Aqua walking as an alternative exercise modality during cardiac rehabilitation for coronary artery disease in older patients with lower extremity osteoarthritis.

BACKGROUND: The purpose of this study was to examine the effects of aqua walking (AW) on coronary artery disease (CAD) and cardiorespiratory fitness in older adults with osteoarthritis in the lower extremity and compare it with that of traditional over-ground walking. METHODS: Sixty consecutive eligible patients who had undergone percutaneous coronary intervention for CAD with limited ambulation due to lower extremity osteoarthritis were recruited. They were randomly assigned to the AW program group, treadmill/track walking (TW) program group, or non-exercise control group (CON). Assessments were performed before and after 24 weeks of medically supervised exercise training. RESULTS: Significant differences were observed in the change in %body fat (TW: -2.7%, AW: -2.8%, CON: -0.4%), total cholesterol level (TW: -23.6 mg/dL, AW: -27.2 mg/dL, CON: 15.8 mg/dL), resting heart rate (TW: -6.3 bpm, AW: -6.9 bpm, CON: 1.3 bpm), and cardiorespiratory fitness expressed as VO2 peak (TW: 2.3 mL/kg·min-1, AW: 2.0 mL/kg·min-1, CON: -2.5 mL/kg·min-1) over 24 weeks among the groups. However, no significant differences in the change in these measures were found between the TW and AW groups. CONCLUSION: AW appears to be a feasible alternative exercise modality to over-ground walking for cardiac rehabilitation and can be recommended for older adults with CAD and osteoarthritis.

Bladder Cancer and Water Disinfection By-product Exposures through Multiple Routes: A Population-Based Case-Control Study (New England, USA).

BACKGROUND: Ingestion of disinfection byproducts has been associated with bladder cancer in multiple studies. Although associations with other routes of exposure have been suggested, epidemiologic evidence is limited. OBJECTIVES: We evaluated the relationship between bladder cancer and total, chlorinated, and brominated trihalomethanes (THMs) through various exposure routes. METHODS: In a population-based case­control study in New England (n=(1,213) cases; n=(1,418) controls), we estimated lifetime exposure to THMs from ingestion, showering/bathing, and hours of swimming pool use. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using unconditional logistic regression adjusted for confounders. RESULTS: Adjusted ORs for bladder cancer comparing participants with exposure above the 95th percentile with those in the lowest quartile of exposure (based on the distribution in controls) were statistically significant for average daily intake mg/d of total THMs [OR=1.53 (95% CI: 1.01, 2.32), p-trend=0.16] and brominated THMs [OR=1.98 (95% CI: 1.19, 3.29), p-trend=0.03]. For cumulative intake mg, the OR at the 95th percentile of total THMs was 1.45 (95% CI: 0.95, 2.2), p-trend=0.13; the ORs at the 95th percentile for chlorinated and brominated THMs were 1.77 (95% CI: 1.05, 2,.99), p-trend=0.07 and 1.78 (95% CI: 1.05, 3.00), p-trend=0.02, respectively. The OR in the highest category of showering/bathing for brominated THMs was 1.43 (95% CI: 0.80, 2.42), p-trend=0.10. We found no evidence of an association for bladder cancer and hours of swimming pool use. CONCLUSIONS: We observed a modest association between ingestion of water with higher THMs (>95th percentile vs.<25th percentile) and bladder cancer. Brominated THMs have been a particular concern based on toxicologic evidence, and our suggestive findings for multiple metrics require further study in a population with higher levels of these exposures. Data from this population do not support an association between swimming pool use and bladder cancer. https://doi.org/10.1289/EHP89.

Occurrence and health risk assessment of halogenated disinfection byproducts in indoor swimming pool water.

Swimming pool disinfection byproducts (DBPs) have become a concern in many countries all over the world. In this study, the concentrations of several categories of DBPs, including trihalomethanes (THMs), haloacetic acids (HAAs), haloacetonitriles (HANs), haloketones (HKs) and trichloronitromethane (TCNM), in 13 public indoor swimming pools in Nanjing, China were determined, the correlations between DBPs and water quality parameters as well as between different DBP categories were evaluated, and the health risks of the DBPs to human were examined. The results indicate that the DBP levels in the swimming pools in Nanjing were relatively high, with HAAs as the most dominant category, followed by THMs, HANs, HKs and TCNM sequentially. Bromochloroacetic acid (BCAA), trichloromethane (TCM), dichloroacetonitrile (DCAN), and 1,1,1-trichloropropanone (1,1,1-TCP) were the most dominant species among HAAs, THMs, HANs, and HKs, respectively. For all the different categories of DBPs, the concentrations in the pool disinfected with ozonation/chlorination were lower than those in the pool disinfected with chlorination. The DBP levels were generally not affected by the number of swimmers and the DBP levels on different dates were relatively stable. Besides, the chlorine residual seemed to be a critical concern in most of the swimming pools in this study. Moreover, there were some correlations between DBPs and water quality parameters as well as between different DBP categories. It is to be noted that the predicted cancer and health risks of the DBPs in these swimming pools were generally higher than the regulatory limits by USEPA, and thus DBPs in these swimming pools should be concerned.

Drowning in Pretoria, South Africa: A 10-year review.

Drowning is classified as the 3rd leading cause of accidental deaths worldwide and is deemed to be a preventable cause of death. Bodies retrieved from a water medium pose several challenges to the forensic pathologist with the diagnosis of drowning being primarily one of exclusion. The aim of this study was to do a retrospective descriptive case audit of bodies retrieved from water and immersion related deaths, which were investigated at the Pretoria Medico-Legal Laboratory (PMLL) over a 10 year period (January 2002 through December 2011). A total of 346 cases were identified for inclusion into this study. In 6% (20) of these cases, the death was not related to drowning; in 14% (48) no clear cause of death could be ascertained and in 278 cases (80%) the cause of death was considered to have been due to drowning. Infants (under 1 year, of age) constituted 41 (15%) of the cases; toddlers (aged 1-2 years) comprised 52 (19%) cases; children (aged 2-13 years) 49 (18%) cases; adolescents (aged 13-18 years) comprised 10 (3%) cases; adults (above 18, years) made up 126 (45%) of the cases. The majority of the drownings, occurred in swimming pools [125 cases (38%)]. In infants 23 (56%) of, drownings occurred in swimming pools followed by buckets [7 cases (17%)]. Sixty-nine per cent of toddler drownings (36 cases) occurred in swimming, pools. In the adult population, 40 (32%) of cases occurred in pools and 35 cases (28%) in rivers. Positive blood alcohol results were recorded in 48, (42%) out of 113 cases where the test was requested, 40 (35%) of these, cases higher than 0.05 g per 100 ml. This study suggests that many drowning deaths in Pretoria may be preventable by introducing greater public awareness of the risks and instituting relatively simple, protective measures.

Predicting human exposure and risk from chlorinated indoor swimming pool: a case study.

This study predicted human exposure to disinfection by-products (DBPs) in a chlorinated indoor swimming pool. Human exposure was predicted through ingestion, inhalation, and dermal routes while ingestion exposure was accidental with water intake of 18-34 mL/h. The number of pool attendants and duration and frequency of swimming were in the ranges of 14-62 persons/day, 40-85 min/event, and 26-48 times/year, respectively. Trihalomethanes (THMs) in pool water and air were 28.7-95.5 µg/L and 44.1-133.6 µg/m(3), respectively, while haloacetic acids (HAAs) in pool water were 68.9-158.9 µg/L. The brominated THMs in water and air were 95.4 and 94.3% of total THMs, respectively, while brominated HAAs were 94.4 % of total HAAs. Chronic daily intakes of THMs and HAAs were 2.16 × 10(-5)-3.14 × 10(-3) and 8.4 × 10(-8)-4.6 × 10(-6) mg/kg-day, respectively. The cancer risk from three THMs and two HAAs was 2.46 × 10(-5) with a range of 8.1 × 10(-6)-5.7 × 10(-5), in which THMs contributed 99.6% of total risks. Approximately 99.3% of risks were through inhalation and dermal routes, indicating that the ingestion route may be insignificant. The cancer risks from THMs in swimming pool were 4.06-6.64 times to the cancer risks from THMs in drinking water.

Swimming pool attendance is related to asthma among atopic school children: a population-based study.

BACKGROUND: By-products of water disinfectants have been suggested to cause asthma, especially in atopic children. However, studies on indoor swimming pool attendance and asthma in children have presented conflicting results. The present study examined the relationship between indoor swimming pool attendance and asthma among sensitized and non-sensitized children aged 11-12 years. METHODS: An extended ISAAC questionnaire was sent to the families of all children attending fifth or sixth grade, aged 11-12 years, in two municipalities in Northern Sweden in 2010. A total of 1866 participated (96% of those invited) in the questionnaire study and 1652 (89%) also participated in skin prick testing for 10 standard airborne allergens. Asthma was defined as physician-diagnosed asthma in combination with wheeze or use of asthma medication in the last 12 months. Current swimming pool attendance was reported as ≥ 1/week or <1/week. Logistic regression models were used for data analysis. RESULTS: The prevalence of current asthma was 8.9% (10.0% of boys; 7.9% of girls) and 14% had attended indoor pools ≥ 1/week. Children currently attending swimming pools ≥ 1/week had an increased risk of current asthma. Stratified analyses for allergic sensitization adjusted for sex, parental smoking, parental asthma, and damp housing, showed a statistically significant association for current asthma only among sensitized subjects (OR 95% CI 1.90 1.09-3.32). No association was found between current pool attendance and wheeze, sensitization, rhinitis or eczema. CONCLUSIONS: The present study supports the proposed link between indoor swimming pool attendance and asthma in sensitized children.

Childhood drowning in South Africa: local data should inform prevention strategies.

STUDY OBJECTIVE: Drowning is an important cause of childhood injury, however, little is known about drowning in Africa. The aim of this study is to investigate submersion incidents in Cape Town, South Africa and provide specific prognostic factors as well as to develop age-appropriate prevention strategies. METHODS: A retrospective chart review performed at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa. Patients admitted because of 'drowning' or 'near-drowning' between January 2007 and April 2013 were included. RESULTS: 75 children were included. 63 (84 %) survived without complications, 8 (10.7 %) died and 4 (5.3 %) had permanent neurological sequelae. The median age was 2.2 years (range 0.1-12.4). 46 (60.5 %) incidents happened in or around the home, only 14 (18.7 %) were witnessed. 42 (56 %) took place in a pool (29 private, 13 public). Significant predictors of the outcome were: estimated submersion time, duration of apnea, unresponsive and dilated pupils, intubation and use of inotropes. On arrival at the ER we found these significant predictors of the outcome: CPR, a GCS <5, hypothermia, bradycardia, asystole, as well as the PIM2-calculated mortality risk for patients admitted to the ICU. CONCLUSION: The majority of incidents were unwitnessed and occurred in or around the home. Prevention programs should be focused on adult supervision for younger children and creating awareness on the dangers of drowning in the home environment. While bathing in baths or buckets, children should never be left alone and parents should be made aware of the dangers. In our study, the majority of incidents occurred in swimming pools and limiting access to these could prevent many incidents of drowning among older children. Although children of all language groups are at risk for drowning, English- or Afrikaans-speaking children were particularly at risk for drowning in private pools while Xhosa-speaking children mostly drowned in baths or buckets. We also report multiple prognostic factors for the outcome, but none of them were absolute predictive of the outcome, indicating that each victim of submersion deserves full resuscitative treatment.

Randomized Trial of Two Dissemination Strategies for a Skin Cancer Prevention Program in Aquatic Settings.

OBJECTIVES: We compared 2 strategies for disseminating an evidence-based skin cancer prevention program. METHODS: We evaluated the effects of 2 strategies (basic vs enhanced) for dissemination of the Pool Cool skin cancer prevention program in outdoor swimming pools on (1) program implementation, maintenance, and sustainability and (2) improvements in organizational and environmental supports for sun protection. The trial used a cluster-randomized design with pools as the unit of intervention and outcome. The enhanced group received extra incentives, reinforcement, feedback, and skill-building guidance. Surveys were collected in successive years (2003-2006) from managers of 435 pools in 33 metropolitan areas across the United States participating in the Pool Cool Diffusion Trial. RESULTS: Both treatment groups improved their implementation of the program, but pools in the enhanced condition had significantly greater overall maintenance of the program over 3 summers of participation. Furthermore, pools in the enhanced condition established and maintained significantly greater sun-safety policies and supportive environments over time. CONCLUSIONS: This study found that more intensive, theory-driven dissemination strategies can significantly enhance program implementation and maintenance of health-promoting environmental and policy changes. Future research is warranted through longitudinal follow-up to examine sustainability.

Assessment of water quality of some swimming pools: a case study in Alexandria, Egypt.

In spite of the importance and popularity of swimming pools in summer, they have been identified as posing some public health risks to users due to either chemical or microbiological contamination. This study was carried out aiming at assessing the quality of water for some Alexandria's swimming pools in order to determine its compliance with the Egyptian standards no. 418/1995. Five swimming pools were selected randomly from different districts. Physical and chemical parameters, as well as biological examination of a total of 30 samples, were carried out using standard analytical methods. Water samples were collected from the studied swimming pools monthly over 6 months and pool water monitoring was carried out during afternoon of the weekends when the pools were most heavily used. The results indicated overall poor compliance with the standards. Compliance of the pool water to the microbial parameters, residual chlorine, pH, and turbidity were 56.7% (17 samples), 20% (6 samples), 46.7% (14 samples), and 46.7% (14 samples), respectively. Statistical analysis showed significant association between water contamination with microbial indicators and physical-chemical aspects such as residual chlorine, temperature, turbidity, and load of swimmers. Furthermore, Cryptosporidium oocysts and Giardia lamblia cysts has been found in 10% of samples. It was concluded that there is a need to improve disinfection and cleaning procedures, with consideration given to safety, and size of the pool in relation to bathing load. There is also a need to monitor swimming pool water quality continuously, and to increase bather hygienic practices and awareness of the risks as well as training of governmental inspectors.

What's in the pool? A comprehensive identification of disinfection by-products and assessment of mutagenicity of chlorinated and brominated swimming pool water.

BACKGROUND: Swimming pool disinfectants and disinfection by-products (DBPs) have been linked to human health effects, including asthma and bladder cancer, but no studies have provided a comprehensive identification of DBPs in the water and related that to mutagenicity. OBJECTIVES: We performed a comprehensive identification of DBPs and disinfectant species in waters from public swimming pools in Barcelona, Catalonia, Spain, that disinfect with either chlorine or bromine and we determined the mutagenicity of the waters to compare with the analytical results. METHODS: We used gas chromatography/mass spectrometry (GC/MS) to measure trihalomethanes in water, GC with electron capture detection for air, low- and high-resolution GC/MS to comprehensively identify DBPs, photometry to measure disinfectant species (free chlorine, monochloroamine, dichloramine, and trichloramine) in the waters, and an ion chromatography method to measure trichloramine in air. We assessed mutagenicity with the Salmonella mutagenicity assay. RESULTS: We identified > 100 DBPs, including many nitrogen-containing DBPs that were likely formed from nitrogen-containing precursors from human inputs, such as urine, sweat, and skin cells. Many DBPs were new and have not been reported previously in either swimming pool or drinking waters. Bromoform levels were greater in brominated than in chlorinated pool waters, but we also identified many brominated DBPs in the chlorinated waters. The pool waters were mutagenic at levels similar to that of drinking water (approximately 1,200 revertants/L-equivalents in strain TA100-S9 mix). CONCLUSIONS: This study identified many new DBPs not identified previously in swimming pool or drinking water and found that swimming pool waters are as mutagenic as typical drinking waters.

Genotoxic effects in swimmers exposed to disinfection by-products in indoor swimming pools.

BACKGROUND: Exposure to disinfection by-products (DBPs) in drinking water has been associated with cancer risk. A recent study (Villanueva et al. 2007; Am J Epidemiol 165:148-156) found an increased bladder cancer risk among subjects attending swimming pools relative to those not attending. OBJECTIVES: We evaluated adults who swam in chlorinated pools to determine whether exposure to DBPs in pool water is associated with biomarkers of genotoxicity. METHODS: We collected blood, urine, and exhaled air samples from 49 nonsmoking adult volunteers before and after they swam for 40 min in an indoor chlorinated pool. We estimated associations between the concentrations of four trihalomethanes (THMs) in exhaled breath and changes in micronuclei (MN) and DNA damage (comet assay) in peripheral blood lymphocytes before and 1 hr after swimming; urine mutagenicity (Ames assay) before and 2 hr after swimming; and MN in exfoliated urothelial cells before and 2 weeks after swimming. We also estimated associations and interactions with polymorphisms in genes related to DNA repair or to DBP metabolism. RESULTS: After swimming, the total concentration of the four THMs in exhaled breath was seven times higher than before swimming. The change in the frequency of micronucleated lymphocytes after swimming increased in association with higher exhaled concentrations of the brominated THMs (p = 0.03 for bromodichloromethane, p = 0.05 for chlorodibromomethane, p = 0.01 for bromoform) but not chloroform. Swimming was not associated with DNA damage detectable by the comet assay. Urine mutagenicity increased significantly after swimming, in association with the higher concentration of exhaled bromoform (p = 0.004). We found no significant associations with changes in micronucleated urothelial cells. CONCLUSIONS: Our findings support potential genotoxic effects of exposure to DBPs from swimming pools. The positive health effects gained by swimming could be increased by reducing the potential health risks of pool water.

Short-term changes in respiratory biomarkers after swimming in a chlorinated pool.

BACKGROUND: Swimming in chlorinated pools involves exposure to disinfection by-products (DBPs) and has been associated with impaired respiratory health. OBJECTIVES: We evaluated short-term changes in several respiratory biomarkers to explore mechanisms of potential lung damage related to swimming pool exposure. METHODS: We measured lung function and biomarkers of airway inflammation [fractional exhaled nitric oxide (FeNO), eight cytokines, and vascular endothelial growth factor (VEGF) in exhaled breath condensate], oxidative stress (8-isoprostane in exhaled breath condensate), and lung permeability [surfactant protein D (SP-D) and the Clara cell secretory protein (CC16) in serum] in 48 healthy nonsmoking adults before and after they swam for 40 min in a chlorinated indoor swimming pool. We measured trihalomethanes in exhaled breath as a marker of individual exposure to DBPs. Energy expenditure during swimming, atopy, and CC16 genotype (rs3741240) were also determined. RESULTS: Median serum CC16 levels increased from 6.01 to 6.21 microg/L (average increase, 3.3%; paired Wilcoxon test p = 0.03), regardless of atopic status and CC16 genotype. This increase was explained both by energy expenditure and different markers of DBP exposure in multivariate models. FeNO was unchanged overall but tended to decrease among atopics. We found no significant changes in lung function, SP-D, 8-isoprostane, eight cytokines, or VEGF. CONCLUSIONS: We detected a slight increase in serum CC16, a marker of lung epithelium permeability, in healthy adults after they swam in an indoor chlorinated pool. Exercise and DBP exposure explained this association, without involving inflammatory mechanisms. Further research is needed to confirm the results, establish the clinical relevance of short-term serum CC16 changes, and evaluate the long-term health impacts.

Assessment of lifetime exposure to trihalomethanes through different routes.

OBJECTIVES: To evaluate lifetime exposure to trihalomethanes (THM) through ingestion, inhalation, and dermal absorption in a hospital based case-control study of bladder cancer conducted between 1998 and 2001 in five areas of Spain. The study base was comprised of subjects living in the catchment areas of the participating hospitals. METHODS: Individual information on water related habits was obtained from personal interviews of 1219 cases and 1271 controls: residential and occupational history, drinking water source at each residence and job, amount of water consumption, frequency and duration of showering, bathing, and swimming pool attendance. THM levels, water source history, and year when chlorination started in study areas were ascertained through measurements in drinking water samples and questionnaires to water companies and local authorities. Estimates of THM levels covered 79% of the subjects' person-years of exposure. RESULTS: Current and historical average THM levels in water were correlated. Control subjects reported that drinking water source in the last residence was municipal for 63%, bottled for 22%, private well for 2%, and other sources for 13%. For the time window between age 15 and the time of interview, average residential THM level was 32.2 mug/l. THM exposure through ingestion was 23.7 mug/day on average, and was correlated with the ingestion THM level in the workplace. Overall, 79% usually took showers, 16% usually took baths, and 13% had ever attended a swimming pool. Between 21% and 45% of controls unexposed to THM through ingestion were evaluated as moderately or highly exposed through showering or bathing, and 5-10% were exposed through swimming in pools. CONCLUSION: The importance of evaluating different routes is underscored by findings from experimental studies showing substantial differences in THM uptake and internal distribution by route.