Gestational PBDE concentrations, persistent externalizing, and emerging internalizing behaviors in adolescents: The HOME study.

BACKGROUND: Polybrominated diphenyl ethers (PBDEs) are ubiquitous environmental chemicals used as flame retardants in commercial and consumer products. Gestational PBDE concentrations are associated with adverse behaviors in children; however, the persistence of these associations into adolescence remains understudied. OBJECTIVE: We estimated the association of gestational PBDE serum concentrations with early adolescent self- and caregiver-reported behaviors at age 12 years and determined the consistency with previously observed associations in childhood with caregiver-reported behaviors in a prospective pregnancy and birth cohort. METHODS: We measured maternal serum concentrations of five individual PBDE congeners and created a summary exposure variable (∑5BDE: 28, -47, -99, -100 and -153) during pregnancy. At age 12 years, we assessed behaviors for 237 adolescents using self- and caregiver-reports with the Behavioral Assessment System for Children-3 (BASC3). We used multivariable linear regression models to estimate covariate-adjusted associations of lipid standardized, log10-transformed gestational PBDE concentrations with BASC3 scores. We obtained estimates and 95% confidence intervals through a bootstrapping approach. We evaluated potential effect measure modification (EMM) of adolescent sex by examining sex-stratified regression models and estimating the EMM p-values. RESULTS: Gestational PBDE concentrations were positively associated with adolescent-reported BASC3 composite indices for inattention & hyperactivity (BDE-28, -47, -99, -100, ∑5BDE), internalizing problems (BDE-28, -47, -99), functional impairment (BDE-28, ∑5BDE), and emotional symptoms (BDE-28). Gestational PBDE concentrations were positively associated with caregiver-reported BASC3 composite indices for externalizing problems (BDE-28, -47, -99, -100, -153, ∑5BDE) and behavioral symptoms (BDE-99). For caregiver reported behaviors, we observed stronger associations with gestational BDE concentrations among males, especially for executive functioning (BDE-28, -47, -99, -100, ∑5BDE). DISCUSSION: Gestational PBDE serum concentrations were associated with self-reported internalizing and externalizing behavior problems in early adolescence. Caregiver-reported externalizing behaviors recognized during childhood remain associated with gestational PBDE concentrations and persist into early adolescence. Internalizing behaviors were less recognized by caregivers.

Assessment of indoor bioaerosol exposure using direct-reading versus traditional methods-potential application to home health care.

Home healthcare workers (HHCWs) can be occupationally exposed to bioaerosols in their clients' homes. However, choosing the appropriate method to measure bioaerosol exposures remains a challenge. Therefore, a systematic comparison of existing measurement approaches is essential. Bioaerosol measurements with a real-time, fluorescence-based Wideband Integrated Bioaerosol Sensor (WIBS) were compared to measurements with four traditional off-line methods (TOLMs). The TOLMS included optical microscopic counting of spore trap samples, microbial cultivation of impactor samples, qPCR, and next-generation sequencing (NGS) of filter samples. Measurements were conducted in an occupied apartment simulating the environments that HHCWs could encounter in their patients' homes. Descriptive statistics and Spearman's correlation test were computed to compare the real-time measurement with those of each TOLM. The results showed that the geometric mean number concentrations of the total fluorescent aerosol particles (TFAPs) detected with the WIBS were several orders of magnitude higher than those of total fungi or bacteria measured with the TOLMs. Among the TOLMs, concentrations obtained with qPCR and NGS were the closest to the WIBS detections. Correlations between the results obtained with the WIBS and TOLMs were not consistent. No correlation was found between the concentrations of fungi detected using microscopic counting and any of the WIBS fluorescent aerosol particle (FAP) types, either indoors or outdoors. In contrast, the total concentrations detected with microbial cultivation correlated with the WIBS TFAP results, both indoors and outdoors. Outdoors, the total concentration of culturable bacteria correlated with FAP-type AC. In addition, fungal and bacterial concentrations obtained with qPCR correlated with FAP types AB and AC. For a continuous, high-time resolution but broad scope, the real-time WIBS could be considered, whereas a TOLM would be the best choice for specific and more accurate microbial characterization. HHCWs' activities tend to re-aerosolize bioaerosols causing wide temporal variation in bioparticle concentrations. Thus, the advantage of using the real-time instrument is to capture those variations. This study lays a foundation for future exposure assessment studies targeting HHCWs.

Investigating and Treating a Corneal Ulcer Due to Extensively Drug-Resistant Pseudomonas aeruginosa.

Resistant Gram-negative bacteria are a growing concern in the United States, leading to significant morbidity and mortality. We identified a 72-year-old female patient who presented with unilateral vision loss. She was found to have a large corneal ulcer with hypopyon. Culture of corneal scrapings grew extensively drug-resistant Pseudomonas aeruginosa. Treatment involved a combination of systemic and topical antibiotics. Whole genome sequencing revealed the presence of blaVIM-80, blaGES-9, and other resistance determinants. This distinctive organism was linked to an over-the-counter artificial tears product.

Suction drainage in total knee replacement does not influence early functional outcomes or blood loss: a randomized control trial.

INTRODUCTION: The use of wound drainage following total knee arthroplasty (TKA) remains controversial. The purpose of this study was to evaluate the impact of suction drainage on early postoperative outcomes in patients who underwent TKA with concomitant administration of intravenous tranexamic acid (TXA). METHOD: One hundred forty-six patients undergoing primary TKA with systematic intravenous TXA were prospectively selected and randomly divided into two groups. The first "Study group" (n = 67) received no suction drain and the second "Control" group (n = 79) had a suction drain. Perioperative hemoglobin levels, blood loss, complications, and length of hospital stay were assessed in both groups. Preoperative and postoperative range of motion and Knee Injury and Osteoarthritis Outcome Scores (KOOS) were also compared at a 6-week follow-up. RESULTS: The study group was found to have higher hemoglobin levels preoperatively and during the first two days following surgery, and no difference was found between the groups on the third day. No significant discrepancies at any time were found between groups in terms of blood loss, length of hospitalization, knee range of motion, and KOOS score. Complications requiring further treatment were observed in one patient from the study group and ten patients from the control group. CONCLUSION: The use of suction drains after TKA with TXA did not alter early postoperative outcomes.

Evaluation of academic detailing to educate clinicians regarding childhood lead poisoning prevention: a pilot study.

CONTEXT: Environmental exposures are associated with approximately 19% of disease globally, and exposure to neurotoxic chemicals is estimated to cost the United States $50 billion per year. Despite calls from the Institute of Medicine to increase training for clinicians regarding environmental health since the 1990s, there is still little instruction in environmental health for clinicians. This leaves gaps in knowledge that need to be bridged through outreach and education to practicing clinicians. Academic detailing (AD) is an educational intervention associated with improved prescribing practices in healthcare professionals but has not been applied to preventive or environmental health. Childhood lead exposure is a common condition associated with lifetime increased risk of cognitive and behavioral problems. Ohio has more than 2 million homes built before 1978, making exposure to lead-based paint a significant public health problem; however, only 50% of high-risk children are tested for lead. Few receive health promotion information regarding lead poisoning prevention, in part because this is not a part of training for healthcare providers (HCPs). OBJECTIVES: The objectives of this study were twofold: (1) implement a pilot of AD sessions on the topic of childhood lead poisoning prevention with frontline HCPs and their staff in different practice settings; and (2) evaluate the acceptability of these training sessions utilizing quantitative and qualitative methods. METHODS: Physicians, nurses, social workers, community health workers, and clinical office staff were recruited from clinics who care for children at high risk for lead exposure. Trainings consisting of small group AD style sessions were presented at these sites. Learning objectives included increasing knowledge regarding lead testing requirements, enabling identification of lead's impact on child development and equipping participants to provide anticipatory guidance for parents regarding lead poisoning prevention. Participants provided feedback through an anonymous questionnaire and qualitative feedback. RESULTS: There were 46 participants (12 physicians in practice/in training, 21 nursing or office staff, and 13 community health or social workers); more than 90% of the participants reported that the training achieved its learning objectives. Small-group presentations were preferred (91%); approximately 39% of participants requested an online format. Participants preferred that the presenters be either a public health or lead clinical expert, and they suggested that future activities include clinical vignettes. CONCLUSIONS: Academic-detailing style training shows promise in promoting childhood lead poisoning prevention for frontline HCPs.

Assessing residential indoor and outdoor bioaerosol characteristics using the ultraviolet light-induced fluorescence-based wideband integrated bioaerosol sensor.

We assessed and compared indoor and outdoor residential aerosol particles in a third-floor apartment from August through September 2020. The measurements were conducted using a direct-reading ultraviolet light-induced fluorescence (UV-LIF) wideband integrated bioaerosol spectrometer (WIBS). It measures individual particle light scattering and fluorescence from which particle properties can be derived. The number concentrations of total aerosol particles (TAP) and total fluorescent aerosol particles (TFAP) were significantly higher indoors. Daily and hourly TFAP mean concentrations followed the same trends as the TAP, both indoors and outdoors. The daily mean rank of the TFAP fraction (TFAP/TAP) was significantly higher indoors (23%) than outdoors (19%). Particles representing bacteria dominated indoors while particles representing fungi and pollen dominated outdoors. The mean volume-weighted median diameters for TFAP were 1.67 µm indoors and 2.09 µm outdoors. Higher TFAP fraction indoors was likely due to occupants' activities that generated or resuspended particles. This study contributes to understanding the characteristics of residential aerosol particles in situations when occupants spend most of their time indoors. Based on our findings, a large portion of all indoor aerosol particles could be biological (15-20%) and of respirable particle size (≥95%). Using a novel direct reading UV-LIF-based sensor can help quickly assess aerosol exposures relevant to human health.

Spinal Metastasis in Multiple Primary Malignancies Involving Lung Cancer: Clinical Characteristics and Survival.

OBJECTIVE: The incidence of multiple primary malignancies (MPM) has increased in recent decades. Our aim was to evaluate incidence, clinical features, and survival in cases of spinal metastases from MPM in which one of the malignancies is lung cancer. METHODS: We retrospectively reviewed an institutional database of lung cancer patients with spinal metastasis and extracted all cases of MPM. RESULTS: Among 275 patients who had spinal metastasis with lung cancer as one of the diagnoses, 21 (7.6%) patients with MPM were identified. Mean patient age was 68.5 years (95% confidence interval [CI], 65.3-71.7). The most common cancers diagnosed in addition to lung cancer were breast cancer (5 patients, 24%), upper aerodigestive tract cancer (4 patients, 19%), and prostate cancer (4 patients, 19%). Eighteen (86%) patients walked independently, and 3 (14%) patients walked with help. Seventeen (80.9%) patients had a good Karnofsky performance scale score. The median survivals from the date of first cancer diagnosis, last cancer diagnosis, and spinal metastasis diagnosis were 109.8 months (95% CI, 23.5-196.1), 17.8 months (95% CI, 5.8-29.8), and 10.3 months (95% CI, 5.4-15.2), respectively. Actual rates of survival at 6 months, 12 months, and 24 months from the date of spinal metastasis diagnosis were 81%, 42.9%, and 23.8%, respectively. CONCLUSIONS: The present study is the first series to our knowledge to show that survival of patients with spinal metastasis and MPM involving lung cancer is not clearly inferior to that of patients with spinal metastasis and lung cancer alone.

Use of IMMPACT Recommendations to Explore Pain Phenotypes in People with Knee Osteoarthritis.

OBJECTIVE: Knee osteoarthritis (OA) is a disease of multiple phenotypes of which a chronic pain phenotype (PP) is known. Previous PP studies have focused on one domain of pain and included heterogenous variables. We sought to identify multidimensional PPs using the IMMPACT recommendations and their relationship to clinical outcomes. METHODS: Participants >40 years of age with knee OA having a first-time orthopedic consultation at five university affiliated hospitals in Montreal, Quebec, and Hamilton (Canada) were recruited. Latent profile analysis was used to determine PPs (classes) using variables recommended by IMMPACT. This included pain variability, intensity and qualities, somatization, anxiodepressive symptoms, sleep, fatigue, pain catastrophizing, neuropathic pain, and quantitative sensory tests. We used MANOVA and χ2 tests to assess differences in participant characteristics across the classes and linear and Poisson regression to evaluate the association of classes to outcomes of physical performance tests, self-reported function and provincial healthcare data. RESULTS: In total, 343 participants were included (mean age 64 years, 64% female). Three classes were identified with increasing pain burden (class3 > class1), characterized by significant differences across most self-report measures and temporal summation, and differed in terms of female sex, younger age, lower optimism and pain self-efficacy. Participants in class2 and class3 had significantly worse self-reported function, stair climb and 40 m walk tests, and higher rates of healthcare usage compared to those in class1. CONCLUSIONS: Three distinct PPs guided by IMMPACT recommendations were identified, predominated by self-report measures and temporal summation. Using this standardized approach may improve PP study variability and comparison.

Gestational exposure to polybrominated diphenyl ethers and social skills and problem behaviors in adolescents: The HOME study.

BACKGROUND: Polybrominated diphenyl ethers (PBDEs) are persistent environmental pollutants used as flame retardants. Gestational PBDE exposure has been associated with a variety of behavior problems in children, but little is known about its impact into adolescence, particularly on social skills, which are important for achieving social competence, establishing identity, and forming lasting relationships. OBJECTIVE: We investigated associations between gestational exposure to PBDEs and social skills and problem behaviors in early adolescence in a longitudinal pregnancy and birth cohort in Cincinnati, Ohio (recruited 2003-2006). METHODS: We measured maternal serum concentrations of five PBDE congeners during gestation. At age 12, we measured social skills and problem behaviors scores for 243 adolescents using self- and caregiver-report on the Social Skills Improvement System (SSiS). We used multivariable linear regression models to estimate associations between maternal PBDE concentrations and SSiS scores, controlling for potential covariates. We report associations for the five congeners and a summary exposure variable (∑5BDE: the sum of BDE- 28, 47, 99, 100, and 153, n = 197). RESULTS: We found sex-specific associations of ∑5BDE concentrations with adolescent-reported Problem Behaviors (∑5BDE × sex pint = 0.02) and caregiver-reported Social Skills (∑5BDE × sex pint = 0.02). In sex-stratified models, log10 transformed data revealed increased maternal ∑5BDE concentration among males was associated with decreased caregiver-reported Social Skills composite score (ß = -10.2, 95% CI: -19.5, -1.0), increased adolescent-reported Problem Behaviors composite score (ß = 12.1, 95% CI: 5.4, 18.8), and increased caregiver-reported Problem Behaviors composite score (ß = 6.2, 95% CI: 0.7, 11.7). Further analysis on SSiS subscales revealed similar patterns in significant associations among males. There were no statistically significant associations in stratified models among females despite higher ∑5BDE exposure (Female GM=40.15 ng/g lipid, GSE=1.10; Male GM=35.30 ng/g lipid, GSE=1.09). DISCUSSION: We found gestational PBDE exposure in males was associated with poorer behavioral outcomes, extending previous findings among this cohort into early adolescence.

Does the Region of the Spine Involved with Metastatic Tumor Affect Outcomes of Surgical Treatments?

OBJECTIVE: Spinal metastases occur primarily in the thoracic spine (50%-60%), less commonly in the lumbar (30%-35%), and, infrequently, in the cervical spine (10%-15%). There has been only 1 study with a limited population comparing the postoperative outcome among cervical, thoracic, and lumbar spine metastasis. The aim of this study is to identify whether the region of surgically treated spinal metastasis affects postoperative outcomes. METHODS: A retrospective study of patients with spinal metastasis was performed. The collected data were as follows: age, gender, smoking history, tumor histology, revised Tokuhashi score, preoperative and postoperative American Spinal Injury Association score, region of spinal metastasis, ambulatory status, surgical approach, surgery time, blood loss, complications, length of hospital stay, postoperative pain relief, postoperative adjuvant therapy, and survival. Data were analyzed to identify the factors affecting the survival and postoperative functional outcome. RESULTS: We studied 191 patients with spinal metastasis including 47 cervical spine metastases, 96 thoracic spine metastases, and 48 lumbar spine metastases, with a mean age of 60.91 ± 9.72 years. The overall median survival was 7 months (95% confidence interval, 2.9-20.63 months). Univariate analysis showed that region of the spine involved with metastasis did not significantly affect the survival and postoperative motor function improvement. Multivariate analysis showed that revised Tokuhashi score, postoperative radiotherapy, and postoperative chemotherapy were independent factors affecting survival. The rate of 30-day complications among patients with different regions of spine metastasis did not reach significance. CONCLUSIONS: The postoperative outcomes of patients undergoing surgery for metastases are not affected by the region of the spine.

Comparing adolescent self staging of pubertal development with hormone biomarkers.

OBJECTIVES: Physical examinations to characterize pubertal maturation may be unacceptable for children enrolled in research studies. Studies confirm the utility of pubertal self staging for research, but there has been limited comparison of self examination with hormone biomarkers. Our objective was to assess concordance of pubertal self staging with hormone biomarkers of puberty. METHODS: Participants were enrolled in the Health Outcomes and Measures of the Environment Study, a longitudinal pregnancy and birth cohort study. At age 12 years, 139 females and 112 males completed pubertal self staging including breast and pubic hair development in females and pubic hair development in males. No clinical physical examination was performed. Hormone concentrations were measured in 102 females and 96 males including serum dehydroepiandrosterone sulfate, luteinizing hormone, and follicle-stimulating hormone in all; estradiol in females; and testosterone in males. RESULTS: Estradiol was significantly associated with female breast stage, even when adjusted for BMI, with geometric least squares means (95%CI) of 13.2 (8.7, 20.2), 38.3 (29.9, 49.1), 59.4 (39.8, 88.6), and 81.2 (45.6, 144) pg/mL for breast stage 1-2, 3, 4, and 5, respectively. Testosterone was significantly associated with male pubic hair stage, with adjusted geometric least squares means (95%CI) of 37.6 (19.9, 71.1), 43.4 (27.7, 68.3), 126 (78.4, 203), 275 (146, 521), and 559 (237, 1319) ng/dL for pubic hair stage 1, 2, 3, 4, and 5, respectively. CONCLUSIONS: Self assessed pubertal development was positively associated with hormonal biomarkers of puberty.

Identifying sensitive windows of airborne lead exposure associated with behavioral outcomes at age 12.

Despite the precipitous decline of airborne lead concentrations following the removal of lead in gasoline, lead is still detectable in ambient air in most urban areas. Few studies, however, have examined the health effects of contemporary airborne lead concentrations in children. METHODS: We estimated monthly air lead exposure among 263 children (Cincinnati Childhood Allergy and Air Pollution Study; Cincinnati, OH; 2001-2005) using temporally scaled predictions from a validated land use model and assessed neurobehavioral outcomes at age 12 years using the parent-completed Behavioral Assessment System for Children, 2nd edition. We used distributed lag models to estimate the effect of airborne lead exposure on behavioral outcomes while adjusting for potential confounding by maternal education, community-level deprivation, blood lead concentrations, greenspace, and traffic related air pollution. RESULTS: We identified sensitive windows during mid- and late childhood for increased anxiety and atypicality scores, whereas sensitive windows for increased aggression and attention problems were identified immediately following birth. The strongest effect was at age 12, where a 1 ng/m3 increase in airborne lead exposure was associated with a 3.1-point (95% confidence interval: 0.4, 5.7) increase in anxiety scores. No sensitive windows were identified for depression, somatization, conduct problems, hyperactivity, or withdrawal behaviors. CONCLUSIONS: We observed associations between exposure to airborne lead concentrations and poor behavioral outcomes at concentrations 10 times lower than the National Ambient Air Quality Standards set by the US Environmental Protection Agency.

Evaluation of a Program to Reduce Home Environment Risks for Children with Asthma Residing in Urban Areas.

Pediatric asthma morbidity is often linked to challenges including poor housing quality, inability to access proper medical care, lack of medications, and poor adherence to medical regimens. Such factors also propagate known disparities, by race and income, in asthma-related outcomes. Multimodal home visits have an established evidence base in support of their use to improve such outcomes. The Collaboration to Lessen Environmental Asthma Risks (CLEAR) is a partnership between the Cincinnati Children's Hospital Medical Center and the local health department which carries out home visits to provide healthy homes education and write orders for remediation should code violations and environmental asthma triggers be identified. To assess the strengths and weaknesses of the program, we obtained qualitative feedback from health professionals and mothers of children recently hospitalized with asthma using key informant interviews. Health professionals viewed the program as a positive support system for families and highlighted the potential benefit of education on home asthma triggers and connecting families with services for home improvements. Mothers report working to correct asthma triggers in the home based on the education they received during the course of their child's recent illness. Some mothers indicated mistrust of the health department staff completing home visits, indicating a further need for research to identify the sources of this mistrust. Overall, the interviews provided insights into successful areas of the program and areas for program improvement.

Residential dust lead levels and the risk of childhood lead poisoning in United States children.

BACKGROUND: The United States Environmental Protection Agency (EPA) recently lowered residential floor and windowsill dust lead hazard standards, but maintained previous post-abatement clearance standards. We examined whether the discrepancy in these regulations places children at higher risk of lead poisoning. METHODS: In 250 children from Cincinnati, Ohio (2004-2008) living in homes built before 1978, we measured residential floor and windowsill dust lead loadings and blood lead concentrations at ages 1 and 2 years. Using linear regression with generalized estimating equations, we estimated covariate-adjusted associations of dust lead levels with blood lead concentrations and risk of lead poisoning. RESULTS: An increase in floor dust lead from 10 (revised dust lead hazard standard) to 40 µg/ft2 (post-abatement clearance standard) was associated with 26% higher (95% confidence interval (CI):15, 38) blood lead concentrations and 2.1 times the risk of blood lead concentrations ≥5 µg/dL (95% CI: 1.44, 3.06). Extrapolating our findings to US children age 1-5 years, we estimated that 6.9% (95% CI: 1.5, 17.2) of cases of blood lead concentrations ≥5 µg/dL are attributable to floor dust lead loadings between 10 and ≤40 µg/ft2. CONCLUSIONS: The EPA's residential dust lead regulations place children at increased risk of lead poisoning. We recommend adopting more protective dust lead standards. IMPACT: We determined whether children are at increased risk of lead poisoning with the 2019 EPA residential post-abatement lead clearance standards being higher than dust lead hazard standards. In this observational study, 2019 EPA dust lead clearance standards were associated with increased risk of lead poisoning compared to the revised dust lead hazard standard. Both EPA standards were associated with increased risk of lead poisoning compared to more stringent standards employed in our study. Extrapolating our findings to US children, the 2019 EPA dust lead clearance standards could place up to 36,700 children at risk of lead poisoning.

Severe acitretin-induced diffuse idiopathic skeletal hyperostosis: a case report.

Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier-Rotes-Querol disease, is a systemic noninflammatory disease characterized by ossification of the entheses. DISH predominantly affects the spine. Although peripheral involvement is also often reported, it rarely affects patients' function. A 77-year-old man presented to our emergency department because of incapacitating pain and stiffness in the spine and hips. The patient had been diagnosed with biopsy-proven mycosis fungoides 3 years earlier and had been treated with oral acitretin at 25 to 50 mg daily since diagnosis. However, the patient gradually developed a severely limited range of motion in his spine and hips (left > right), significantly impairing his mobility and activities of daily living. Cervical and dorsolumbar radiographs showed extensive ossification along the anterior longitudinal ligament; this finding was compatible with DISH and had not been present in radiographs taken 3 years earlier. Pelvic radiographs showed multiple enthesophytes predominantly around the coxofemoral joints. DISH has been reported as a possible long-term adverse effect of acitretin. Despite optimal conservative treatment, the patient remained severely impaired and thus finally underwent extensive osteophyte excision and total hip replacement on the left side. His acitretin therapy was also stopped to prevent further progression of his DISH.

HEPA filtration improves asthma control in children exposed to traffic-related airborne particles.

Traffic-related airborne particles are associated with asthma morbidity. The aim of this study was to assess the impact of a high-efficiency particulate air (HEPA) filtration on the concentrations of traffic particles and the resultant effect on children with asthma. Forty-three children with asthma were enrolled in this double-blind, placebo-controlled crossover design. A HEPA air cleaner or a placebo "dummy" was placed in participants' homes for four weeks, interrupted by a one-month washout period, before crossing over to the other treatment arm for four weeks. Air sampling and health outcomes, including asthma control (ACQ) and quality of life (AQLQ) measures, were completed prior to and at the end of each treatment arm. Indoor concentrations of traffic particles were significantly reduced with the HEPA treatment but not with the "dummy" treatment. In participants with poorly controlled asthma and lower quality of life at baseline, ACQ and AQLQ scores were significantly improved (1.3 to 0.9, P = .003 and 4.9 to 5.5, P = .02, respectively) following the HEPA treatment. In this study, HEPA filtration is associated with improved clinical outcomes and quality of life measures in children with uncontrolled asthma.

Standardizing Clinical Response to Results of Lead Screening: A Quality Improvement Study.

BACKGROUND AND OBJECTIVES: Lead exposure remains common and is associated with adverse intellectual and behavioral outcomes. Despite quality improvement used to increase screening rates, clinical response to elevated lead levels remains variable. Our aim was to increase provider adherence to published guidelines for addressing elevated lead levels. METHODS: We created a protocol for addressing elevated lead levels on the basis of published guidelines. The protocol included ordering multivitamins with iron and follow-up lead testing, educating families about identifying and reducing sources of lead exposure, and referring to a specialty environmental health clinic when indicated. We used quality improvement methods to increase provider adherence to the protocol in a large, academic primary care center among patients 9 to 27 months old. The outcome measure was the percentage of elevated lead levels for which providers adhered to all elements of the protocol. This measure was plotted on a control chart. Statistical process control was used to determine a significant change to system performance. RESULTS: Adherence to the protocol rose from 5% to 90%. Key interventions included decision support in the e-health records and weekly review of reports of lead levels. These interventions were supported by staffing adjustments and individualized feedback to create accountability. CONCLUSIONS: Simple process changes dramatically improved adherence to complex guidelines for addressing lead exposure in primary care. These changes could be used to similarly standardize clinical responses to other screens.

Indoor particulate matter and lung function in children.

People generally spend more time indoors than outdoors resulting in a higher proportion of exposure to particulate matter (PM) occurring indoors. Consequently, indoor PM levels, in contrast to outdoor PM levels, may have a stronger relationship with lung function. To test this hypothesis, indoor and outdoor PM2.5 and fungal spore data were simultaneously collected from the homes of forty-four asthmatic children aged 10-16 years. An optical absorption technique was utilized on the collected PM2.5 mass to obtain concentrations of black carbon (BC) and ultraviolet light absorbing particulate matter, (UVPM; a marker of light absorbing PM2.5 emitted from smoldering organics). Enrolled children completed spirometry after environmental measurements were made. Given the high correlation between PM2.5, BC, and UVPM, principal component analysis was used to obtain uncorrelated summaries of the measured PM. Separate linear mixed-effect models were developed to estimate the association between principal components of the PM variables and spirometry values, as well as the uncorrelated original PM variables and spirometry values. A one-unit increase in the first principal component variable representing indoor PM (predominantly composed of UVPM and PM2.5) was associated with 4.1% decrease (99% CI = -6.9, -1.4) in FEV1/FVC ratio. 11.3 µg/m3 increase in indoor UVPM was associated with 6.4% and 14.7% decrease (99% CI = -10.4, -2.4 and 99% CI = -26.3, -2.9, respectively) in percent predicted FEV1/FVC ratio and FEF25-75 respectively. Additionally, 17.7 µg/m3 increase in indoor PM2.5 was associated with 6.1% and 12.9% decrease (99% CI = -10.2, -1.9 and 99% CI = -24.9, -1.0, respectively) in percent predicted FEV1/FVC ratio and FEF25-75, respectively. Outdoor PM, indoor BC, and indoor fungal spores were not significantly associated with lung function. The results indicate that indoor PM is more strongly associated with lung function in children with asthma as compared with outdoor PM.

The feasibility of an inter-professional transitions of care service in an older adult population.

BACKGROUND: Older adults discharged from the Emergency Department (ED) are at high risk for medication interactions and side effects; examples of practice models addressing this transition of care are lacking. METHODS: This was a prospective cohort study for adults in one of two urban community EDs. Patients ≥50 years of age discharged with at least one new, non-schedule II prescription medication were included. Patients had the option of three transitions of care services: 1) pharmacist-only with home delivery of discharge medications and full medication reconciliation, 2) pharmacist and home health care, including home delivery, medication reconciliation, and a visit from a home health nurse, or 3) either of the above without home delivery. RESULTS: Over seven months, 440 ED patients were screened. Of those, 43 patients were eligible, and three patients elected to join the study. All three patients selected pharmacy-only. Identified barriers to enrollment include the rate of schedule II prescriptions from the ED (53% of potential patients) and high patient loyalty to their community pharmacist. CONCLUSIONS: A pharmacy and home health care transitions of care program was not feasible at an urban community ED. While the pharmacist team identified and managed multiple medication issues, most patients did not qualify due to prescriptions ineligible for delivery. Patients did not want pharmacist or home health nurse involvement in their post ED visit care, many due to loyalty to their community pharmacy. Multiple barriers must be addressed to create a successful inter-professional transition of care model.