Relationship between clinician documented blast exposure and pulmonary function: a retrospective chart review from a national specialty clinic.

BACKGROUND: Service member exposure to explosive blast overpressure waves is common with considerable attention to traumatic brain injury (TBI) and neuropsychological sequalae. Less is known about the impacts on the respiratory system, particularly long-term effects, despite vulnerability to overpressure. Using a national registry, we previously observed an independent relationship between self-reported blast exposure and respiratory symptoms; however, the impact on objective measures of pulmonary function is poorly understood. METHODS: 307 Veterans referred to our national specialty center for post-deployment health concerns underwent a comprehensive multi-day evaluation that included complete pulmonary function testing (PFT), occupational and environmental medicine history, neuropsychological or psychological evaluation. We developed an a priori chart abstraction process and template to classify Veterans into blast exposure groups: (1) none, (2) single-mild, or (3) multiple-mild. This template focused primarily on clinician documented notes of blast related TBI that were used as proxy for blast overpressure injury to thorax. PFT variables characterizing flow (FEV1%; %∆FEV1), volume (TLC%), diffusion (DLCO%) and respiratory mechanics (forced oscillometry) were selected for analysis. RESULTS: Veterans (40.5 ± 9.7 years; 16.3% female) were referred 8.6 ± 3.6 years after their last deployment and presented with considerable comorbid conditions and health problems (e.g., 62% post-traumatic stress, 55% dyspnea). After chart abstraction, Veterans were assigned to none (n = 208), single mild (n = 52) and multiple mild (n = 47) blast exposure groups. Among the blast exposed, clinicians documented 73.7% were < 50 m from the blast and 40.4% were physically moved by blast. PFT outcome measures were similar across all groups (p value range: 0.10-0.99). CONCLUSIONS: In this referred sample of deployed Veterans, PFT measures of flow, volume, diffusion, and respiratory mechanics were not associated with clinician documented blast exposure per the retrospective chart abstraction methodology applied. Yet, these clinical findings suggest future research should determine and assess distinction between Veteran recollections of perceived blast experiences versus overpressure wave exposure to the respiratory system.

Development and Comparison of Complementary Methods to Study Potential Skin and Inhalational Exposure to Pathogens During Personal Protective Equipment Doffing.

BACKGROUND: Fluorescent tracers are often used with ultraviolet lights to visibly identify healthcare worker self-contamination after doffing of personal protective equipment (PPE). This method has drawbacks, as it cannot detect pathogen-sized contaminants nor airborne contamination in subjects' breathing zones. METHODS: A contamination detection/quantification method was developed using 2-µm polystyrene latex spheres (PSLs) to investigate skin contamination (via swabbing) and potential inhalational exposure (via breathing zone air sampler). Porcine skin coupons were used to estimate the PSL swabbing recovery efficiency and limit of detection (LOD). A pilot study with 5 participants compared skin contamination levels detected via the PSL vs fluorescent tracer methods, while the air sampler quantified potential inhalational exposure to PSLs during doffing. RESULTS: Average PSL skin swab recovery efficiency was 40% ± 29% (LOD = 1 PSL/4 cm2 of skin). In the pilot study, all subjects had PSL and fluorescent tracer skin contamination. Two subjects had simultaneously located contamination of both types on a wrist and hand. However, for all other subjects, the PSL method enabled detection of skin contamination that was not detectable by the fluorescent tracer method. Hands/wrists were more commonly contaminated than areas of the head/face (57% vs 23% of swabs with PSL detection, respectively). One subject had PSLs detected by the breathing zone air sampler. CONCLUSIONS: This study provides a well-characterized method that can be used to quantitate levels of skin and inhalational contact with simulant pathogen particles. The PSL method serves as a complement to the fluorescent tracer method to study PPE doffing self-contamination.

Effect of an Intervention Package and Teamwork Training to Prevent Healthcare Personnel Self-contamination During Personal Protective Equipment Doffing.

BACKGROUND: More than 28 000 people were infected with Ebola virus during the 2014-2015 West African outbreak, resulting in more than 11 000 deaths. Better methods are needed to reduce the risk of self-contamination while doffing personal protective equipment (PPE) to prevent pathogen transmission. METHODS: A set of interventions based on previously identified failure modes was designed to mitigate the risk of self- contamination during PPE doffing. These interventions were tested in a randomized controlled trial of 48 participants with no prior experience doffing enhanced PPE. Contamination was simulated using a fluorescent tracer slurry and fluorescent polystyrene latex spheres (PLSs). Self-contamination of scrubs and skin was measured using ultraviolet light visualization and swabbing followed by microscopy, respectively. Doffing sessions were videotaped and reviewed to score standardized teamwork behaviors. RESULTS: Participants in the intervention group contaminated significantly fewer body sites than those in the control group (median [interquartile range], 6 [3-8] vs 11 [6-13], P = .002). The median contamination score was lower for the intervention group than the control group when measured by ultraviolet light visualization (23.15 vs 64.45, P = .004) and PLS swabbing (72.4 vs 144.8, P = .001). The mean teamwork score was greater in the intervention group (42.2 vs 27.5, P < .001). CONCLUSIONS: An intervention package addressing the PPE doffing task, tools, environment, and teamwork skills significantly reduced the amount of self-contamination by study participants. These elements can be incorporated into PPE guidance and training to reduce the risk of pathogen transmission.

Impact of air-handling system exhaust failure on dissemination pattern of simulant pathogen particles in a clinical biocontainment unit.

Biocontainment units (BCUs) are facilities used to care for patients with highly infectious diseases. However, there is limited guidance on BCU protocols and design. This study presents the first investigation of how HVAC (heating, ventilation, air-conditioning) operating conditions influence the dissemination of fluorescent tracer particles released in a BCU. Test conditions included normal HVAC operation and exhaust failure resulting in loss of negative pressure. A suspension of optical brightener powder and water was nebulized to produce fluorescent particles simulating droplet nuclei (0.5-5 µm). Airborne particle number concentrations were monitored by Instantaneous Biological Analyzers and Collectors (FLIR Systems). During normal HVAC operation, fluorescent tracer particles were contained in the isolation room (average concentration = 1 × 104 ± 3 × 103 /Lair ). Under exhaust failure, the automated HVAC system maximizes airflow into areas adjacent to isolation rooms to attempt to maintain negative pressure differential. However, 6% of the fluorescent particles were transported through cracks around doors/door handles out of the isolation room via airflow alone and not by movement of personnel or doors. Overall, this study provides a systematic method for evaluating capabilities to contain aerosolized particles during various HVAC scenarios. Recommendations are provided to improve situation-specific BCU safety.

Application of ATP-based bioluminescence for bioaerosol quantification: effect of sampling method.

An adenosine triphosphate (ATP)-based bioluminescence has potential to offer a quick and affordable method for quantifying bioaerosol samples. Here we report on our investigation into how different bioaerosol aerosolization parameters and sampling methods affect bioluminescence output per bacterium, and implications of that effect for bioaerosol research. Bacillus atrophaeus and Pseudomonas fluorescens bacteria were aerosolized by using a Collison nebulizer (BGI Inc., Waltham, MA) with a glass or polycarbonate jar and then collected for 15 and 60 min with: (1) Button Aerosol Sampler (SKC Inc., Eighty Four, PA) with polycarbonate, PTFE, and cellulose nitrate filters, (2) BioSampler (SKC Inc.) with 5 and 20 mL of collection liquid, and (3) our newly developed Electrostatic Precipitator with Superhydrophobic Surface (EPSS). For all aerosolization and sampling parameters we compared the ATP bioluminescence output per bacterium relative to that before aerosolization and sampling. In addition, we also determined the ATP reagent storage and preparation conditions that that do not affect the bioluminescence signal intensity. Our results show that aerosolization by a Collison nebulizer with a polycarbonate jar yields higher bioluminescence output per bacterium compared to the glass jar. Interestingly enough, the bioluminescence output by P. fluorescens increased substantially after its aerosolization compared to the fresh liquid suspension. For both test microorganisms, the bioluminescence intensity per bacterium after sampling was significantly lower than that before sampling suggesting negative effect of sampling stress on bioluminescence output. The decrease in bioluminescence intensity was more pronounces for longer sampling times and significantly and substantially depended on the sampling method. Among the investigated method, the EPSS was the least injurious for both microorganisms and sampling times. While the ATP-based bioluminescence offers a quick bioaerosol sample analysis method, this works demonstrates that the method output depends on bioaerosol generation and sampling methods, as well as reagent storage.

Current frameworks for environmental and health assessment of hydrocarbon streams and products are flexible and ready for alternative non crude oil-based feeds.

Hazard and risk assessment of complex petroleum-derived substances has been in a state of continuous improvement since the 1970s, with the development of approaches that continue to be applied and refined. Alternative feeds are defined here as those coming into a refinery or chemical plant that are not hydrocarbons from oil and gas extraction such as biologically derived oils, pyrolysis oil from biomass or other, and recycled materials. These feeds are increasingly being used for production of liquid hydrocarbon streams, and hence, there is a need to assess these alternatives, subsequent manufacturing and refining processes and end products for potential risk to humans and the environment. Here we propose a tiered, problem formulation-driven framework for assessing the safety of hydrocarbon streams and products derived from alternative feedstocks in use. The scope of this work is only focused on petrochemical safety assessment, though the principles may be applicable to other chemistries. The framework integrates combinations of analytical chemistry, in silico and in vitro tools, and targeted testing together with conservative assumptions/approaches to leverage existing health, environmental, and exposure data, where applicable. The framework enables the identification of scenarios where de novo hazard and/or exposure assessments may be needed and incorporates tiered approaches to do so. It can be applied to enable decisions efficiently and transparently and can encompass a wide range of compositional space in both feedstocks and finished products, with the objective of ensuring safety in manufacturing and use.

Methods to assess dermal exposures in occupational settings: a scoping review.

OBJECTIVES: The dermal exposure route is expected to become increasingly significant relative to total worker exposure as inhalational exposure limits continue to decrease. However, standardization of occupational exposure assessment methods and scientific consensus are needed. This is the first scoping review mapping the literature across all dermal exposure assessment methods and their targeted substances/chemicals in occupational settings. METHODS: Eligibility criteria broadly included studies reporting any noninvasive dermal exposure assessment method in an occupational setting. The literature search (Web of Science and MEDLINE) was restricted to peer-reviewed, primary literature published in the last 20 years (2002-2022). Titles/abstracts were dual independently screened. Data charting was performed by a single reviewer using standard template. All stages were pilot tested. The JBI (formerly, the Joanna Briggs Institute) scoping review methods and PRISMA-ScR checklist (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) were used. RESULTS: In total, 493 articles were data charted and categorized by 4 study types: methods development (22%), exposure assessment (51%), health outcomes (21%), and controls assessment (6%). Fourteen types of dermal exposure assessment methods were charted with biomarkers (51%), dosimeters (21%), and qualitative assessments such as questionnaires or surveys (17%) most common. Seventeen different chemicals/substances were charted; pesticides (28%) and polycyclic aromatic hydrocarbons (PAHs) (22%) associated with crude oil products and combustion were most common. Mapping between substances and exposure assessment method categories, pesticide dosimeters (11%), and PAH biomarker studies (14%) were most reported. Literature gaps were identified for cleaning agents, hair dyes, glycol ether, N,N-dimethylformamide/N-methyl-2-pyrrolidone, dioxins, and bisphenol A. CONCLUSIONS: To foster scientific consensus, standardization across study reporting is needed for describing: (i) exposure assessment methods used, (ii) worker tasking/conditions, (iii) targeted substances and substance state, and (iv) targeted exposure routes. Overall, this review categorizes, maps, and defines the scope of literature for occupational dermal exposure assessment methods.

An analysis of alternative forced oscillation technique reporting and validation methods for within- and between-sessions in healthy adults.

Forced oscillation technique (FOT) provides unique information on respiratory system mechanical properties complementing pulmonary function testing. However, a lack of evidence guiding acquisition/reporting of parameters has slowed clinical FOT adoption. Current European Respiratory Society (ERS) standards recommend 3-5 trials per session comprising three trials with a coefficient of variation (CoV) ≤ 10% for low-frequency resistance. We present an analysis of different combinations of trial selection methods and session validity thresholding variables (low- and mid-frequency resistance and reactance [R5, R19, X5], low-frequency reactance area [AX] and tidal volume) comparing proportion of subjects achieving valid data across two test sessions (7 ± 3 days apart) and within and between session measurement variabilities. 126 (98%) subjects achieved valid data across both sessions (2666 trials). With R5 or R19 as criteria and selection of any three trials from ≥ 4 attempts, ≥ 75% of subjects achieved validity. Furthermore, with R5 or R19 criteria and selection of any trials from ≥ 5 attempts, CoVs for resistance outcomes were reduced within session while variabilities of FOT outcomes between sessions remained consistent. Within session differences in measurement variabilities were not clinically meaningful. Our analyses support current ERS reporting recommendations for healthy adults. Future work should apply this analytic approach to patient populations.

Employing the Forced Oscillation Technique for the Assessment of Respiratory Mechanics in Adults.

There is increasing interest in the use of the forced oscillation technique (FOT) or oscillometry to characterize respiratory mechanics in healthy and diseased individuals. FOT, a complementary method to traditional pulmonary function testing, utilizes a range of oscillatory frequencies superimposed on tidal breathing to measure the functional relationship between airway pressure and flow. This passive assessment provides an estimate of respiratory system resistance (Rrs) and reactance (Xrs) that reflect airway caliber and energy storage and dissipation, respectively. Despite the recent increase in popularity and updated Technical Standards, clinical adoption has been slow which relates, in part, to the lack of standardization regarding the acquisition and reporting of FOT data. The goal of this article is to address the lack of standardization across laboratories by providing a comprehensive written protocol for FOT and an accompanying video. To illustrate that this protocol can be utilized irrespective of a particular device, three separate FOT devices have been employed in the case examples and video demonstration. This effort is intended to standardize the use and interpretation of FOT, provide practical suggestions, as well as highlight future questions that need to be addressed.

A comparison of alternative selection methods for reporting spirometric parameters in healthy adults.

Alternative methods have been proposed to report spirometry indices from test sessions (forced expiratory volume 1 s, FEV1; forced vital capacity, FVC). However, most use the American and European Societies' standard (ATS/ERS) which stops sessions once a repeatability threshold is met which may not accurately represent intra-session variability. Our goal was to repeat trials beyond the repeatability threshold and evaluate alternative reporting methods. 130 adults performed spirometry across two visits. Spirometry indices were reported using the ATS/ERS standard and four alternatives. 78 participants (60%) had valid data for all methods and visits. Intra-session coefficients of variation were low (FEV1: 3.1-3.7%; FVC: 2.3-2.8%). Our four alternative methods yielded FEV1 and FVC values ≤ 0.08 L different from ATS/ERS standard, which is not clinically meaningful. Intraclass correlation coefficients were ≥ 0.97 indicating consistency across repeated measures. The smallest real differences ranged from FEV1: 0.20-0.27 L and FVC: 0.18-0.24 L indicating consistency and low measurement error. Overall, all methods for reporting FEV1 and FVC demonstrated similar measurement error, precision, and stability within- and between-visits. These results suggest that once ATS/ERS repeatability is achieved, which approach is used for reporting spirometric variables may be of low clinical significance in a healthy population.

Routine Decontamination of Working Canines: A Study on the Removal of Superficial Gross Contamination.

Odor detection canines are a valuable resource used by multiple agencies for the sensitive detection of explosives, narcotics, firearms, agricultural products, and even human bodies. These canines and their handlers are frequently deployed to pathogen-contaminated environments or to work in close proximity with potentially sick individuals. Appropriate decontamination protocols must be established to mitigate both canine and handler exposure in these scenarios. Despite this potential risk, extremely limited guidance is available on routine canine decontamination from pathogenic biological materials. In this article, we evaluate the ability of several commercial off-the-shelf cleansing products, used in wipe form, to remove superficial contamination from fur, canine equipment, and toys. Using Glo Germ MIST as a proxy for biological contamination, our analysis demonstrated more than a 90% average reduction in contamination after wiping with a Nolvasan scrub solution, 0.5% chlorhexidine solution, or 70% isopropyl alcohol. Wiping with nondisinfectant baby wipes or water yielded an almost 80% average removal of contaminant from all surfaces. Additionally, researchers used Gwet's AC2 measurement to assess interrater reliability, which demonstrated substantial agreement (P < .001). These data provide key insights toward the development of a rapid, convenient, and fieldable alternative to traditional water-intensive bathing of working canines.

Review of Biomarkers and Analytical Methods for Organophosphate Pesticides and Applicability to Nerve Agents.

INTRODUCTION: Recent malicious use of chemical warfare agents (CWAs) is a reminder of their severity and ongoing threat. One of the main categories of CWAs is the organophosphate (OP) nerve agents. Presently, there is an urgent need to identify and evaluate OP nerve agent biomarkers that can facilitate identification of exposed individuals post-CWA incident. While exposures to OP nerve agents may be scenario-specific, the public is commonly exposed to OP compounds through the ubiquitous use of OP pesticides, which are chemically related to nerve agents. Therefore, a systematic literature review and methodological quality assessment were conducted for OP pesticide biomarker studies to serve as a baseline to assess if these approaches may be adapted to OP nerve agent exposures. MATERIALS AND METHODS: We conducted a systematic literature review to identify biomarkers of OP pesticide exposures. English language studies of any design that reported primary data on biomarkers for exposures in nonhuman primates or adult human study participants were eligible for inclusion. Using standard criteria for assessing the completeness of reported analytical methods, the quality of study methods was critically evaluated. RESULTS: A total of 1,044 studies of biomarkers of OP pesticide exposure were identified, of which 75 articles satisfied the inclusion and exclusion criteria. These studies described 143 different analyte/sample matrix combinations: 99 host-based biomarkers, 28 metabolites, 12 pesticides, and 4 adducts. The most commonly reported biomarkers were dialkyl phosphate urinary metabolites (22 studies), blood acetylcholinesterase, and plasma butyrylcholinesterase (26 studies each). None of the assessed quality review criteria were fully addressed by all identified studies, with almost all criteria scoring less than 50%. CONCLUSION: Cholinesterase activity may have utility for identifying individuals with exposures surpassing a given threshold of OP nerve agent, but further investigation of how acetylcholinesterase and butyrylcholinesterase levels correlate with observed patient symptoms may be required to ensure accuracy of results. As CWAs and nerve agents are more readily used, more standardized reporting of biomarker measurements are needed to develop new approaches for OP nerve agent biomarkers.

Inactivation of Pure Bacterial Biofilms by Impaction of Aerosolized Consumer Products Containing Nanoparticulate Metals.

The ability of nanotechnology-enabled consumer sprays to inactivate bacteria has direct health implications. This research investigated the ability of six nanosilver-based consumer sprays to inactivate bacteria. We determined the minimal inhibitory concentrations (MICs) of the products by an agar dilution method, collected particles released from sprays onto bacterial films using impactors, and determined metal concentrations in the products using ICPMS. Also, the size of silver nanoparticles in the products' suspensions was determined using single particle (sp)ICPMS. Two of the six nanoproducts inhibited growth of Escherichia coli and Bacillus atrophaeus bacteria (MICs of 40,000 and 160,000 ppm). Collection of particles aerosolized from these two products onto films of the same bacteria inhibited bacterial growth; however, the mass concentration deposited onto bacterial films was lower than the MICs. Furthermore, these two nanoproducts had the lowest silver concentrations compared to the other four nanosilver products. Yet, they had the smallest nanosilver particles: mean size of ~20 to 30 nm vs. ~45 nm for the other products. Their suspensions were more acidic (pH ~3-5) and had higher concentrations of zinc and magnesium compared to other products. This research illustrates that some consumer nanoproducts have antibacterial potential and may affect our microbiota. Yet, the inactivation potential cannot solely be presumed based on the nanosilver presence and concentration in the product; the final nanoproduct's form, including its matrix, must be considered. As nanomaterials are increasingly incorporated into consumer goods, this research highlights the need to investigate final-form consumer nanoproducts and their potential to affect our microbial environment.

Identifying Potential Provider and Environmental Contamination on a Clinical Biocontainment Unit Using Aerosolized Pathogen Simulants.

The Johns Hopkins Hospital created a biocontainment unit (BCU) to care for patients with highly infectious diseases while assuring healthcare worker safety. Research to date for BCU protocols and practices are based on case reports and lessons learned from patient care and exercises. This study seeks to be the first to explore the influences of healthcare worker movement and personal protective equipment (PPE) doffing on the transport of simulant pathogen particles in a BCU. A cough device released 1 µm fluorescent polystyrene beads (PSLs) in the patient room. PSL transport was then examined under 2 scenarios: (1) PSL release only, no healthcare workers; and (2) PSL release during 5-minute simulated activity by healthcare workers. Airborne PSL concentrations were quantified every second for 30 minutes per scenario by 7 optical particle sensors located throughout the BCU. PSLs were not detected in the donning room at any time nor in the doffing room during the first test scenario where no healthcare worker was present. The main difference detected between the tested scenarios was the presence of PSLs in the doffing room when healthcare workers were removing PPE, potentially due to re-aerosolization of PSLs off the exterior PPE surface or opening of the patient room door. Future work will further explore the potential for re-aerosolization of particles off of PPE during doffing. The present study provides the groundwork for a systematic method for evaluating the BCU and doffing procedures for their respective safety, and it also pilots a systematic method for evaluating potential pathogen exposure pathways for BCU healthcare workers.

Field Performance of a Novel Passive Bioaerosol Sampler using Polarized Ferroelectric Polymer Films.

Passive bioaerosol samplers can improve environmental and health protection by enhancing the practicality and cost-effectiveness of air sampling. Here, we present the outdoor field testing of a novel, passive bioaerosol sampler, the Rutgers Electrostatic Passive Sampler (REPS), based on the use of polarized, ferroelectric polymer film (poly(vinylidene fluoride)). Four 10-day-long field campaigns were conducted to compare total (culturable + non-culturable) and culturable bioaerosol collection efficiencies of REPS to passive samplers (PTFE settling filters and agar settling plates). These collection efficiencies were calculated relative to performance of an active, reference Button Sampler. Compared to passive PTFE filters, which exclusively rely on gravitational particle deposition, REPS collected a 7-fold higher total microorganism quantity. Relative to the Button Sampler, REPS collected 25% of the total number of bacteria and fungi and 65% of the culturable bacteria. Furthermore, REPS achieved this performance without any air movers, pumps, batteries or external power. Since the Button Samplers operated at 4 L/min, REPS was calibrated to have equivalent sampling rates of 2.6 L/min and 1.0 L/min for culturable bacteria and total microorganisms, respectively. These results suggest that REPS can passively collect airborne microorganisms, including culturable bacteria, with high efficiency over long-term sampling durations. REPS can provide better preservation of bacterial culturability because it has no active airflow, which desiccates microbes in active samplers. Since there are limited options available for long-term, unattended bioaerosol sampling, REPS can complement currently available bioaerosol sampling technologies for numerous environmental health applications, such as exposure assessment for epidemiology and monitoring aeroallergen trends.

Cut-laceration injuries and related career groups in New Jersey career, vocational, and technical education courses and programs.

Investigations of young workers, including limited surveys in supervised school settings, suggested their elevated injury risk. This study identified factors contributing to cuts-lacerations among adolescents in New Jersey secondary school career, technical, and vocational education programs. Of 1,772 injuries reported between December 1, 1998, and September 1, 2010, 777 (44%) were cuts-lacerations; analyses focused on 224 reports (n = 182 post-exclusions) submitted after fall 2005 in three career groups-Food, Hospitality & Tourism (FH&T) (n = 71), Manufacturing & Construction (M&C) (n = 84), and Automotive & Transportation (A&T) (n = 27). Most students were "struck by" tools or hard surfaces (n = 93, 51%); 63 cuts were from knives in FH&T. In M&C, most cuts-lacerations were caused by hand-held tools (n = 18) and being "struck against/by" or "caught between hard surfaces" (n = 19). Males reported more cuts-lacerations (n = 145), most commonly among 11th graders (n = 54) and ages 16 to 17 years (n = 79). Fingers (n = 117) were most often injured, usually by cutting tools (n = 83). Training, supervision, and appropriate equipment, and further assessments of "struck by" and "pinch point" hazards, are needed.