Evaluation of ozone emissions and exposures from consumer products and home appliances.

Ground-level ozone can cause serious adverse health effects and environmental impacts. This study measured ozone emissions and impacts on indoor ozone levels and associated exposures from 17 consumer products and home appliances that could emit ozone either intentionally or as a by-product of their functions. Nine products were found to emit measurable ozone, one up to 6230 ppb at a distance of 5 cm (2 inches). One use of these products increased room ozone concentrations by levels up to 106 ppb (mean, from an ozone laundry system) and personal exposure concentrations of the user by 12-424 ppb (mean). Multiple cycles of use of one fruit and vegetable washer increased personal exposure concentrations by an average of 2550 ppb, over 28 times higher than the level of the 1-h California Ambient Air Quality Standard for ozone (0.09 ppm). Ozone emission rates ranged from 1.6 mg/h for a refrigerator air purifier to 15.4 mg/h for a fruit and vegetable washer. The use of some products was estimated to contribute up to 87% of total daily exposures to ozone. The results show that the use of some products may result in potential health impacts.

Formaldehyde and acetaldehyde exposure and risk characterization in California early childhood education environments.

Little information is available about air quality in early childhood education (ECE) facilities. We collected single-day air samples in 2010-2011 from 40 ECE facilities serving children ≤6 years old in California and applied new methods to evaluate cancer risk in young children. Formaldehyde and acetaldehyde were detected in 100% of samples. The median (max) indoor formaldehyde and acetaldehyde levels (µg/m3 ) were 17.8 (48.8) and 7.5 (23.3), respectively, and were comparable to other California schools and homes. Formaldehyde and acetaldehyde concentrations were inversely associated with air exchange rates (Pearson r = -0.54 and -0.63, respectively; P < 0.001). The buildings and furnishings were generally >5 years old, suggesting other indoor sources. Formaldehyde levels exceeded California 8-h and chronic Reference Exposure Levels (both 9 µg/m3 ) for non-cancer effects in 87.5% of facilities. Acetaldehyde levels exceeded the U.S. EPA Reference Concentration in 30% of facilities. If reflective of long-term averages, estimated exposures would exceed age-adjusted 'safe harbor levels' based on California's Proposition 65 guidelines (10-5 lifetime cancer risk). Additional research is needed to identify sources of formaldehyde and acetaldehyde and strategies to reduce indoor air levels. The impact of recent California and proposed U.S. EPA regulations to reduce formaldehyde levels in future construction should be assessed.

VOC exposures in California early childhood education environments.

Little information exists about exposures to volatile organic compounds (VOCs) in early childhood education (ECE) environments. We measured 38 VOCs in single-day air samples collected in 2010-2011 from 34 ECE facilities serving California children and evaluated potential health risks. We also examined unknown peaks in the GC/MS chromatographs for indoor samples and identified 119 of these compounds using mass spectral libraries. VOCs found in cleaning and personal care products had the highest indoor concentrations (d-limonene and decamethylcyclopentasiloxane [D5] medians: 33.1 and 51.4 µg/m³, respectively). If reflective of long-term averages, child exposures to benzene, chloroform, ethylbenzene, and naphthalene exceeded age-adjusted "safe harbor levels" based on California's Proposition 65 guidelines (10-5 lifetime cancer risk) in 71%, 38%, 56%, and 97% of facilities, respectively. For VOCs without health benchmarks, we used information from toxicological databases and quantitative structure-activity relationship models to assess potential health concerns and identified 12 VOCs that warrant additional evaluation, including a number of terpenes and fragrance compounds. While VOC levels in ECE facilities resemble those in school and home environments, mitigation strategies are warranted to reduce exposures. More research is needed to identify sources and health risks of many VOCs and to support outreach to improve air quality in ECE facilities.

Socioeconomic status is an important determinant of the use of invasive procedures after acute myocardial infarction in New York State.

BACKGROUND: Patient and hospital characteristics influence the use of invasive cardiac procedures. Whether socioeconomic status (SES) has an influence that is independent of these other determinants is unclear. The purpose of the present study was to examine the influence of household income as a measure of SES on the use of invasive cardiac procedures among a large group of patients with acute myocardial infarction. METHODS AND RESULTS: We analyzed administrative discharge data from 231 nonfederal acute care hospitals in New York State that involved 28 698 black or white inpatients with International Classification of Diseases, Ninth Revision, Clinical Modification code 410.XX in the principal diagnosis position between January 1 and December 31, 1995. Household income was derived from postal ZIP codes and census data. The use of cardiac catheterization, PTCA, CABG, and any revascularization procedure was examined across groups stratified by income. Patients who resided in lower-income neighborhoods were more often female or black, had a higher prevalence of coexistent illness, had a higher use of Medicaid insurance, and were less often admitted to urban hospitals or hospitals that provide on-site CABG and PTCA. Crude and adjusted odds ratios for catheterization, PTCA, CABG, and any revascularization procedure were related to income in a graded fashion. After adjustment, patients in the highest quintile of income were 22% more likely to undergo catheterization, 74% more likely to undergo PTCA, 48% more likely to undergo CABG, and 76% more likely to undergo any revascularization procedure than were patients in the lowest quintile. The difference in cardiac catheterization did not fully account for income-based differences in revascularization, because income remained a significant determinant of revascularization after accounting for whether a catheterization was performed. Even among patients treated in hospitals that provide on-site CABG and PTCA, income was a significant determinant of procedures. CONCLUSIONS: Lower-income patients hospitalized for acute myocardial infarction are more often female or black, have more coexisting illnesses, and are less often admitted to urban hospitals or hospitals that provide CABG and PTCA. Even after adjustment for these and other factors, lower income is a negative predictor of procedure use.

Clinical outcomes in heart failure: report from a community hospital-based registry.

PURPOSE: Most of the recent information on the prognosis of patients with heart failure has come from large clinical trials or tertiary care centers. This study reports current information from a community hospital-based heart failure registry. SUBJECTS AND METHODS: We compiled data from 2,906 unselected consecutive patients with heart failure who were admitted to 10 acute care community hospitals in New York State between 1995 and 1997. Patients were followed prospectively for 6 months after hospital discharge or until their death. RESULTS: The mean (+/- SI)) age of the sample was 76 +/- 11 years. The majority of the patients were women (56%) and most were white (95%). Hospital length of stay averaged 7.4 +/- 7.6 days; hospital charges averaged $7,460 +/- $6,114. Mortality during the index admission was 5%. Among the 2,508 patients for whom mortality or follow-up data were available, an additional 411 died during follow-up, for a cumulative 6-month mortality of 23%. Progressive pump failure was the predominant cause of death in the hospital and after discharge. Although mean functional class (on a 1 to 4 scale) improved from 3.4 +/- 0.7 at hospital admission to 2.3 +/- 0.9 at 1 month after discharge, 43% of patients had at least one hospital readmission during follow-up and 25% had at least one recurrent admission for heart failure. The mean time from index discharge to first rehospitalization was 60 +/- 56 days. In all, 55% of patients (1,370 of 2,508) were rehospitalized or died during the study period. CONCLUSIONS: Despite advances in the management of heart failure, patients recently hospitalized for this disorder remain at high risk of death, hospital readmission, and poor clinical outcome. Discovery or implementation of new or existing methods of prevention and treatment remain a high priority.

Systolic versus diastolic heart failure in community practice: clinical features, outcomes, and the use of angiotensin-converting enzyme inhibitors.

BACKGROUND: Among patients with heart failure, there is controversy about whether there are clinical features and laboratory tests that can differentiate patients who have low ejection fractions from those with normal ejection fractions. The usefulness of angiotensin-converting enzyme (ACE) inhibitors among heart failure patients who have normal left ventricular ejection fractions is also not known. METHODS: From a registry of 2,906 unselected consecutive patients with heart failure who were admitted to 10 acute-care community hospitals during 1995 and 1997, we identified 1291 who had a quantitative measurement of their left ventricular ejection fraction. Patients were separated into three groups based on ejection fraction: < or =0.39 (n = 741, 57%), 0.40 to 0.49 (n = 238, 18%), and > or =0.50 (n = 312, 24%). In-hospital mortality, prescription of ACE inhibitors at discharge, subsequent rehospitalization, quality of life, and survival were measured; survivors were observed for at least 6 months after hospitalization. RESULTS: The mean (+/- SD) age of the sample was 75+/-11 years; the majority (55%) of patients were women. In multivariate models, age >75 years, female sex, weight >72.7 kg, and a valvular etiology for heart failure were associated with an increased probability of having an ejection fraction > or =0.50; a prior history of heart failure, an ischemic or idiopathic cause of heart failure, and radiographic cardiomegaly were associated with a lower probability of having an ejection fraction > or =0.50. Total mortality was lower in patients with an ejection fraction > or =0.50 than in those with an ejection fraction < or =0.39 (odds ratio [OR] = 0.69, 95% confidence interval [CI 0.49 to 0.98, P = 0.04). Among hospital survivors with an ejection fraction of 0.40 to 0.49, the 65% who were prescribed ACE inhibitors at discharge had better mean adjusted quality-of-life scores (7.0 versus 6.2, P = 0.02), and lower adjusted mortality (OR = 0.34, 95% CI: 0.17 to 0.70, P = 0.01) during follow-up than those who were not prescribed ACE inhibitors. Among hospital survivors with an ejection fraction > or =0.50, the 45% who were prescribed ACE inhibitors at discharge had better (lower) adjusted New York Heart Association (NYHA) functional class (2.1 versus 2.4, P = 0.04) although there was no significant improvement in survival. CONCLUSIONS: Among patients treated for heart failure in community hospitals, 42% of those whose ejection fraction was measured had a relatively normal systolic function (ejection fraction > or 0.40). The clinical characteristics and mortality of these patients differed from those in patients with low ejection fractions. Among the patients with ejection fractions > or =0.40, the prescription of ACE inhibitors at discharge was associated favorable effects.

The results of a randomized trial of a quality improvement intervention in the care of patients with heart failure. The MISCHF Study Investigators.

PURPOSE: Quality improvement and disease management programs for heart failure have improved quality of care and patient outcomes at large tertiary care hospitals. The purpose of this study was to measure the effects of a regional, multihospital, collaborative quality improvement intervention on care and outcomes in heart failure in community hospitals. PATIENTS AND METHODS: This randomized controlled study included 10 acute care community hospitals in upstate New York. After a baseline period, 5 hospitals were randomly assigned to receive a multifaceted quality improvement intervention (n = 762 patients during the baseline period; n = 840 patients postintervention), while 5 were assigned to a "usual care" control (n = 640 patients during the baseline period; n = 664 patients postintervention). Quality of care was determined using explicit criteria by reviewing the charts of consecutive patients hospitalized with the primary diagnosis of heart failure during the baseline period and again in the postintervention period. Clinical outcomes included hospital length of stay and charges, in-hospital and 6-month mortality, hospital readmission, and quality of life measured after discharge. RESULTS: Patients had similar characteristics in the baseline and postintervention phases in the intervention and control groups. Using hospital-level analyses, the intervention had mixed effects on 5 quality-of-care markers that were not statistically significant. The mean of the average length of stay among hospitals decreased from 8.0 to 6.2 days in the intervention group, with a smaller decline in mean length of stay in the control group (7.7 to 7.0 days). The net effects of the intervention were nonsignificant changes in length of stay of -1.1 days (95% confidence interval [CI]: -2.9 to 0.7 days, P = 0.18) and in hospital charges of -$817 (95% CI: -$2560 to $926, P = 0.31). There were small and nonsignificant effects on mortality, hospital readmission, and quality of life. CONCLUSIONS: The incremental effect of regional collaboration among peer community hospitals toward the goal of quality improvement was small and limited to a slightly, but not significantly, shorter length of stay.

Challenges to implementing the current pediatric cholesterol screening guidelines into practice.

OBJECTIVE: The Expert Panel on Blood Cholesterol Levels in Children and Adolescents of the National Cholesterol Education Program (NCEP) recommends selective screening of children for high blood cholesterol. We determined the number of children, who, according to the guidelines, should be targeted for cholesterol screening. DESIGN: Population survey. SETTING: Permanent household residents in Otsego County, NY. PARTICIPANTS: Total population-based sample of 17,444 households (86.6% response rate) including 44,565 participants, of whom 10,457 were children, aged 2 through 19 years. MAIN OUTCOME MEASURES: Percent of children qualifying for cholesterol screening under the NCEP Children's Panel guidelines. RESULTS: Children from two-parent families were more likely to have known family history of coronary heart disease (CHD) before 60 years of age (41.8% vs 25.8%, P < .001), and twice as likely as children from single-parent families to have known parental hypercholesterolemia (18.8% vs 9.5%, P < .001). Only 39% of parents reported having had their cholesterol level checked; they were better educated and more likely to have health insurance. Parents with a first-degree relative with CHD before 60 years of age were more likely to report having their cholesterol level checked and to report a high cholesterol level. We calculated that 27% of children (18% of children from single-parent households and 29% of children from two-parent households) would report a known family history of premature CHD (ie, CHD before 55 years of age) and qualify for lipoprotein analysis, and that 11% of children would qualify for total cholesterol screening because of known parental hypercholesterolemia without a family history of premature CHD. Thirty-five percent of children had incomplete or unavailable family health history and/or unknown parental cholesterol status. CONCLUSIONS: In this population, 38% of children would be targeted for cholesterol screening, exceeding the estimate of the NCEP Children and Adolescents Panel. The selection process, however, would tend to miss children from single-parent families, children with incomplete family health history, and children whose parents have not had their cholesterol levels measured. The currently recommended pediatric cholesterol screening policy needs to be evaluated further in additional communities and population settings. Alternative cholesterol screening strategies are needed when family health history is incomplete and/or parental cholesterol status is unknown.

Association between diuretic use, clinical response, and death in acute heart failure.

Because the impact of diuretic use on mortality in acute congestive heart failure (CHF) is not known, we examined the association between drug use, fluid balance, and death among 1,150 patients hospitalized for evaluation and treatment of CHF. After adjusting for other relevant intergroup differences, we observed that less net weight loss and a greater number of intravenous drug doses retained significant predictive value for death, suggesting that more frequent diuretic dosing or diuretic resistance may be related to mortality in acute CHF.

Socioeconomic status as an independent risk factor for hospital readmission for heart failure.

The management of heart failure is characterized by high rates of hospital admission as well as rehospitalization after inpatient treatment of this disorder, whereas skillful medical care may reduce the risk of hospital admission. The purpose of this study was to examine the relation between income (as a measure of socioeconomic status) and the frequency of hospital readmission among a large and diverse group of persons treated for heart failure. We analyzed administrative discharge data from 236 nonfederal acute-care hospitals in New York State, involving 41,776 African-American or Caucasian hospital survivors with International Classification of Diseases, Ninth Revision, Clinical Modification codes for heart failure in the principal diagnosis position between January 1 and December 31, 1995. Household income was derived from postal ZIP codes and census data. We found that patients residing in lower income neighborhoods were more often women or African-Americans, had more comorbid illness, had higher use of Medicaid insurance, and were more often admitted to rural hospitals. There was a stepwise decrease in the crude frequency of readmission from the lowest quartile of income (23.2%) to the highest (20.0%) (p <0.0001 for Mantel-Haenszel chi-square test for trend across all quartiles; p <0.0001 for comparison between quartiles 1 and 4). After adjustment for baseline differences and process of care, income remained a significant predictor, with an increase in the risk of readmission noted in association with lower levels of income (adjusted odds ratio for quartile 1:4 comparison, 1.18; 95% confidence interval, 1.10 to 1.26, p <0.0001). We conclude that lower income patients hospitalized for treatment of heart failure in New York differ from higher income patients in important clinical and demographic comparisons. Even after adjustment for these fundamental differences and other potential confounding factors, lower income is a positive predictor of readmission risk.