Impact of an integrated nutrition, health, water sanitation and hygiene, psychosocial care and support intervention package delivered during the pre- and peri-conception period and/or during pregnancy and early childhood on linear growth of infants in the first two years of life, birth outcomes and nutritional status of mothers: study protocol of a factorial, individually randomized controlled trial in India.

BACKGROUND: The period from conception to two years of life denotes a critical window of opportunity for promoting optimal growth and development of children. Poor nutrition and health in women of reproductive age and during pregnancy can negatively impact birth outcomes and subsequent infant survival, health and growth. Studies to improve birth outcomes and to achieve optimal growth and development in young children have usually tested the effect of standalone interventions in pregnancy and/or the postnatal period. It is not clearly known whether evidence-based interventions in the different domains such as health, nutrition, water sanitation and hygiene (WASH) and psychosocial care, when delivered together have a synergistic effect. Further, the effect of delivery of an intervention package in the pre and peri-conception period is not fully understood. This study was conceived with an aim to understand the impact of an integrated intervention package, delivered across the pre and peri-conception period, through pregnancy and till 24 months of child age on birth outcomes, growth and development in children. METHODS: An individually randomized controlled trial with factorial design is being conducted in urban and peri-urban low- to mid-socioeconomic neighbourhoods in South Delhi, India. 13,500 married women aged 18 to 30 years will be enrolled and randomized to receive either the pre and peri-conception intervention package or routine care (first randomization). Interventions will be delivered until women are confirmed to be pregnant or complete 18 months of follow up. Once pregnancy is confirmed, women are randomized again (second randomization) to receive either the intervention package for pregnancy and postnatal period or to routine care. Newborns will be followed up till 24 months of age. The interventions are delivered through different study teams. Outcome data are collected by an independent outcome ascertainment team. DISCUSSION: This study will demonstrate the improvement that can be achieved when key factors known to limit child growth and development are addressed together, throughout the continuum from pre and peri-conception until early childhood. The findings will increase our scientific understanding and provide guidance to nutrition programs in low- and middle-income settings. TRIAL REGISTRATION: Clinical Trial Registry - India #CTRI/2017/06/008908; Registered 23 June 2017, http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=19339&EncHid=&userName=society%20for%20applied%20studies.

A whale of a tale: A One Environmental Health approach to study metal pollution in the Sea of Cortez.

Marine metal pollution is an emerging concern for human, animal, and ecosystem health. We considered metal pollution in the Sea of Cortez, which is a relatively isolated sea rich in biodiversity. Here there are potentially significant anthropogenic inputs of pollution from agriculture and metal mining. We considered the levels of 23 heavy metals and selenium in seven distinct cetacean species found in the area. Our efforts considered two different periods of time: 1999 and 2016/17. We considered the metal levels in relation to (1) all species together across years, (2) differences between suborders Odontoceti and Mysticeti, (3) each species individually across years, and (4) gender differences for each of these comparisons. We further compared metal levels found in sperm whale skin samples collected during these voyages to a previous voyage in 1999, to assess changes in metal levels over a longer timescale. The metals Mg, Fe, Al, and Zn were found at the highest concentrations across all species and all years. For sperm whales, we observed decreased metal levels from 1999 to 2016/2017, except for iron (Fe), nickel (Ni), and chromium (Cr), which either increased or did not change during this time period. These results indicate a recent change in the metal input to the Sea of Cortez, which may indicate a decreased concern for human, animal, and ecosystem health for some metals, but raises concern for the genotoxic metals Cr and Ni. This work was supported by NIEHS grant ES016893 (J.P.W.) and numerous donors to the Wise Laboratory.

Expanding the Concept of Translational Research: Making a Place for Environmental Health Sciences.

SUMMARY: The National Institute of Environmental Health Sciences (NIEHS) introduces a new translational research framework that builds upon previous biomedical models to create a more comprehensive and integrated environmental health paradigm. The framework was developed as a graphical construct that illustrates the complexity of designing, implementing, and tracking translational research in environmental health. We conceptualize translational research as a series of concentric rings and nodes, defining "translation" as movement either from one ring to another or between nodes on a ring. A "Fundamental Questions" ring expands upon the research described in other frameworks as "basic" to include three interrelated concepts critical to basic science research: research questions, experimental settings, and organisms. This feature enables us to capture more granularity and thus facilitates an approach for categorizing translational research and its growth over time. We anticipate that the framework will help researchers develop compelling long-term translational research stories and accelerate public health impacts by clearly mapping out opportunities for collaborations. By using this paradigm, researchers everywhere will be better positioned to design research programs, identify research partners based on cross-disciplinary research needs, identify stakeholders who are likely to use the research for environmental decision-making and intervention, and track progress toward common goals. https://doi.org/10.1289/EHP3657.

A Framework for Integrating Environmental and Occupational Health and Primary Care in a Postdisaster Context.

CONTEXT: Integration of environmental and occupational health (EOH) into primary care settings is a critical step to addressing the EOH concerns of a community, particularly in a postdisaster context. Several barriers to EOH integration exist at the physician, patient, and health care system levels. PROGRAM: This article presents a framework for improving the health system's capacity to address EOH after the Deepwater Horizon oil spill and illustrates its application in the Environmental and Occupational Health Education and Referral (EOHER) program. This program worked with 11 Federally Qualified Health Center systems in the Gulf Coast region to try to address the EOH concerns of community members and to assist primary care providers to better understand the impact of EOH factors on their patients' health. IMPLEMENTATION: The framework uses a 3-pronged approach to (1) foster coordination between primary care and EOH facilities through a referral network and peer consultations, (2) increase physician capacity in EOH issues through continuing education and training, and (3) conduct outreach to community members about EOH issues. EVALUATION: The EOHER program highlighted the importance of building strong partnerships with community members and other relevant organizations, as well as high organizational capacity and effective leadership to enable EOH integration into primary care settings. Physicians in the EOHER program were constrained in their ability to engage with EOH issues due to competing patient needs and time constraints, indicating the need to improve physicians' ability to assess which patients are at high risk for EOH exposures and to efficiently take environmental and occupational histories. DISCUSSION: This article highlights the importance of addressing EOH barriers at multiple levels and provides a model that can be applied to promote community health, particularly in the context of future natural or technological disasters.

Environmental Health Related Socio-Spatial Inequalities: Identifying "Hotspots" of Environmental Burdens and Social Vulnerability.

Differential exposure to multiple environmental burdens and benefits and their distribution across a population with varying vulnerability can contribute heavily to health inequalities. Particularly relevant are areas with high cumulative burdens and high social vulnerability termed as "hotspots". This paper develops an index-based approach to assess these multiple burdens and benefits in combination with vulnerability factors at detailed intra-urban level. The method is applied to the city of Dortmund, Germany. Using non-spatial and spatial methods we assessed inequalities and identified "hotspot" areas in the city. We found modest inequalities burdening higher vulnerable groups in Dortmund (CI = -0.020 at p < 0.05). At the detailed intra-urban level, however, inequalities showed strong geographical patterns. Large numbers of "hotspots" exist in the northern part of the city compared to the southern part. A holistic assessment, particularly at a detailed local level, considering both environmental burdens and benefits and their distribution across the population with the different vulnerability, is essential to inform environmental justice debates and to mobilize local stakeholders. Locating "hotspot" areas at this detailed spatial level can serve as a basis to develop interventions that target vulnerable groups to ensure a health conducive equal environment.

[FEATURES OF THE CONTENT OF MOVABLE FORMS OF HEAVY METALS AND SELENIUM IN SOILS OF THE YAROSLAVL REGION].

With the use of the method of inversion voltammetry there was analyzed the content of movableforms of trace elements: (selenium, zinc, copper lead, cadmium) in soils in the Yaroslavl district of the Yaroslavl region, and also content of zinc, copper lead, cadmium in soils and snow cover in the city of Yaroslavl. According to values of concentrations of movable compounds in soils determined trace elements can be ranked into the following row: zinc > lead > copper > selenium > cadmium. There was revealed insufficient if compared with literature data concentrations, content of movable compounds of selenium, copper and zinc in examined explored soils. The maximal concentrations of lead are revealed in the close proximity to both the city of Yaroslavl and large highways of the city. It indicates to the anthropogenic pollution of soils by this element.

Environmental Chemical Assessment in Clinical Practice: Unveiling the Elephant in the Room.

A growing body of evidence suggests chemicals present in air, water, soil, food, building materials and household products are toxicants that contribute to the many chronic diseases typically seen in routine medical practice. Yet, despite calls from numerous organisations to provide clinicians with more training and awareness in environmental health, there are multiple barriers to the clinical assessment of toxic environmental exposures. Recent developments in the fields of systems biology, innovative breakthroughs in biomedical research encompassing the "-omics" fields, and advances in mobile sensing, peer-to-peer networks and big data, provide tools that future clinicians can use to assess environmental chemical exposures in their patients. There is also a need for concerted action at all levels, including actions by individual patients, clinicians, medical educators, regulators, government and non-government organisations, corporations and the wider civil society, to understand the "exposome" and minimise the extent of toxic exposures on current and future generations. Clinical environmental chemical risk assessment may provide a bridge between multiple disciplines that uses new technologies to herald in a new era in personalised medicine that unites clinicians, patients and civil society in the quest to understand and master the links between the environment and human health.

Programa de largo seguimiento de supervivientes de cáncer pediátrico en la Región de Murcia: preferencias y actitudes de los profesionales de Atención Primaria / Long-term follow up of childhood cancer survivors in the Murcia Region: preferences and attitudes of Primary Care professionals

OBJETIVO: Evaluar actitudes, creencias y conocimientos de los profesionales médicos de Atención Primaria acerca del seguimiento de los supervivientes de cáncer pediátrico (SCP) y divulgar el Programa de Largo Seguimiento de Supervivientes de Cáncer Pediátrico en la Región de Murcia (PLASESCAP-MUR). MATERIAL Y MÉTODOS: Estudio transversal descriptivo mediante cuestionario estructurado y autocumplimentado. Se enviaron cuestionarios a todos los profesionales médicos de Atención Primaria del Área de Salud 1 del Servicio Murciano de Salud. RESULTADOS: Tasa de respuesta del 58% (100/172). El 71 y el 22% eran médicos de familia y pediatras, respectivamente. El 49% atendió algún SCP en los últimos 5 años. El 84% refiere que nunca o pocas veces recibió un informe detallado de evaluación global del superviviente. Más del 75% encuentran bastante o muy útiles el acceso a información detallada de largo seguimiento. El 95% prefiere atender a los supervivientes conjuntamente con consulta de largo seguimiento. Un 80% considera que mejorando la calidad ambiental del entorno podría disminuir la morbimortalidad de los supervivientes. Se encontró una relación estadísticamente significativa entre años practicando medicina y percepción de importancia de algunos factores medioambientales. CONCLUSIONES: Para el largo seguimiento de los SCP parece importante aumentar la capacitación de los profesionales sanitarios de Atención Primaria y la información detallada a través de un plan personalizado de largo seguimiento de cada superviviente. PLASESCAP-MUR proporciona un seguimiento integrativo a los supervivientes de cáncer pediátrico en un modelo de atención compartida entre la Unidad de Largo Seguimiento y Atención Primaria

OBJECTIVE: To assess attitudes, beliefs and knowledge of primary medical care professionals as regards the follow-up of Childhood Cancer Survivors (CCS) and the introduction of a Long-Term Follow-Up Program for Childhood Cancer Survivors in the Region of Murcia (PLASESCAP-MUR). MATERIAL AND METHODS: Descriptive cross-sectional study using a structured, self-administered questionnaire. These questionnaires were sent to all primary medical care professionals in Murcia Health District 1. RESULTS: Response rate of 58% (100/172), with 71% and 22% being family physicians and pediatricians, respectively, of whom 49% provided medical care to a CCS in the last 5 years, with 84% reporting that they never or rarely received a detailed report of overall assessment of the survivor. More than 75% found that access to detailed follow-up information was quite or very useful; 95% prefer to consult experts when providing medical care to survivors, and 80% believe that improving the quality of the environment may decrease the morbidity and mortality of the survivors. A statistically significant relationship was found between the length of practicing medicine and the perception of the importance of environmental factors. CONCLUSIONS: It seems to be important to increase the training of primary care professionals for the long-term follow-up of CCS, as well as having the detailed information through a personalized long-term follow-up of each survivor. PLASESCAP-MUR offers an integrated follow-up to CCS in a model of shared care between Long Term Monitoring Units and Primary Care Units

Human health-related ecosystem services of avian-dense coastal wetlands adjacent to a Western Lake Erie swimming beach.

Wetlands provide many valuable ecosystem services, including water quality improvement to protect downstream aquatic ecosystems such as lakes, rivers, and estuaries. However, their ability to improve water quality to safe levels for direct human exposure while largely surrounded by agricultural lands and hosting large wildlife populations remains unknown. Our aim was to examine the ecosystem service capabilities of an avian-dense coastal wetland surrounded by agricultural lands along the southwestern shore of Lake Erie in Ohio by assessing the quality of water as it flows through the wetland (Ottawa National Wildlife Refuge (ONWR)) and into Lake Erie beach waters. Our study used total phosphorus and fecal indicator (Escherichia coli) concentrations as water quality metrics across the wetland and at an adjacent Lake Erie swimming beach during the 2012 summer swim season. E. coli and total P levels were consistently highest at the site, where water enters the ONWR (mean E. coli = 507 CFU/100 mL; mean total P = 535 µg/L), and steadily decreased as water flowed through the wetland and into the adjacent beach (mean E. coli = 10 CFU/100 mL; mean total P = 41 µg/L). E. coli and total P showed statistically significant (α = 0.01) correlations with phycocyanin, chlorophyll-a, turbidity, specific conductivity, dissolved oxygen, and pH; total P was also significantly correlated with total N. The results suggest that this wetland may be contributing to improving water quality, which is beneficial for human health as well as to downstream ecosystem health (e.g., limiting eutrophication promoting conditions, etc.).

(13)C discrimination between diet, faeces, milk and milk components.

Stable isotope analysis is a fundamental tool in food origin and authenticity testing. Its use in livestock production requires knowledge of isotope discrimination between product and diet. Here, we report (13)C discrimination ((13)Δ) for milk, milk components (fat, casein and lactose) and faeces in eight lactating dairy cows, which grazed pasture or were fed fresh pasture herbage in the stall. Cows were supplemented with grain maize at 1.72 kg d(-1) (dry matter). Feed components were collected daily, and faeces, milk fat, casein, lactose and whole milk 4 times per week during an 8-week-long sampling period. Carbon isotope composition (δ(13)C) of each sample was analysed. δ(13)C was lowest in milk fat (-29.8‰) and highest in casein (-26.4‰). Compared to the diet, whole milk was depleted in (13)C ((13)Δ = 0.4‰) due to a strong (13)C-depletion of fat ((13)Δ = 2.2‰), which was not fully compensated by the (13)C-enrichment of casein ((13)Δ = -1.1‰) and lactose ((13)Δ = -0.7‰). Faeces were also depleted in (13)C ((13)Δ =1.7‰). Influences of feeding environment (stall vs. pasture) and herbage quality were minor (<0.4‰). A review of literature data shows large variation between studies. We consider that the present results are superior, as they are based on a much larger data set regarding the number of cows and milkings (total n = 256) with greater detail in analyses of diet and milk products. Also, the study covered both stall- and pasture-feeding scenarios in realistic settings with long periods of equilibration. This is the first comprehensive analysis of (13)C discrimination between diet and all main milk components (as well as faeces). Thus, the results will improve the use of stable isotope analyses in regard to authenticity testing and proof of origin.

Cense: a tool to assess combined exposure to environmental health stressors in urban areas.

This paper describes the structure of the Combined Environmental Stressors' Exposure (CENSE) tool. Individuals are exposed to several environmental stressors simultaneously. Combined exposure represents a more serious hazard to public health. Consequently, there is a need to address co-exposure in a holistic way. Rather than viewing chemical and physical health stressors separately for decision making and environmental sustainability considerations, the possibility of an easy-to-comprehend co-exposure assessment is herein considered. Towards this aim, the CENSE tool is developed in the programming environment of Delphi. The graphical user's interface facilitates its tractable application. Studying different scenarios is easy since the execution time required is negligible. The tool incorporates co-exposure indicators and takes into account the potential dose of each chemical stressor by considering the physical activities of each citizen in an urban (micro)environment. The capabilities of the CENSE tool are demonstrated through its application for the case of Thessaloniki, Greece. The test case highlights usability and validation insights and incorporates health stressors and local characteristics of the area considered into a well identified user/decision maker interface. The main conclusion of the work reported is that a decision maker can trust CENSE for urban planning and environmental sustainability considerations, since it supports a holistic assessment of the combined potential damage attributed to multiple health stressors. CENSE abandons the traditional approach of viewing chemical and physical stressors separately, which represents the most commonly adopted strategy in real life decision support cases.

Urban ecosystem health assessment: perspectives and Chinese practice.

The concept of ecosystem health is a way to assess the holistic operations and development potential of urban ecosystems. Accelerated by the practical need for integrated ecosystem management, assessment of urban ecosystem health has been greatly developed and extensively applied in urban planning and management. Development is aimed at comprehensively evaluating the performance of urban ecosystems, identifying the limiting factors, and providing suggestions for urban regulation. The time has come for reviewing and establishing an instructional framework for urban ecosystem health assessment to shed light on certain essential issues of urban ecosystem health. Based on literature reviews and series of practice, a holistic framework of urban ecosystem health assessment is proposed. The framework covers the essential elements of urban ecosystem health and integrates three dimensions: theoretical foundation, assessment method, and practical application. Concrete assessment methods are also established, focusing on both external performance and internal metabolic processes. The practice of urban ecosystem health assessment in China is illustrated to briefly demonstrate the application of the established framework and methods. Some prospects are discussed for urban ecosystem health assessment and its application in urban planning and management.

Caring about community, ecology and the lives of women.

The front lines of caring extend far beyond U.S. borders. Some holistic nurses are using their skill and knowledge to create sustainable change in other countries. With the help of her local Vermont community, AHNA member Margarita (Rita) Severinghaus is applying the principles and values of holistic nursing to improve women's lives in her mother's childhood village in the Dominican Republic.

Toward a holistic approach in the presentation of benefits and risks of medical radiation.

Frequently messages are conveyed about benefit and risk in medical imaging or in imaging-guided medical intervention that are quite different from the intended communication. This is because communication is not merely the words used to express an idea. The message involves many personal factors on the part of the communicator and on the part of the audience. The intent of this article is to disclose some of the underlying factors that disproportionately bias communication of benefit and risk. Suggestions on how to develop a holistic communication of benefits and risks are presented. It is recommended that communication about the application of radiation to patients be disassociated from standard radiation protection concepts. The medical profession should develop unique communication tools to deliver a message that focuses on benefit/risk as a holistic entity, not benefit or risk as separate entities.

Linking population, health, and the environment: an overview of integrated programs and a case study in Nepal.

Population, health, and environment programs are cross-sectoral development initiatives that link conservation, health, and family planning interventions. These programs are generally located in biodiversity hotspots, where population pressure is among the factors contributing to environmental degradation. This review describes the general structure of population, health, and environment programs and provides selected examples to highlight various aspects of this approach. We focus in depth on a case study from the Integrating Population and Health into Forestry Management Agendas program in Nepal that simultaneously addressed deforestation from fuel-wood harvesting, indoor air pollution from wood fires, acute respiratory infections related to smoke inhalation, as well as family planning in communities in Nepal's densely populated forest corridors. Keys to the success of the Nepal project included empowerment of community forest user groups with population, health, and environment program know-how and appropriate technology. Lessons learned in Nepal point to the critical role that nongovernmental organizations can play as catalysts of cross-sectoral responses to complex development issues such as this one. The population, health, and environment approach can be an effective method for achieving sustainable development and meeting both conservation and health objectives.