall platform stability was performed. The three Mann-Whitney tests returned no significant difference between the set of TSPs for each filter condition. These results suggest that the spectroradiometer takes measurements of equivalent accuracy under both control schemas, and can be deployed as a wearable device for the measurement of wavelength resolved UV and visible radiation.

Potential Impacts of Different Occupational Outdoor Heat Exposure Thresholds among Washington State Crop and Construction Workers and Implications for Other Jurisdictions.

Occupational heat exposure is associated with substantial morbidity and mortality among outdoor workers. We sought to descriptively evaluate spatiotemporal variability in heat threshold exceedances and describe potential impacts of these exposures for crop and construction workers. We also present general considerations for approaching heat policy-relevant analyses. We analyzed county-level 2011-2020 monthly employment (Bureau of Labor Statistics Quarterly Census of Employment and Wages) and environmental exposure (Parameter-elevation Relationships on Independent Slopes Model (PRISM)) data for Washington State (WA), USA, crop (North American Industry Classification System (NAICS) 111 and 1151) and construction (NAICS 23) sectors. Days exceeding maximum daily temperature thresholds, averaged per county, were linked with employment estimates to generate employment days of exceedances. We found spatiotemporal variability in WA temperature threshold exceedances and crop and construction employment. Maximum temperature exceedances peaked in July and August and were most numerous in Central WA counties. Counties with high employment and/or high numbers of threshold exceedance days, led by Yakima and King Counties, experienced the greatest total employment days of exceedances. Crop employment contributed to the largest proportion of total state-wide employment days of exceedances with Central WA counties experiencing the greatest potential workforce burden of exposure. Considerations from this analysis can help inform decision-making regarding thresholds, timing of provisions for heat rules, and tailoring of best practices in different industries and areas.

Trends in the Use of Face Coverings in Publicly Accessible Spaces During the COVID-19 Pandemic, King County, Washington, November 2020-May 2021.

OBJECTIVES: Appropriate face covering use at public venues can help mitigate the transmission of SARS-CoV-2 in the absence of widespread vaccination and provide protection when viral variants become more infectious. The objective of this study was to evaluate compliance with a statewide face mask mandate by examining trends in face covering use in publicly accessible spaces in King County, Washington. METHODS: From November 27, 2020, through May 11, 2021, we conducted a repeated cross-sectional observational study of face covering use across publicly accessible venues (eg, grocery and convenience stores, airport, transit center, post office). Trained observers recorded perceived sex, estimated age group, and face covering use. We calculated estimates of overall face covering use and prevalence ratios (PRs) with 95% CIs. RESULTS: We observed 9865 people in 53 unique venues during 229 observation intervals during 6 observation periods. Correct face covering use was 87.2% overall and lowest at semi-outdoor venues such as transit hubs (78.1%) and the pick-up curb of Seattle-Tacoma International Airport (69.0%). Correct face covering use was lowest among men (PR = 1.42; 95% CI, 1.27-1.58) and among people aged 2-11 years (PR = 2.74; 95% CI, 2.37-3.17) and 12-17 years (PR = 1.36; 95% CI, 1.07-1.72). Compliance declined among adults aged ≥60 years and among younger age groups before vaccine eligibility. CONCLUSIONS: Overall compliance with the statewide face mask mandate in King County was high. Layered mitigation strategies, including but not limited to the use of face coverings, and methods to assess adherence to them are crucial to preventing SARS-CoV-2 transmission.

Field study of early implementation of UV sources and their relative effectiveness for public health and safety.

The emergence of COVID-19 and its corresponding public health burden has prompted industries to rapidly implement traditional and novel control strategies to mitigate the likelihood of SARS-CoV-2 transmission, generating a surge of interest and application of ultraviolet germicidal irradiation (UVGI) sources as disinfection systems. With this increased attention the need to evaluate the efficacy and safety of these types of devices is paramount. A field study of the early implementation of UVGI devices was conducted at the Space Needle located in Seattle, Washington. Six devices were evaluated, including four low-pressure (LP) mercury-vapor lamp devices for air and surface sanitation not designed for human exposure and two krypton chloride (KrCl*) excimer lamp devices to be operated on and around humans. Emission spectra and ultraviolet (UV) irradiance at different locations from the UV devices were measured and germicidal effectiveness against SARS-CoV-2 was estimated. The human safety of KrCl* excimer devices was also evaluated based on measured irradiance and estimated exposure durations. Our results show all LP devices emitted UV radiation primarily at 254 nm as expected. Both KrCl* excimers emitted far UVC irradiation at 222 nm as advertised but also emitted at longer, more hazardous wavelengths (228 to 262 nm). All LP devices emitted strong UVC irradiance, which was estimated to achieve three log reduction of SARS-CoV-2 within 10 sec of exposure at reasonable working distances. KrCl* excimers, however, emitted much lower irradiance than needed for effective disinfection of SARS-CoV-2 (>90% inactivation) within the typical exposure times. UV fluence from KrCl* excimer devices for employees was below the American Conference of Governmental Industrial Hygienists (ACGIH) Threshold Limit Values (TLVs) under the reported device usage and work shifts. However, photosensitive individuals, human susceptibility, or exposure to multiple UV sources throughout a worker's day, were not accounted for in this study. Caution should be used when determining the acceptability of UV exposure to workers in this occupational setting and future work should focus on UVGI sources in public settings.

Using an alternatives assessment framework to evaluate waterborne versus solventborne basecoats used in automotive refinishing.

We evaluated two types of automotive basecoats used in automotive refinishing (i.e., in auto body shops): waterborne and solventborne. The primary tool we used for this evaluation was the Alternatives Assessment Guide (version 1.0) developed by the Interstate Chemicals Clearinghouse (IC2). The term "solventborne," as used in this article, refers to products that contain relatively high concentrations of volatile organic compounds (referred to as "high-volatile organic compound [VOC] basecoats" in the industry). These products are distinct from the "low-VOC" solventborne products used widely in California and elsewhere. From a health and environmental hazard perspective, our evaluation found that waterborne basecoats contained fewer hazardous ingredients and at lower concentrations than their solventborne counterparts. Automotive painters who spray-painted vehicles with waterborne products experienced significantly lower exposures to several harmful solvents. Waterborne products are readily available and offer advantages with regard to social impacts. Some of these advantages include lower worker and community exposure to VOCs, reduced VOC release and smog formation, and reduced potential for generation of and exposure to hazardous waste. Based on our assessment in auto body shops, we consider waterborne basecoats to be safer alternatives from both a human health and environmental perspective. Integr Environ Assess Manag 2022;18:1101-1113. Published 2021. This article is a U.S. Government work and is in the public domain in the USA.

Potential impacts of Washington State's wildfire worker protection rule on construction workers.

Driven by climate change, wildfires are increasing in frequency, duration, and intensity across the Western United States. Outdoor workers are being exposed to increasing wildfire-related particulate matter and smoke. Recognizing this emerging risk, Washington adopted an emergency rule and is presently engaged in creating a permanent rule to protect outdoor workers from wildfire smoke exposure. While there are growing bodies of literature on the exposure to and health effects of wildfire smoke in the general public and wildland firefighters, there is a gap in knowledge about wildfire smoke exposure among outdoor workers generally and construction workers specifically-a large category of outdoor workers in Washington totaling 200,000 people. Several data sources were linked in this study-including state-collected employment data and national ambient air quality data-to gain insight into the risk of PM2.5 exposure among construction workers and evaluate the impacts of different air quality thresholds that would have triggered a new Washington emergency wildfire smoke rule aimed at protecting workers from high PM2.5 exposure. Results indicate the number of poor air quality days has increased in August and September in recent years. Over the last decade, these months with the greatest potential for particulate matter exposure coincided with an annual peak in construction employment that was typically 9.4-42.7% larger across Washington counties (one county was 75.8%). Lastly, the 'encouraged' threshold of the Washington emergency rule (20.5 µg m-3) would have resulted in 5.5 times more days subject to the wildfire rule on average across all Washington counties compared to its 'required' threshold (55.5 µg m-3), and in 2020, the rule could have created demand for 1.35 million N-95 filtering facepiece respirators among construction workers. These results have important implications for both employers and policy makers as rules are developed. The potential policy implications of wildfire smoke exposure, exposure control strategies, and data gaps that would improve understanding of construction worker exposure to wildfire smoke are also discussed.

Use of medical cannabis by patients with fibromyalgia in Canada after cannabis legalisation: a cross-sectional study.

OBJECTIVES: Medications have only small to moderate effects on symptoms in fibromyalgia (FM). Cannabinoids, including medical cannabis (MC) may have potential to fill this gap. Since recreational legalisation of cannabis in Canada, patients have easier access and may be self-medicating with cannabis. We have examined the prevalence and characteristics of MC use in FM patients. METHODS: During a two-month period (June-August 2019), consecutive attending rheumatology patients participated in an onsite survey comprising 2 questionnaires: 1) demographic and disease information completed by the rheumatologist, 2) patient anonymous questionnaire of health status, cannabis use (recreational and/or medicinal) and characteristics of use. RESULTS: In a cohort of 1000 rheumatology attendees, 117 (11.7%) were diagnosed with FM. Ever use of MC was reported by 28 (23.9%; 95%CI: 16.5%-32.7%) FM patients compared to 98 (11.1%; 95%CI: 9.1%-13.4%) non-FM patients. Among FM ever users, 17 (61%) patients continued use of MC. FM ever users vs. FM nonusers tended to be younger, 53 vs. 58 years (p=0.072), were more likely unemployed or disabled 39% vs. 17% (p=0.019) and used more medication types (p=0.013) but did not differ in symptom severity parameters. Cigarette smoking and recreational cannabis were more common in ever users. Global symptom relief on a VAS (1-10) was 7.0±2.3. CONCLUSIONS: FM patients have commonly used MC, with more than half continuing use. Reported symptom relief was substantial. Cigarette smoking and recreational cannabis use may play a facilitatory role in MC use in FM. Adjunctive MC may be a treatment consideration for some FM patients.

Readmission following urgent transcatheter aortic valve implantation versus urgent balloon aortic valvuloplasty in patients with decompensated heart failure or cardiogenic shock.

BACKGROUND: Urgent transcatheter aortic valve implantation (TAVI) is a feasible option for aortic stenosis (AS) patients with decompensated heart failure (HF) and cardiogenic shock (CS) as compared to the more traditional urgent balloon aortic valvuloplasty (BAV). OBJECTIVES: We conducted a retrospective analysis to compare risk and cause of readmission in these two high-risk groups. METHODS: Nationwide Readmission Database (NRD) 2011-2014 was retrospectively analyzed to identify patients with AS having either urgent TAVI or urgent BAV using appropriate ICD-9 codes. Propensity scores were used to match patients with urgent TAVI as compared to patients with urgent BAV. Statistical analysis was performed using the Stata 15.1 software. RESULTS: We identified a weighted sample of 6,670 patients with urgent BAV and 6,964 patients with urgent TAVI. The all-cause 30- and 90-day readmission was lower in the urgent TAVI group compared to urgent BAV (15.4 vs. 22.5%, (aHR): 0.92 [0.90-0.95] p < .001). 30-day readmission due to CV cause and HF was also lower in the urgent TAVI group (aHR, 0.93: p < .001 and aHR, 0.98: p = .040, respectively). The 30-day gastrointestinal (GI) bleed readmission rate was three times higher in urgent TAVI group (aHR, 3.00:95% CI (1.23-7.33), p = .016), but was not statistically significant at 90-days. Cardiac causes of readmission were the predominant cause of readmission in both groups, but more pronounced in urgent BAV group (60.3 vs. 40.5%, p < .001). CONCLUSION: Urgent TAVI appears beneficial in patients with AS and decompensated HF or CS driven by roughly 10 and 25% reductions in overall readmissions at 30 and 90 days, and marked reductions in reintervention, although offset partially by higher risk of readmission due to GI bleeding at 30 days.

Characterization of Naturally Occurring Alpha-Diketone Emissions and Exposures at a Coffee Roasting Facility and Associated Retail Café.

BACKGROUND: Alpha-diketones such as diacetyl and 2,3-pentanedione have been used as artificial flavorings in a variety of industries and are produced naturally when food products such as coffee beans are roasted. Exposure to these compounds has been associated with bronchiolitis obliterans, a rare and severe respiratory disease. In the current paper, we (i) evaluate which steps in the coffee production process are associated with the highest alpha-diketone emissions at a small craft coffee roaster and associated café, (ii) determine the extent to which direct-reading measurements of CO, CO2, and total volatile organic compounds (VOCs) can serve as lower-cost surrogate indicators for diacetyl concentrations, and (iii) conduct a limited emissions study to quantify the effect that the process variable of roast type has on diacetyl emissions from grinding beans. METHODS: Exposure and area concentration data for diacetyl and 2,3-pentanedione were collected over 4 days of sampling at a single coffee roaster and associated café. Additional measurements of café patrons' exposure to diacetyl were collected in seven other craft roastery/cafes in Seattle, WA. For the emissions experiments, integrated area air samples for diacetyl were collected using sorbent tubes over 30-min intervals for each roast type with the sorbent tubes positioned next to a grinder placed in an exposure chamber. Sorbent tubes were analyzed for alpha-diketones using gas chromatography-mass spectrometry. A photoionization detector (PID) was also used to measure continuous total VOC concentrations at the coffee roastery, and during each grinding experiment. RESULTS: Diacetyl concentrations in five of the seven personal samples from the craft roastery were above the United States National Institute of Occupational Safety and Health (NIOSH) Recommended Exposure Limit (REL) of 5 ppb as an 8-h time-weighted average (TWA)-and one of the seven personal samples exceeded the NIOSH REL for 2,3-pentanedione-9.3 ppb as an 8-h TWA. Median diacetyl and 2,3-pentanedione emissions were highest at the bagging machine followed by the grinder, roaster, barista, and background areas. The arithmetic mean diacetyl concentrations from the seven personal samples collected from café patrons was 3.96 ppb, suggesting that diacetyl exposure poses a negligible health risk to café patrons. Correlations between diacetyl and total VOCs, CO, and CO2 showed that diacetyl was well correlated with total VOCs, but poorly correlated with CO and CO2. Based on our limited emissions study, French roast was associated with the highest mass emission factor of diacetyl. CONCLUSIONS: Results from the exposure assessment study indicated that coffee production workers at this facility had elevated exposures to diacetyl and 2,3-pentanedione compared to recommended guidelines, whereas baristas and café patrons received lower exposures. Area sampling showed that the areas with the highest alpha-diketone emissions were the grinder and the bagging machine, which are both areas associated with tasks involving ground roasted coffee. Future research could focus on designing and evaluating effective engineering controls, in the form of local exhaust ventilation, with the goal of reducing alpha diketone exposures, as well as conducting similar studies at other small-scale craft coffee roasters and cafés to better understand the variability in these emissions and exposures within these types of facilities.

Impact of Frailty on Mortality, Readmissions, and Resource Utilization After TAVI.

With aging population and preponderance of severe aortic stenosis occurring in elderly patients, the number of transcatheter aortic valve implantations (TAVI) performed in the elderly are growing. Frailty is common in the elderly and is known to be associated with worse outcomes. We aimed to evaluate the impact of frailty on hospital readmissions rates after TAVI. We used the 2016 Nationwide Readmission Database and categorized patients who underwent TAVI low, intermediate, and high frailty status. The primary outcome was 6-months readmission rates across the 3 frailty categories. Secondary outcomes included causes of readmissions, in-hospital mortality and cost of care. STATA 16.0 was used for survey-specific statistical tests. Of 20,504 patients who underwent TAVI, 58.9% were low-, 39.6% were intermediate-, and 1.5% were in the high-frailty group. Overall in-hospital mortality was 1.9% (n = 396), and was 0.6%, 3.3%, and 16.8% (p <0.01) with increasing frailty. Of the 20,108 patients who survived to discharge, 6,427 (32%) patients were readmitted within 6-months after TAVI. Readmission rates increased across the categories from 27.9% in low, 37.6% in intermediate and 51.1% in high frailty group (p <0.01). While cardiac causes (mostly heart failure) were the predominant readmission etiologies across frailty categories (low: 51.2%, intermediate: 34.1%, high: 27.2%), rates of infectious and injury-related readmissions increased (low: 11%, intermediate: 30%, high: 45%). Mortality during readmissions also worsened from 0.8%, 5.3%, and 8.5% (p <0.01). Over 40% of patients undergoing TAVI were of intermediate-high frailty. In conclusion, an increasing frailty was associated with significantly worse postprocedure mortality, readmissions, and related mortality.

Medical Cannabis Use by Rheumatology Patients Following Recreational Legalization: A Prospective Observational Study of 1000 Patients in Canada.

OBJECTIVE: Recreational legalization of cannabis may influence the medical use by patients. When only medical access was legally available in Canada, 4.3% of rheumatology patients reported use. With the current recreational legalization, we have reexamined the prevalence and characteristics of medical cannabis use in this same rheumatology setting. METHODS: Consecutively attending rheumatology patients participated in an onsite survey comprising the following two questionnaires: 1) demographic and disease information completed by the rheumatologist and 2) patient anonymous questionnaire of health status, cannabis use (recreational and/or medicinal), and characteristics of cannabis use. RESULTS: Of 1047 attendees from June to August 2019, with 1000 participating, medical cannabis had been used by 12.6% of patients (95% confidence interval 10.7%-14.8%), with half continuing use for mostly pain relief. Discontinuation was due to lack of effect in 57% of patients and side effects in 28% of patients. Ever medical users were younger (61.2 vs. 64.9 years; P = 0.006), more likely unemployed/disabled (16.7% vs. 5.9%; P < 0.001), and had more previous (47.6% vs. 25.5%; P < 0.001) and current recreational cannabis use (17.5% vs. 3.1%; P < 0.001) than nonusers. Most patients used multiple methods of administration, including smoking, vaporizing, and using oral oil preparations, but were poorly knowledgeable of product content, which was bought solely via the legal medical route by only 20%, and only one-third disclosed their use to the rheumatologist. CONCLUSION: Medical cannabis use has tripled for rheumatology patients since recreational legalization, with users being younger, not working, and having recreational cannabis experience. Concerning issues are the poor knowledge of the product being used, access via the nonmedical route, and nondisclosure to the physician.

A meta-analysis of 1-year outcomes of transcatheter versus surgical aortic valve replacement in low-risk patients with severe aortic stenosis.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) for the treatment symptomatic severe aortic stenosis (AS) is indicated in patients with intermediate or higher surgical risk. Latest trials showed TAVR, and surgical aortic valve replacement (SAVR) perform similarly at 1-year for the composite outcomes of mortality, stroke and rehospitalization. We performed a comprehensive meta-analysis to compare individual outcomes at 1-year for TAVR compared to SAVR in low-risk patients. METHODS: PubMed, Embase, and Cochrane central were searched for all the randomized controlled trials (RCTs) that reported 1-year comparative outcomes of TAVR and surgical aortic valve replacement (SAVR). Our conclusions are based upon the random-effects model using DerSimonian-Laird estimator. RESULTS: Data from 4 trials and 2887 randomized patients showed that TAVR had lower rates of all-cause mortality, cardiovascular mortality, and atrial fibrillation compared to SAVR at 1-year follow-up (P < 0.05 for all). Also, TAVR was also associated with a significantly higher risk of permanent pacemaker implantation and moderate-severe paravalvular leak (P < 0.05). CONCLUSIONS: The latest randomised trial data demonstrates that in short-term, TAVR is safe and effective in reducing all-cause mortality or stroke. Longer follow-up of RCTs is needed to determine the durability of clinical benefits in TAVR over SAVR in low-risk patients.

5-year efficacy and safety of secukinumab in patients with ankylosing spondylitis: end-of-study results from the phase 3 MEASURE 2 trial.

BACKGROUND: Secukinumab, a fully human monoclonal antibody that directly inhibits interleukin 17A, has shown significant and sustained improvement in the signs and symptoms of ankylosing spondylitis over 3 years in the MEASURE 2 study. We report the 5-year (end-of-study) results of subcutaneous secukinumab 150 mg in the MEASURE 2 study. METHODS: MEASURE 2 was a phase 3, double-blind, randomised, placebo-controlled, study done in 13 countries and 53 centres. Patients with ankylosing spondylitis who were 18 years of age or older and fulfilled the modified New York criteria were randomly assigned to receive secukinumab (150 mg or 75 mg) or placebo subcutaneously at baseline and weeks 1, 2, and 3, and then every 4 weeks from week 4. At week 16, patients initially given placebo were randomly assigned again (placebo switchers) to receive secukinumab 150 mg or 75 mg. Efficacy results are reported for patients initially randomised to secukinumab 150 mg and those who switched from placebo to secukinumab 150 mg at week 16. An optional dose escalation from secukinumab 75 mg to 150 mg was initiated beginning week 140. We assessed efficacy endpoints at week 260 (5 years), including Assessment of Spondyloarthritis International Society (ASAS) 20 and ASAS 40, inactive disease according to ankylosing spondylitis disease activity score with C-reactive protein (ASDAS-CRP), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), BASDAI50, Bath Ankylosing Spondylitis Metrology Index, Bath Ankylosing Spondylitis Functional Index, Short Form-36 Physical Component Summary, and ASAS partial remission. Analyses were stratified by anti-tumour necrosis factor (TNF) status (anti-TNF-naive and anti-TNF inadequate response). The safety analysis included all patients who received one dose or more of secukinumab. We report data as observed without accounting for missing data. The MEASURE 2 study was registered with ClinicalTrials.gov, NCT01649375. FINDINGS: 219 patients were randomly assigned during the trial and 150 (68%) completed 5 years of treatment, including 82 (77%) of 106 patients in the secukinumab 150 mg group and 68 (65%) of 105 in the secukinumab 75 mg group. Efficacy analysis in the secukinumab 150 mg group included 53 patients who completed the study and one additional patient who was assessed in the treatment period weeks 212-260, but did not complete the study. 134 (61%) of 219 patients were anti-TNF-naive and 85 (39%) were anti-TNF inadequate responders. ASAS responses at 5 years with secukinumab 150 mg were 36 (67%) of 54 patients (ASA20) and 27 (50%) patients (ASAS40). Sustained improvement was observed across other efficacy endpoints with secukinumab 150 mg at 5 years. At 5 years, the proportion of patients achieving efficacy endpoints of BASDAI 50 response was 53% (44/83); ASAS 5/6 response was 51% (42/83); ASDAS-CRP inactive disease was 21% (17/81); and ASAS partial remission was 25% (21/83). Exposure-adjusted incidence rates with any secukinumab dose for selected adverse events were 1·0 per 100 patient-years (95% CI 0·4-1·9) for Candida infections, 0·5 (0·1-1·2) for Crohn's disease, 0·4 (0·1-1·1) for ulcerative colitis, 0·6 (0·2-1·4) for major adverse cardiovascular events, 0·5 (0·1-1·2) for uveitis, and 0·6 (0·2-1·4) for malignant or unspecified tumours. INTERPRETATION: Secukinumab 150 mg provided sustained improvement in the signs, symptoms, and physical function in patients with ankylosing spondylitis after 5 years of treatment. The safety profile of secukinumab remained consistent with previous reports. FUNDING: Novartis Pharma.

Lessons Learned in Providing Claims-Based Data to Participants in Health Care Innovation Models.

The Centers for Medicare & Medicaid Services (CMS) has been providing data to organizations participating in a range of innovation models to help them implement interventions and to provide feedback on performance. The authors studied 18 CMS models to gain a better understanding of factors contributing to model participants' use or nonuse of CMS-provided data. Factors that contribute to greater use include providing data that participants view as actionable, some type of accountability for performance, robust learning support, participants having resources to work with the data, and soliciting ongoing feedback about the data and related learning needs. Factors that discourage data uptake include time lag, lack of aggregated multi-payer data, exclusion of data for sensitive diagnoses, and small sample sizes. Claims-based data from payers can be an important source of information to innovation model participants. Lessons from this study can increase the usefulness of such data.