A task-based assessment of parental occupational exposure to pesticides and childhood acute lymphoblastic leukemia.

OBJECTIVES: Associations between parental occupational pesticide exposure and childhood acute lymphoblastic leukemia (ALL) vary across studies, likely due to different exposure assessment methodologies. METHODS: We assessed parental occupational pesticide exposure from the year before pregnancy to the child's third year of life for 669 children diagnosed with ALL and 1021 controls. We conducted expert rating using task-based job modules (JM) to estimate exposure to pesticides among farmer workers, gardeners, agricultural packers, and pesticide applicators. We compared this method to (1) partial JM using job titles and a brief description, but without completing the task-based questionnaire, and (2) job exposure matrix (JEM) linking job titles to the International Standard Classifications of Occupation Codes. We used unconditional logistic regression to calculate odds ratios (OR) and 95% confidence intervals (95% CI) for ALL cancer risk and pesticide exposure adjusting for child's sex, age, race/ethnicity and household income. RESULTS: Compared to complete JMs, partial JMs and JEM led to 3.1% and 9.4% of parents with pesticide exposure misclassified, respectively. Misclassification was similar in cases and controls. Using complete JMs, we observed an increased risk of ALL for paternal occupational exposure to any pesticides (OR=1.7; 95% CI=1.2, 2.5), with higher risks reported for pesticides to treat nut crops (OR=4.5; 95% CI=0.9, 23.0), and for children diagnosed before five years of age (OR=2.3; 95% CI: 1.3, 4.1). Exposure misclassification from JEM attenuated these associations by about 57%. Maternal occupational pesticide exposure before and after birth was not associated with ALL. CONCLUSIONS: The risk of ALL was elevated in young children with paternal occupational pesticide exposure during the perinatal period, using more detailed occupational information for exposure classification.

A task-based assessment of parental occupational exposure to organic solvents and other compounds and the risk of childhood leukemia in California.

PURPOSE: Data on parental occupational exposures and risk of childhood leukemia lack specificity. Using 19 task-based job modules, we examined the relationship between occupational exposure to organic solvents and other compounds and the risk of leukemia in children. METHODS: Latino (48%) and non-Latino (52%) children with acute lymphoblastic leukemia (ALL; n=670), acute myeloid leukemia (AML; n=104), and controls (n=1021) were enrolled in a study in California (2000-2008). Logistic regression models were used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs), adjusted for socio-demographic factors. RESULTS: Among children with non-Latino fathers, none of the exposures evaluated were associated with risks of ALL and AML. In contrast, exposure to any organic solvents in Latino fathers was associated with an increased risk of childhood ALL (OR=1.48; 95% CI: 1.01-2.16); in multivariable analyses, the OR for chlorinated hydrocarbons was 2.28 (95% CI: 0.97-5.37) while the ORs were close to one for aromatic hydrocarbons, glycol ethers, and other hydrocarbon mixtures. We also observed an increased risk of ALL with exposure to combustion exhaust/polycyclic aromatic hydrocarbons (PAHs) (ORs=1.70; 95% CI: 1.16-2.57, and 1.46; 95% CI: 0.94-2.26 with and without adjustment for chlorinated hydrocarbons, respectively). Moderately elevated risks of ALL were seen with exposure to metals, paints, and wood dust, although not statistically significant. An increased risk was reported for asbestos based on small numbers of exposed Latino fathers. No associations were reported between maternal exposures to any exposures and childhood ALL and AML. CONCLUSIONS: Our data support associations between paternal occupational exposures to chlorinated hydrocarbons, combustion exhaust, metals, and possibly asbestos and the risk of ALL in the children of Latino fathers only.

Annual average ambient particulate matter exposure estimates, measured home particulate matter, and hair nicotine are associated with respiratory outcomes in adults with asthma.

BACKGROUND: While exposure to outdoor particulate matter (PM) has been associated with poor asthma outcomes, few studies have investigated the combined effects of outdoor and indoor PM (including secondhand tobacco smoke). OBJECTIVE: To examine the associations between PM and asthma outcomes. METHODS: We analyzed data from a cohort of adults with asthma and rhinitis (n=302; 82% both conditions; 13% asthma only; 5% rhinitis alone) including measures of home PM, tobacco smoke exposure (hair nicotine and self-report), ambient PM from regional monitoring, distance to roadway, and season (wet or dry). The outcomes of interest were frequent respiratory symptoms and forced expiratory volume in 1 second (FEV1) below the lower limit of normal (NHANES reference values). Multivariable regression analyses examined the associations (Odds Ratio [OR] and 95% Confidence Interval [95%CI]) between exposures and these outcomes, adjusted by sociodemographic characteristics. RESULTS: In adjusted analyses of each exposure, the highest tertile of home PM and season of interview were associated with increased odds for more frequent respiratory symptoms (OR=1.64 95%CI: [1.00, 2.69] and OR=1.66 95%CI: [1.09, 2.51]). The highest tertile of hair nicotine was significantly associated with FEV1 below the lower limit of normal (OR=1.80 95%CI: [1.00, 3.25]). In a model including home PM, ambient PM, hair nicotine, and season, only two associations remained strong: hair nicotine with FEV1 below the lower limit of normal and season of measurement (dry, April-October) with increased respiratory symptoms (OR=1.85 95%CI: [1.00, 3.41] and OR=1.54 95%CI: [1.0, 2.37]). When that model was stratified by sex, the highest tertiles of ambient PM and hair nicotine were associated with FEV1 below the lower limit of normal among women (OR=2.23 95%CI: [1.08, 4.61] and OR=2.90 95%CI: [1.32, 6.38]), but not men. The highest tertile of hair nicotine was also associated with increased respiratory symptoms in women but not men (OR=2.38 95%CI: [1.26, 4.49]). When stratified by age, the middle quartile of ambient PM and the highest hair nicotine tertile were associated with increased respiratory symptoms (OR=2.07 95%CI: [1.01, 4.24] and OR=2.55 95%CI: [1.21, 5.36]) in those under 55 but not in the older stratum. CONCLUSIONS: Exposure to PM from both home and ambient sources is associated with increased symptoms and lower lung function in adults with asthma, although these associations vary by type of PM, the respiratory outcome studied, sex and age.

Solvent exposures and Parkinson disease risk in twins.

OBJECTIVE: Several case reports have linked solvent exposure to Parkinson disease (PD), but few studies have assessed associations with specific agents using an analytic epidemiologic design. We tested the hypothesis that exposure to specific solvents is associated with PD risk using a discordant twin pair design. METHODS: Ninety-nine twin pairs discordant for PD ascertained from the National Academy of Sciences/National Research Council World War II Veteran Twins Cohort were interviewed regarding lifetime occupations and hobbies using detailed job task-specific questionnaires. Exposures to 6 specific solvents selected a priori were estimated by expert raters unaware of case status. RESULTS: Ever exposure to trichloroethylene (TCE) was associated with significantly increased risk of PD (odds ratio [OR], 6.1; 95% confidence interval [CI] 1.2-33; p = 0.034), and exposure to perchloroethylene (PERC) and carbon tetrachloride (CCl(4) ) tended toward significance (respectively: OR, 10.5; 95% CI, 0.97-113; p = 0.053; OR, 2.3; 95% CI, 0.9-6.1; p = 0.088). Results were similar for estimates of exposure duration and cumulative lifetime exposure. INTERPRETATION: Exposure to specific solvents may increase risk of PD. TCE is the most common organic contaminant in groundwater, and PERC and CCl(4) are also ubiquitous in the environment. Our findings require replication in other populations with well-characterized exposures, but the potential public health implications are substantial.

Fungal chitin from asthma-associated home environments induces eosinophilic lung infiltration.

Development of asthma and allergic inflammation involves innate immunity, but the environmental contributions remain incompletely defined. Analysis of dust collected from the homes of asthmatic individuals revealed that the polysaccharide chitin is environmentally widespread and associated with ß-glucans, possibly from ubiquitous fungi. Cell wall preparations of Aspergillus isolated from house dust induced robust recruitment of eosinophils into mouse lung, an effect that was attenuated by enzymatic degradation of cell wall chitin and ß-glucans. Mice expressing constitutively active acidic mammalian chitinase in the lungs demonstrated a significant reduction in eosinophil infiltration after fungal challenge. Conversely, chitinase inhibition prolonged the duration of tissue eosinophilia. Thus, fungal chitin derived from home environments associated with asthma induces eosinophilic allergic inflammation in the lung, and mammalian chitinases, including acidic mammalian chitinase, limit this process.

Higher environmental relative moldiness index values measured in homes of adults with asthma, rhinitis, or both conditions.

Higher values of the environmental relative moldiness index (ERMI), a DNA-based method for quantifying indoor molds, have been associated with asthma in children. In this study, settled dust samples were collected from the homes of adults with asthma, rhinitis, or both conditions (n=139 homes) in Northern California. The ERMI values for these samples were compared to those from dust collected in homes from the same geographic region randomly selected as part of the 2006 American Healthy Home Survey (n=44). The median ERMI value in homes of adult with airway disease (6) was significantly greater than median ERMI value (2) in the randomly selected homes (p<0.0001). In this study in Northern California, the homes of adults with asthma had ERMI values consistent with a heavier burden of indoor mold than that measured in other homes from the same region.

Spine Surgery Patients' Perceptions of Postoperative Pulmonary Complications.

Postoperative pulmonary complications (PPCs) are associated with poor patient outcomes, increased costs and prolonged hospitalizations. Incentive spirometry (IS) reduces PPC incidence, but patient IS adherence is often suboptimal. Thus, the purpose of this study was to explore patients' beliefs about, and knowledge of PPCs and IS. We observed IS technique and conducted interviews guided by qualitative descriptive methodologies and the Health Belief Model. Verbatim transcripts of interviews were analyzed using inductive and deductive content analytic methods. Twenty postoperative spinal surgery patients at a single tertiary hospital were enrolled. Five categories related to PPC and IS beliefs and knowledge were identified: (1) social support, (2) preventing a PPC, (3) learning about PPCs, (4) reminders, and (5) lack of IS knowledge. Understanding why patients do not adhere to IS protocols is crucial for minimizing the risk of iatrogenic PPCs and developing strategies to improve adherence to IS.

COVID-19-A Qualitative Orthopaedic Nurse Perspective.

In response to a March 2020, New York State mandate, our elective surgery center began a physical and operational transformation to provide inpatient care to COVID-19 patients. Research study aims included (1) a description of the orthopaedic nurses' experience during the pandemic, and (2) tactics used to cope with related stress. Researchers used a descriptive, qualitative design to achieve study aims. During April to December 2020, nine nurses responded to seven open-ended, study prompts asking them to journal their thoughts about the pandemic. The majority (66%) of participants were experienced nurses and all provided direct patient care. Nurses provided 51 journal entries that generated 12 themes, which encapsulated their experience living through the pandemic: (1) Whirlwind, (2) War, (3) Control, (4) Death and Dying, (5) Staying Safe, (6) Loss, (7) Looking for Meaning, (8) Whatever It Takes, (9) Adaptability and Resilience, (10) What I Have Learned, (11) The New Normal, and (12) When Will This Be Over? Orthopaedic nurses in this study pivoted to the needs of patients requiring them to draw on all their training and resources. Nurses described the enormity and taxing nature of the viral threat and their ability to manage their well-being while caring for patients and loved ones, amidst social distancing and need for aggressive infection control. Support from peers and leadership were paramount factors in nurse coping. Positive thinking and personal resilience were considered essential. Most participants described personal growth; however, decreased participation in journal responses overtime, suggested emotional strain. Future studies should examine nurses' observations about the impact of changes to their practice brought on by the pandemic, and reliance on technology.

An integrated model of environmental factors in adult asthma lung function and disease severity: a cross-sectional study.

BACKGROUND: Diverse environmental exposures, studied separately, have been linked to health outcomes in adult asthma, but integrated multi-factorial effects have not been modeled. We sought to evaluate the contribution of combined social and physical environmental exposures to adult asthma lung function and disease severity. METHODS: Data on 176 subjects with asthma and/or rhinitis were collected via telephone interviews for sociodemographic factors and asthma severity (scored on a 0-28 point range). Dust, indoor air quality, antigen-specific IgE antibodies, and lung function (percent predicted FEV1) were assessed through home visits. Neighborhood socioeconomic status, proximity to traffic, land use, and ambient air quality data were linked to the individual-level data via residential geocoding. Multiple linear regression separately tested the explanatory power of five groups of environmental factors for the outcomes, percent predicted FEV1 and asthma severity. Final models retained all variables statistically associated (p < 0.20) with each of the two outcomes. RESULTS: Mean FEV1 was 85.0 +/- 18.6%; mean asthma severity score was 6.9 +/- 5.6. Of 29 variables screened, 13 were retained in the final model of FEV1 (R2 = 0.30; p < 0.001) and 15 for severity (R2 = 0.16; p < 0.001), including factors from each of the five groups. Adding FEV1 as an independent variable to the severity model further increased its explanatory power (R2 = 0.25). CONCLUSIONS: Multivariate models covering a range of individual and environmental factors explained nearly a third of FEV1 variability and, taking into account lung function, one quarter of variability in asthma severity. These data support an integrated approach to modeling adult asthma outcomes, including both the physical and the social environment.

Using the nursing interventions classification as a potential measure of nurse workload.

Standardized terminologies, such as the Nursing Interventions Classification (NIC) taxonomy, may be used in multiple ways to represent nursing constructs. This study is the first known to explore the NIC as a framework for the development of a nursing workload measure. While the NIC may not represent the complexity of nurses' work, the classification system may represent uniformly the work of nurses in health information systems to yield reliable data for a nursing workload measure.

Impact of a Unit-Based Clinical Pharmacist on Communication of Medication Information in an Orthopedic Hospital.

BACKGROUND: Medication management, a complex yet essential part of patient care, requires that clinicians and patients understand indication, dosage, frequency, and adverse effects in order to maximize benefits and minimize errors, as well as to transition patients from hospital to home. Clinical pharmacists improve care transitions and safety by interacting with patients, prescribers, and nurses on medication management and self-care. However, little is known on the use of clinical pharmacists on interdisciplinary teams at the unit level within orthopedics. QUESTIONS/PURPOSES: This study sought to measure the impact of unit-based clinical pharmacists on patient perceptions of communication specific to medication during hospitalization at an orthopedic specialty hospital and on the frequency of medication errors. METHODS: A retrospective, quasi-experimental, two-group evaluative design with nonequivalent controls was used. Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data on six inpatient units was analyzed 6 months before and 6 months after assignment of clinical pharmacists to half these units. Data specific to questions that measure quality of communication as well as medication understanding were analyzed. Additionally, data on medication error frequency were collected and compared between units with and without clinical pharmacists. RESULTS: A total of 2022 surveys were analyzed. The percentage of patients who reported receipt of medication information and medication understanding increased significantly after the implementation of unit-based clinical pharmacists. Comparison of intervention and non-intervention groups showed no statistically significant difference in the frequency of medication errors. CONCLUSION: Results suggest that a clinical pharmacist assigned to an inpatient unit in orthopedics significantly influences patient perceptions of communication about and understanding of their medications.

Occupation versus environmental factors in hypersensitivity pneumonitis: population attributable fraction.

BACKGROUND: Despite well-documented case series of hypersensitivity pneumonitis (HP), epidemiological data delineating relative contributions of risk factors are sparse. To address this, we estimated HP risk in a case-referent study of occupational and nonoccupational exposures. METHODS: We recruited cases of HP by ICD-9 codes from an integrated healthcare delivery system (IHCDS) and a tertiary medical care centre. We drew referents, matched for age and sex, from the IHCDS. Participants underwent comprehensive, structured telephone interviews eliciting details of occupational and home environmental exposures. We employed a hierarchical analytic approach for data reduction based on the false discovery rate method within clusters of exposures. We measured lung function and selected biomarkers in a subset of participants. We used multivariate logistic regression to estimate exposure-associated odds ratios (ORs) and population attributable fractions (PAFs) for HP. RESULTS: We analysed data for 192 HP cases (148 IHCDS; 44 tertiary care) and 229 referents. Occupational exposures combined more than doubled the odds of developing HP (OR 2.67; 95% CI 1.73-4.14) with a PAF of 34% (95% CI 21-46%); nonoccupational bird exposure also doubled the HP odds (OR 2.02; 95% CI 1.13-3.60), with a PAF of 12% (3-21%). Lung function and selected biomarkers did not substantively modify the risk estimates on the basis of questionnaire data alone. DISCUSSION: In a case-referent approach evaluating HP risk, identifiable exposures accounted, on an epidemiological basis, for approximately two in three cases of disease; conversely, for one in three, the risk factors for disease remained elusive.

Mumps vaccine performance among university students during a mumps outbreak.

BACKGROUND: The largest reported mumps outbreak at a US college in 19 years occurred in 2006 at a Kansas university with a 2-dose measles-mumps-rubella (MMR) vaccination policy. We assessed vaccine performance and mumps risk factors, including the possibility of waning vaccine protection. METHODS: Case students were compared with a cohort of the university's approximately 19,000 undergraduates. The secondary attack rate for clinical mumps was determined among roommates exposed to case students. Time from receipt of the second dose of MMR vaccine was compared between case students and roommates without mumps. RESULTS: Coverage with > or =2 dose of MMR vaccine was > or =95% among 140 undergraduate case students and 444 cohort students. The secondary attack rate for clinical mumps among roommates who had received 2 doses of vaccine ranged from 2.2% to 7.7%, depending on the case definition. Compared with roommates without mumps, case students were more likely (odds ratio, 2.46; 95% confidence interval, 1.25-4.82) to have received their second dose of MMR vaccine > or =10 years earlier. The odds of being a case student increased with each 1-year increase in time from receipt of the second dose of MMR vaccine (odds ratio, 1.36; 95% confidence interval, 1.10-1.68) among case students and roommates aged 18-19 years but not among those aged > or =20 years. Students aged 18-19 years had a higher risk of mumps (risk ratio, 3.14; 95% confidence interval, 1.60-6.16), compared with students aged > or =22 years; women living in dormitories had increased risk of mumps (risk ratio, 1.95; 95% confidence interval, 1.01-3.76), compared with men not living in dormitories. CONCLUSION: High 2-dose MMR coverage protected many students from developing mumps but was not sufficient to prevent the mumps outbreak. Vaccine-induced protection may wane. Similar US settings where large numbers of young adults from wild-type naive cohorts live closely together may be at particular risk for mumps outbreaks.

Effects of Localized Cold Therapy on Pain in Postoperative Spinal Fusion Patients: A Randomized Control Trial.

BACKGROUND: Cold therapy used in the sports medicine settings has been found to be effective in reducing postoperative pain; however, there are limited studies that examine the effect of cold therapy on postoperative pain in patients with posterior lumbar spinal fusion. PURPOSE: The purpose of this study was to determine the effects of cold on postoperative spine pain and add to the body of knowledge specific to practical application of cold therapy in the spine surgery setting. METHODS: Researchers used a two-group randomized control design to evaluate the effects of local cold therapy on postoperative pain and analgesia use after lumbar spinal fusion surgery. The primary outcome was postoperative pain. Secondary outcomes included analgesia use and perceived benefit of cold therapy. RESULTS: The intervention (cold) group had a marginally greater reduction in mean Numerical Rating Scale score across all 12 pain checks (M ± SD = -1.1 ± 0.8 points reduction vs. -1.0 ± 0.8 points reduction, p = .589). On average, the intervention group used less morphine equivalents (M ± SD = 12.6 ± 31.5 vs. 23.7 ± 40.0) than the control group across pain checks seven to 12 (p = .042). CONCLUSIONS: This study provides additional evidence to support the use of cold therapy as an adjuvant pain management strategy to optimize pain control and reduce opioid consumption following spine fusion surgical procedures.

Development of permissible exposure limits: the California experience.

The California OSHA Airborne Contaminant Advisory Committee reviewed several hundred substances and recommended occupational exposure limits with the intent of worker and employer protection. The model used offers important benefits. First, by allowing open meetings, the process was transparent, and input could be offered by concerned stakeholders. Second, the process was data-driven and, therefore, less susceptible to bias and error. Third, by incorporating members with backgrounds in toxicology, epidemiology, risk assessment, occupational medicine, and industrial hygiene, the process fostered a thorough and diverse assessment of substances.

Respiratory health effects related to occupational spray painting and welding.

OBJECTIVE: We sought to study respiratory symptoms among automobile assembly workers. METHODS: In a cross-sectional study, we compared rates of respiratory symptoms and of physician-diagnosed asthma and COPD in painters and welders to those in assembly workers. RESULTS: Respiratory symptom reporting was significantly increased among welders (odds ratio [OR] = 1.79-2.61) compared with painters or assembly workers, after age, race, and smoking adjustment in multiple logistic regression analyses. Welders also reported significantly more improvement in symptoms on weekends or vacation. However, no significant elevations in adjusted ORs were observed for physician-diagnosed asthma or chronic obstructive pulmonary disease for welders. In contrast, significantly more painters had physician-diagnosed chronic obstructive pulmonary disease (OR = 3.73, 95% confidence interval = 1.27, 11.0). CONCLUSIONS: Welders and painters in this plant appeared to have increased risk of respiratory health effects compared with assembly workers.

Impact of the home indoor environment on adult asthma and rhinitis.

OBJECTIVE: We sought to study the combined effects of multiple home indoor environmental exposures in adult asthma and rhinitis. METHODS: We studied 226 adults with asthma and rhinitis by structured interviews and home assessments. Environmental factors included dust allergen, endotoxin and glucan concentrations, and indoor air quality (IAQ) variables. Outcomes included forced expiratory volume in 1 second (FEV1) percent predicted, Severity of Asthma Score (SAS), Short-Form (SF)-12 Physical Component Scale (PCS), and asthma Quality of Life (QOL) score. RESULTS: House dust-associated exposures together with limited IAQ variables were related to FEV1 % predicted (R = 0.24; P = 0.0001) and SAS (R = 0.18; P = 0.007). IAQ and limited dust variables were associated with SF-12 PCS (R = 0.15; P = 0.02), but not QOL (R = 0.13; P = 0.16). CONCLUSIONS: The home environment is strongly linked to lung function, health status, and disease severity in adult asthma and rhinitis.

Matrix-assisted laser desorption/ionisation time-of-flight (MALDI-TOF) mass spectrometry (MS) for the identification of mycobacteria from MBBacT ALERT 3D liquid cultures and Lowenstein-Jensen (LJ) solid cultures.

AIMS: Conventional methods for the identification of mycobacteria can be demanding and prolonged. Molecular methodologies, although rapid, are expensive and often exclusive to reference laboratories. Matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS) presents a possible alternative method for the identification and differentiation of mycobacteria. This study describes the design and validation of a mycobacteria inactivation protocol and subsequent evaluation of MALDI-TOF MS for the identification of mycobacteria in a clinical microbiology laboratory setting. METHODS: A total of 65 non-tuberculous mycobacteria (NTM) isolates and 86 Mycobacterium tuberculosis complex (MTC) isolates were tested on the Bruker MALDI Biotyper Microflex, V.3.1. NTM solid-culture (Lowenstein-Jensen, LJ slopes) isolates (n=21) and liquid-culture (MBBacT ALERT 3D bottles) isolates (n=44) were tested. MTC solid-culture isolates (n=30) and liquid-culture isolates (n=56) were also tested. Isolates were subjected to the validated inactivation protocol and analysed on the MALDI-TOF MS instrument. RESULTS: The inactivation protocol designed was successfully validated and applied to all test isolates. MALDI-TOF MS correctly identified 82.8% of all isolates analysed; 96.7% and 96.4% of MTC isolates and 76.2% and 52.3% of NTM isolates were successfully identified from solid and liquid culture, respectively. MALDI-TOF MS failed to identify 35.4% (n=23) of NTM isolates and 3.5% (n=3) of MTC isolates. CONCLUSIONS: MALDI-TOF MS has potential for identifying mycobacteria in the clinical laboratory setting, by reducing identification turnaround time and laboratory costs in isolate referral. Isolates that failed to be identified are explained by limitations of the method.