Fatigue Symptoms During the First Year Following ARDS.

BACKGROUND: Fatigue is commonly reported by ARDS survivors, but empirical data are scarce. RESEARCH QUESTION: This study evaluated fatigue prevalence and associated variables in a prospective study of ARDS survivors. STUDY DESIGN AND METHODS: This analysis is part of the ARDSNet Long-Term Outcomes Study (ALTOS) conducted at 38 US hospitals. Using age- and sex-adjusted, time-averaged random effects regression models, we evaluated associations between the validated Functional Assessment of Chronic Illness Therapy-Fatigue Scale with patient and critical illness variables, and with physical, cognitive, and mental health status at 6 and 12 months following ARDS. RESULTS: Among ARDS survivors, 501 of 711 (70%) and 436 of 659 (66%) reported clinically significant symptoms of fatigue at 6 and 12 months, respectively, with 41% and 28% reporting clinically important improvement and worsening (n = 638). At 6 months, the prevalence of fatigue (70%) was greater than that of impaired physical functioning (50%), anxiety (42%), and depression (36%); 46% reported both impaired physical function and fatigue, and 27% reported co-existing anxiety, depression, and fatigue. Fatigue was less severe in men and in those employed prior to ARDS. Critical illness variables (eg, illness severity, length of stay) had little association with fatigue symptoms. Worse physical, cognitive, and mental health symptoms were associated with greater fatigue at both the 6- and 12-month follow-up. INTERPRETATION: During the first year following ARDS, more than two-thirds of survivors reported clinically significant fatigue symptoms. Due to frequent co-occurrence, clinicians should evaluate and manage survivors' physical, cognitive, and mental health status when fatigue is endorsed.

Derivation of cancer no significant risk levels and screening safety assessment for 2-nitropropane in spray products.

Two proposition 65 no-significant-risk level (NSRL)-type values were derived for 2-nitropropane (2-NP), in the absence of a Californian published NSRL. In addition, a safety assessment was performed based on estimated typical consumer inhalation and dermal exposure to 2-NP during indoor application of paint from a spray can containing the solvent 1-nitropropane. For the NSRL derivation, benchmark dose (BMD) modeling was performed using hepatocellular carcinoma incidence data from 2-NP single exposure inhalation studies in Sprague-Dawley rats. Several BMD models provided an acceptable fit for the male rat hepatocellular carcinoma incidence data (gamma, log-probit, log-logistic and multistage); therefore, the mean of the BMD lower limits from each model were used as the point of departure to derive the inhalation cancer potency. The oral human cancer potency was derived from the inhalation human cancer potency based on the ratio of the uptake factors for inhalation vs. oral routes. The derived inhalation and oral NSRLs are 67 µg/day and 32 µg/day, respectively. For the inhalation and dermal exposure assessment, three key factors were analyzed: the 2-NP residual concentration in the spray paint product, the mass of spray paint used and the frequency of use. Based on the screening exposure assessment, potential consumer inhalation and dermal exposure to 2-NP from indoor application of paint from a spray can does not exceed our proposed NSRLs, and a warning label is therefore not required for spray can products containing the solvent 1-nitropropane where 2-NP is a minor contaminant.

Implementing the access and waiting time standard for early intervention in psychosis in the United Kingdom: An evaluation of referrals and post-assessment outcomes over the first year of operation.

AIM: Improving timely access to evidence-based treatment for people aged 14-65 years experiencing a first episode psychosis (FEP) or an at-risk mental state (ARMS) for psychosis is a national priority within the United Kingdom. An early intervention in psychosis (EIP) access and waiting time standard has been set which has extended the age range and acceptance criteria for services. METHODS: This descriptive evaluation reports upon the referrals and access to treatment times within an EIP service over the first year of operating in line with the access and waiting time standard. Patient pathways and post-assessment status are also described. RESULTS: The service received 406 referrals, of which 88% (n = 357) were assessed. The mean length of time to treatment was 1.5 weeks, with 88% being seen within 2 weeks. Of those who engaged in an assessment, 34% (n = 138) were identified as ARMS cases and 30% (n = 123) were identified as FEP. Over 35 year olds accounted for 22% (n = 80) of the total accepted cases. CONCLUSIONS: The findings indicate clinical and operational issues, which will need careful consideration in the future planning of services. The high number of ARMS cases highlights the importance of clear treatment pathways and targeted interventions and may suggest a need to commission distinct ARMS services. The number of people who met the extended age and service acceptance criteria may suggest a need to adapt or redesign clinical services to meet the age-specific needs of over 35 year olds and those with an ARMS. It is unclear how changes to the remit of EIP services will impact upon future clinical outcomes.

Cleaning and asthma: A systematic review and approach for effective safety assessment.

Research indicates a correlative relationship between asthma and use of consumer cleaning products. We conduct a systematic review of epidemiological literature on persons who use or are exposed to cleaning products, both in occupational and domestic settings, and risk of asthma or asthma-like symptoms to improve understanding of the causal relationship between exposure and asthma. A scoring method for assessing study reliability is presented. Although research indicates an association between asthma and the use of cleaning products, no study robustly investigates exposure to cleaning products or ingredients along with asthma risk. This limits determination of causal relationships between asthma and specific products or ingredients in chemical safety assessment. These limitations, and a lack of robust animal models for toxicological assessment of asthma, create the need for a weight-of-evidence (WoE) approach to examine an ingredient or product's asthmatic potential. This proposed WoE method organizes diverse lines of data (i.e., asthma, sensitization, and irritation information) through a systematic, hierarchical framework that provides qualitatively categorized conclusions using hazard bands to predict a specific product or ingredient's potential for asthma induction. This work provides a method for prioritizing chemicals as a first step for quantitative and scenario-specific safety assessments based on their potential for inducing asthmatic effects. Acetic acid is used as a case study to test this framework.

Pancreaticoduodenectomy hospital resource utilization in octogenarians.

BACKGROUND: Although pancreaticoduodenectomy (PD) is feasible in patients greater than or equal to 80 years, little is known about the potential strain on resource utilization. METHODS: Outcomes and inpatient charges were compared across age cohorts (I: ≤70, II: 71 to 79, III: ≥80 years) in 99 patients who underwent PD (2005 to 2013) at our institution. The generalized linear modeling approach was used to estimate the impact of age. RESULTS: Perioperative complications were equivalent among cohorts. Increasing age was associated with intensive care unit use, increased length of stay (LOS), and the likelihood of discharge to a skilled facility. After controlling for covariates, hospital charges were significantly higher in Cohort III (P = .006) and Cohort II (P = .035) when compared with Cohort I. However, hospital charges between Cohorts II and III were equivalent (P = .374). Complications (P = .005) and LOS (P < .001) were associated with higher hospital charges. CONCLUSIONS: Increasing age was associated with increased intensive care unit, LOS, and discharge to skilled facilities. However, octogenarians had equivalent PD charges and outcome measures when compared with septuagenarians and future studies should validate these findings in larger national studies.

A tiered asthma hazard characterization and exposure assessment approach for evaluation of consumer product ingredients.

Asthma is a complex syndrome with significant consequences for those affected. The number of individuals affected is growing, although the reasons for the increase are uncertain. Ensuring the effective management of potential exposures follows from substantial evidence that exposure to some chemicals can increase the likelihood of asthma responses. We have developed a safety assessment approach tailored to the screening of asthma risks from residential consumer product ingredients as a proactive risk management tool. Several key features of the proposed approach advance the assessment resources often used for asthma issues. First, a quantitative health benchmark for asthma or related endpoints (irritation and sensitization) is provided that extends qualitative hazard classification methods. Second, a parallel structure is employed to include dose-response methods for asthma endpoints and methods for scenario specific exposure estimation. The two parallel tracks are integrated in a risk characterization step. Third, a tiered assessment structure is provided to accommodate different amounts of data for both the dose-response assessment (i.e., use of existing benchmarks, hazard banding, or the threshold of toxicological concern) and exposure estimation (i.e., use of empirical data, model estimates, or exposure categories). Tools building from traditional methods and resources have been adapted to address specific issues pertinent to asthma toxicology (e.g., mode-of-action and dose-response features) and the nature of residential consumer product use scenarios (e.g., product use patterns and exposure durations). A case study for acetic acid as used in various sentinel products and residential cleaning scenarios was developed to test the safety assessment methodology. In particular, the results were used to refine and verify relationships among tiered approaches such that each lower data tier in the approach provides a similar or greater margin of safety for a given scenario.

Mode of action analysis for liver tumors from oral 1,4-dioxane exposures and evidence-based dose response assessment.

1,4-Dioxane is found in consumer products and is used as a solvent in manufacturing. Studies in rodents show liver tumors to be consistently reported after chronic oral exposure. However, there were differences in the reporting of non-neoplastic lesions in the livers of rats and mice. In order to clarify these differences, a reread of mouse liver slides from the 1978 NCI bioassay on 1,4-dioxane in drinking water was conducted. This reread clearly identified dose-related non-neoplastic changes in the liver; specifically, a dose-related increase in the hypertrophic response of hepatocytes, followed by necrosis, inflammation and hyperplastic hepatocellular foci. 1,4-Dioxane does not cause point mutations, DNA repair, or initiation. However, it appears to promote tumors and stimulate DNA synthesis. Using EPA Guidelines (2005), the weight of the evidence suggests that 1,4-dioxane causes liver tumors in rats and mice through cytotoxicity followed by regenerative hyperplasia. Specific key events in this mode of action are identified. A Reference Dose (RfD) of 0.05mg/kgday is proposed to protect against regenerative liver hyperplasia based on a benchmark dose (BMD) approach. Based on this RfD, a maximum contaminant level goal of 350µg/L is proposed using a default relative source contribution for water of 20%.

Application of Markov chain Monte Carlo analysis to biomathematical modeling of respirable dust in US and UK coal miners.

A biomathematical model was previously developed to describe the long-term clearance and retention of particles in the lungs of coal miners. The model structure was evaluated and parameters were estimated in two data sets, one from the United States and one from the United Kingdom. The three-compartment model structure consists of deposition of inhaled particles in the alveolar region, competing processes of either clearance from the alveolar region or translocation to the lung interstitial region, and very slow, irreversible sequestration of interstitialized material in the lung-associated lymph nodes. Point estimates of model parameter values were estimated separately for the two data sets. In the current effort, Bayesian population analysis using Markov chain Monte Carlo simulation was used to recalibrate the model while improving assessments of parameter variability and uncertainty. When model parameters were calibrated simultaneously to the two data sets, agreement between the derived parameters for the two groups was very good, and the central tendency values were similar to those derived from the deterministic approach. These findings are relevant to the proposed update of the ICRP human respiratory tract model with revisions to the alveolar-interstitial region based on this long-term particle clearance and retention model.

Safety assessment of boron by application of new uncertainty factors and their subdivision.

The available toxicity information for boron was reevaluated and four appropriate toxicity studies were selected in order to derive a tolerable daily intake (TDI) using newly proposed uncertainty factors (UFs) presented in Hasegawa et al. (2010). No observed adverse effect levels (NOAELs) of 17.5 and 8.8 mgB/kg/day for the critical effect of testicular toxicity were found in 2-year rat and dog feeding studies. Also, the 95% lower confidence limit of the benchmark doses for 5% reduction of fetal body weight (BMDL(05)) was calculated as 44.9 and 10.3 mgB/kg/day in mouse and rat developmental toxicity studies, respectively. Measured values available for differences in boron clearance between rats and humans and variability in the glomerular filtration rate (GFR) in pregnant women were used to derive chemical specific UFs. For the remaining uncertainty, newly proposed default UFs, which were derived from the latest applicable information with a probabilistic approach, and their subdivided factors for toxicokinetic and toxicodynamic variability were applied. Finally, overall UFs were calculated as 68 for rat testicular toxicity, 40 for dog testicular toxicity, 247 for mouse developmental toxicity and 78 for rat developmental toxicity. It is concluded that 0.13 mgB/kg/day is the most appropriate TDI for boron, based on rat developmental toxicity.

Evaluation of concentration-response options for diacetyl in support of occupational risk assessment.

The current emphasis on occupational exposures to diacetyl has led to new research on its effects. We evaluated whether the data are sufficient to support a transition from a hazard-based risk management approach to a quantitative occupational risk assessment approach, characterized by developing a health-based occupational exposure limit (OEL). Inhalation health effects data were evaluated and issues and uncertainties related to occupational risk assessment needs were identified. A systematic hazard characterization, supported by both the toxicology and epidemiology literature, showed that the respiratory tract effects of diacetyl are the primary end points of relevance for developing an OEL. In an effort to provide a systematic approach for the analysis of the issues that need to be considered in developing an occupational risk assessment for diacetyl, a potential OEL was derived. A concentration-response assessment was completed using tracheobronchial effects in mice as the critical effect. The resulting benchmark concentration (lower bound estimate or BMCL) was adjusted to a human equivalent concentration of 1.8 ppm. A composite uncertainty factor of 10 was recommended to account for extrapolation from an adjusted BMCL from an animal study and for human variability in sensitivity and taking into account other uncertainties in the overall database. The resulting OEL recommendation of 0.2 ppm as a time-weighted average (TWA) was supported by the current occupational epidemiology literature. This evaluation showed that a health-based OEL value can be derived for diacetyl with moderate to high confidence.

Evidence-based dose-response assessment for thyroid tumorigenesis from acrylamide.

Acrylamide is commonly found in various foods. Cancer studies in rats have reported increases in tumors of the thyroid, mammary tissues, tunica vaginalis of the testis, and sometimes tumors at other sites. We review relevant studies on acrylamide's DNA toxicity, tumor formation and the manner of its tumor formation. We find, as do others, that glycidamide (a metabolite of acrylamide) causes point mutations, but acrylamide does not. We also find that thyroid tumors are most consistently sensitive in rats, being evoked in each of four long-term experiments. We evaluate the common manners of this tumor formation in the thyroid, including both mutagenicity and thyroid growth-stimulation. Consistent with the overall weight of the evidence, we conclude that both of these manners or modes of action may be occurring. We conservatively assume that the mutagenic mode of action determines the low-dose-response and we conclude that growth stimulation likely dominates the response at higher doses. Following US EPA guidelines, we determined that the probit model best reflects the overall data set; this model is also preferred because it better reflects the underlying "decoupled" biology of contributions from potentially two modes of action. We use the probit model to identify a health-protective, linear cancer slope factor (SF) of 0.030 (mg/kg-day)(-1) for the low area of the dose-response curve associated with possible mutagenicity. We also identify a Reference Dose (RfD) in the range of 0.05-0.02 mg/kg-day for the high area of the dose-response curve associated with the growth stimulation. This latter value can be used to determine the upper range of risk. This dose-response assessment is briefly summarized in light of other related work.