Pleiotropy of systemic lupus erythematosus risk alleles and cardiometabolic disorders: A phenome-wide association study and inverse-variance weighted meta-analysis.

OBJECTIVES: To test the hypothesis that genetic predisposition to systemic lupus erythematosus (SLE) increases the risk of cardiometabolic disorders. METHODS: Using 41 single nucleotide polymorphisms (SNPs) associated with SLE, we calculated a weighted genetic risk score (wGRS) for SLE. In a large biobank we tested the association between this wGRS and 9 cardiometabolic phenotypes previously associated with SLE: atrial fibrillation, ischemic stroke, coronary artery disease, type 1 and type 2 diabetes, obesity, chronic kidney disease, hypertension, and hypercholesterolemia. Additionally, we performed a phenome-wide association analysis (pheWAS) to discover novel clinical associations with a genetic predisposition to SLE. Findings were replicated in the Electronic Medical Records and Genomics (eMERGE) Network. To further define the association between SLE-related risk alleles and the selected cardiometabolic phenotypes, we performed an inverse variance weighted regression (IVWR) meta-analysis. RESULTS: The wGRS for SLE was calculated in 74,759 individuals of European ancestry. Among the pre-selected phenotypes, the wGRS was significantly associated with type 1 diabetes (OR [95%CI] =1.11 [1.06, 1.17], P-value = 1.05x10-5). In the PheWAS, the wGRS was associated with several autoimmune phenotypes, kidney disorders, and skin neoplasm; but only the associations with autoimmune phenotypes were replicated. In the IVWR meta-analysis, SLE-related risk alleles were nominally associated with type 1 diabetes (P = 0.048) but the associations were heterogeneous and did not meet the adjusted significance threshold. CONCLUSION: A weighted GRS for SLE was associated with an increased risk of several autoimmune-related phenotypes including type I diabetes but not with cardiometabolic disorders.

Probing the Virtual Proteome to Identify Novel Disease Biomarkers.

BACKGROUND: Proteomic approaches allow measurement of thousands of proteins in a single specimen, which can accelerate biomarker discovery. However, applying these technologies to massive biobanks is not currently feasible because of the practical barriers and costs of implementing such assays at scale. To overcome these challenges, we used a "virtual proteomic" approach, linking genetically predicted protein levels to clinical diagnoses in >40 000 individuals. METHODS: We used genome-wide association data from the Framingham Heart Study (n=759) to construct genetic predictors for 1129 plasma protein levels. We validated the genetic predictors for 268 proteins and used them to compute predicted protein levels in 41 288 genotyped individuals in the Electronic Medical Records and Genomics (eMERGE) cohort. We tested associations for each predicted protein with 1128 clinical phenotypes. Lead associations were validated with directly measured protein levels and either low-density lipoprotein cholesterol or subclinical atherosclerosis in the MDCS (Malmö Diet and Cancer Study; n=651). RESULTS: In the virtual proteomic analysis in eMERGE, 55 proteins were associated with 89 distinct diagnoses at a false discovery rate q<0.1. Among these, 13 associations involved lipid (n=7) or atherosclerosis (n=6) phenotypes. We tested each association for validation in MDCS using directly measured protein levels. At Bonferroni-adjusted significance thresholds, levels of apolipoprotein E isoforms were associated with hyperlipidemia, and circulating C-type lectin domain family 1 member B and platelet-derived growth factor receptor-ß predicted subclinical atherosclerosis. Odds ratios for carotid atherosclerosis were 1.31 (95% CI, 1.08-1.58; P=0.006) per 1-SD increment in C-type lectin domain family 1 member B and 0.79 (0.66-0.94; P=0.008) per 1-SD increment in platelet-derived growth factor receptor-ß. CONCLUSIONS: We demonstrate a biomarker discovery paradigm to identify candidate biomarkers of cardiovascular and other diseases.

Epistatic Gene-Based Interaction Analyses for Glaucoma in eMERGE and NEIGHBOR Consortium.

Primary open angle glaucoma (POAG) is a complex disease and is one of the major leading causes of blindness worldwide. Genome-wide association studies have successfully identified several common variants associated with glaucoma; however, most of these variants only explain a small proportion of the genetic risk. Apart from the standard approach to identify main effects of variants across the genome, it is believed that gene-gene interactions can help elucidate part of the missing heritability by allowing for the test of interactions between genetic variants to mimic the complex nature of biology. To explain the etiology of glaucoma, we first performed a genome-wide association study (GWAS) on glaucoma case-control samples obtained from electronic medical records (EMR) to establish the utility of EMR data in detecting non-spurious and relevant associations; this analysis was aimed at confirming already known associations with glaucoma and validating the EMR derived glaucoma phenotype. Our findings from GWAS suggest consistent evidence of several known associations in POAG. We then performed an interaction analysis for variants found to be marginally associated with glaucoma (SNPs with main effect p-value <0.01) and observed interesting findings in the electronic MEdical Records and GEnomics Network (eMERGE) network dataset. Genes from the top epistatic interactions from eMERGE data (Likelihood Ratio Test i.e. LRT p-value <1e-05) were then tested for replication in the NEIGHBOR consortium dataset. To replicate our findings, we performed a gene-based SNP-SNP interaction analysis in NEIGHBOR and observed significant gene-gene interactions (p-value <0.001) among the top 17 gene-gene models identified in the discovery phase. Variants from gene-gene interaction analysis that we found to be associated with POAG explain 3.5% of additional genetic variance in eMERGE dataset above what is explained by the SNPs in genes that are replicated from previous GWAS studies (which was only 2.1% variance explained in eMERGE dataset); in the NEIGHBOR dataset, adding replicated SNPs from gene-gene interaction analysis explain 3.4% of total variance whereas GWAS SNPs alone explain only 2.8% of variance. Exploring gene-gene interactions may provide additional insights into many complex traits when explored in properly designed and powered association studies.

Identification of Four Novel Loci in Asthma in European American and African American Populations.

RATIONALE: Despite significant advances in knowledge of the genetic architecture of asthma, specific contributors to the variability in the burden between populations remain uncovered. OBJECTIVES: To identify additional genetic susceptibility factors of asthma in European American and African American populations. METHODS: A phenotyping algorithm mining electronic medical records was developed and validated to recruit cases with asthma and control subjects from the Electronic Medical Records and Genomics network. Genome-wide association analyses were performed in pediatric and adult asthma cases and control subjects with European American and African American ancestry followed by metaanalysis. Nominally significant results were reanalyzed conditioning on allergy status. MEASUREMENTS AND MAIN RESULTS: The validation of the algorithm yielded an average of 95.8% positive predictive values for both cases and control subjects. The algorithm accrued 21,644 subjects (65.83% European American and 34.17% African American). We identified four novel population-specific associations with asthma after metaanalyses: loci 6p21.31, 9p21.2, and 10q21.3 in the European American population, and the PTGES gene in African Americans. TEK at 9p21.2, which encodes TIE2, has been shown to be involved in remodeling the airway wall in asthma, and the association remained significant after conditioning by allergy. PTGES, which encodes the prostaglandin E synthase, has also been linked to asthma, where deficient prostaglandin E2 synthesis has been associated with airway remodeling. CONCLUSIONS: This study adds to understanding of the genetic architecture of asthma in European Americans and African Americans and reinforces the need to study populations of diverse ethnic backgrounds to identify shared and unique genetic predictors of asthma.

Performance of an electronic health record-based phenotype algorithm to identify community associated methicillin-resistant Staphylococcus aureus cases and controls for genetic association studies.

BACKGROUND: Community associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is one of the most common causes of skin and soft tissue infections in the United States, and a variety of genetic host factors are suspected to be risk factors for recurrent infection. Based on the CDC definition, we have developed and validated an electronic health record (EHR) based CA-MRSA phenotype algorithm utilizing both structured and unstructured data. METHODS: The algorithm was validated at three eMERGE consortium sites, and positive predictive value, negative predictive value and sensitivity, were calculated. The algorithm was then run and data collected across seven total sites. The resulting data was used in GWAS analysis. RESULTS: Across seven sites, the CA-MRSA phenotype algorithm identified a total of 349 cases and 7761 controls among the genotyped European and African American biobank populations. PPV ranged from 68 to 100% for cases and 96 to 100% for controls; sensitivity ranged from 94 to 100% for cases and 75 to 100% for controls. Frequency of cases in the populations varied widely by site. There were no plausible GWAS-significant (p < 5 E -8) findings. CONCLUSIONS: Differences in EHR data representation and screening patterns across sites may have affected identification of cases and controls and accounted for varying frequencies across sites. Future work identifying these patterns is necessary.

Electronic medical records and genomics (eMERGE) network exploration in cataract: several new potential susceptibility loci.

PURPOSE: Cataract is the leading cause of blindness in the world, and in the United States accounts for approximately 60% of Medicare costs related to vision. The purpose of this study was to identify genetic markers for age-related cataract through a genome-wide association study (GWAS). METHODS: In the electronic medical records and genomics (eMERGE) network, we ran an electronic phenotyping algorithm on individuals in each of five sites with electronic medical records linked to DNA biobanks. We performed a GWAS using 530,101 SNPs from the Illumina 660W-Quad in a total of 7,397 individuals (5,503 cases and 1,894 controls). We also performed an age-at-diagnosis case-only analysis. RESULTS: We identified several statistically significant associations with age-related cataract (45 SNPs) as well as age at diagnosis (44 SNPs). The 45 SNPs associated with cataract at p<1×10(-5) are in several interesting genes, including ALDOB, MAP3K1, and MEF2C. All have potential biologic relationships with cataracts. CONCLUSIONS: This is the first genome-wide association study of age-related cataract, and several regions of interest have been identified. The eMERGE network has pioneered the exploration of genomic associations in biobanks linked to electronic health records, and this study is another example of the utility of such resources. Explorations of age-related cataract including validation and replication of the association results identified herein are needed in future studies.

Asymmetry in noise-induced hearing loss: evaluation of two competing theories.

Competing theories exist about why asymmetry is observed in noise-induced hearing loss (NIHL). We evaluated these theories using a cohort of young workers studied over 16 years. The study aim was to describe and evaluate patterns of hearing loss and asymmetry by gender, agricultural exposure and gunfire exposure. This was a secondary analysis of data collected from young adults during follow-up of a randomized controlled trial. This follow-up study evaluated long-term effects of a hearing conservation intervention for rural students. The sample consisted of 392 of 690 participants from the original trial. In total, 355 young adults (aged 29-33 years) completed baseline and follow-up noise exposure surveys and clinical audiometric examinations. Data are displayed graphically as thresholds by frequency and ear and degree of asymmetry between ears (left minus right). In the primary group comparisons, low and high frequency averages and mean high frequency asymmetry were analyzed using mixed linear models. At frequencies >2000 Hz, men showed more hearing loss, with greater asymmetry and a different asymmetry pattern, than women. For men with documented hearing loss, there was a trend toward increasing asymmetry with increasing levels of hearing loss. Asymmetry at high frequencies varied substantially by level of shooting exposure. While "head shadowing" is accepted as the primary explanation for asymmetric hearing loss in the audiologic and related public health literature, our findings are more consistent with physiological differences as the primary cause of asymmetric hearing loss, with greater susceptibility to NIHL in the left ear of men.

Multi-ancestry genome- and phenome-wide association studies of diverticular disease in electronic health records with natural language processing enriched phenotyping algorithm.

OBJECTIVE: Diverticular disease (DD) is one of the most prevalent conditions encountered by gastroenterologists, affecting ~50% of Americans before the age of 60. Our aim was to identify genetic risk variants and clinical phenotypes associated with DD, leveraging multiple electronic health record (EHR) data sources of 91,166 multi-ancestry participants with a Natural Language Processing (NLP) technique. MATERIALS AND METHODS: We developed a NLP-enriched phenotyping algorithm that incorporated colonoscopy or abdominal imaging reports to identify patients with diverticulosis and diverticulitis from multicenter EHRs. We performed genome-wide association studies (GWAS) of DD in European, African and multi-ancestry participants, followed by phenome-wide association studies (PheWAS) of the risk variants to identify their potential comorbid/pleiotropic effects in clinical phenotypes. RESULTS: Our developed algorithm showed a significant improvement in patient classification performance for DD analysis (algorithm PPVs ≥ 0.94), with up to a 3.5 fold increase in terms of the number of identified patients than the traditional method. Ancestry-stratified analyses of diverticulosis and diverticulitis of the identified subjects replicated the well-established associations between ARHGAP15 loci with DD, showing overall intensified GWAS signals in diverticulitis patients compared to diverticulosis patients. Our PheWAS analyses identified significant associations between the DD GWAS variants and circulatory system, genitourinary, and neoplastic EHR phenotypes. DISCUSSION: As the first multi-ancestry GWAS-PheWAS study, we showcased that heterogenous EHR data can be mapped through an integrative analytical pipeline and reveal significant genotype-phenotype associations with clinical interpretation. CONCLUSION: A systematic framework to process unstructured EHR data with NLP could advance a deep and scalable phenotyping for better patient identification and facilitate etiological investigation of a disease with multilayered data.

Determinants of early-stage hearing loss among a cohort of young workers with 16-year follow-up.

OBJECTIVES: The authors had a unique opportunity to study the early impacts of occupational and recreational exposures on the development of noise-induced hearing loss (NIHL) in a cohort of 392 young workers. The objectives of this study were to estimate strength of associations between occupational and recreational exposures and occurrence of early-stage NIHL and to determine the extent to which relationships between specific noise exposures and early-stage NIHL were mitigated through the use of hearing protection. METHODS: Participants were young adults who agreed to participate in a follow-up of a randomised controlled trial. While the follow-up study was designed to observe long-term effects (up to 16 years) of a hearing conservation intervention for high school students, it also provided opportunity to study the potential aetiology of NIHL in this worker cohort. Study data were collected via exposure history questionnaires and clinical audiometric examinations. RESULTS: Over the 16-year study period, the authors documented changes to hearing acuity that exceeded 15 dB at high frequencies in 42.8% of men and 27.7% of women. Analyses of risk factors for NIHL were limited to men, who comprised 68% of the cohort, and showed that risks increased in association with higher levels of the most common recreational and occupational noise sources, as well as chemical exposures with ototoxic potential. Use of hearing protection and other safety measures, although not universal and sometimes modest, appeared to offer some protection. CONCLUSIONS: Early-stage NIHL can be detected in young workers by measuring high-frequency changes in hearing acuity. Hearing conservation programmes should focus on a broader range of exposures, whether in occupational or non-occupational settings. Priority exposures include gunshots, chainsaws, power tools, smoking and potentially some chemical exposures.

A long femur scan field does not alter proximal femur bone mineral density measurements by dual-energy X-ray absorptiometry.

A longer dual-energy X-ray absorptiometry (DXA) femur scan field might be useful for the detection of atypical, subtrochanteric femur fractures (ASFF). Thirty adult subjects underwent triplicate measures of femoral neck (FN) and total hip (TH) bone mineral density (BMD) by DXA using a conventional (i.e., short) and a longer femur scan field. Differences in measured BMD between the 2 scan field lengths were small and less than the precision error inherent in DXA testing. A longer proximal femur scan field does not substantially alter BMD measurements made at the FN and TH and may be useful for the detection of ASFF in clinical practice.

Cataract research using electronic health records.

BACKGROUND: The eMERGE (electronic MEdical Records and Genomics) network, funded by the National Human Genome Research Institute, is a national consortium formed to develop, disseminate, and apply approaches to research that combine DNA biorepositories with electronic health record (EHR) systems for large-scale, high-throughput genetic research. Marshfield Clinic is one of five sites in the eMERGE network and primarily studied: 1) age-related cataract and 2) HDL-cholesterol levels. The purpose of this paper is to describe the approach to electronic evaluation of the epidemiology of cataract using the EHR for a large biobank and to assess previously identified epidemiologic risk factors in cases identified by electronic algorithms. METHODS: Electronic algorithms were used to select individuals with cataracts in the Personalized Medicine Research Project database. These were analyzed for cataract prevalence, age at cataract, and previously identified risk factors. RESULTS: Cataract diagnoses and surgeries, though not type of cataract, were successfully identified using electronic algorithms. Age specific prevalence of both cataract (22% compared to 17.2%) and cataract surgery (11% compared to 5.1%) were higher when compared to the Eye Diseases Prevalence Research Group. The risk factors of age, gender, diabetes, and steroid use were confirmed. CONCLUSIONS: Using electronic health records can be a viable and efficient tool to identify cataracts for research. However, using retrospective data from this source can be confounded by historical limits on data availability, differences in the utilization of healthcare, and changes in exposures over time.

An independently validated, portable algorithm for the rapid identification of COPD patients using electronic health records.

Electronic health records (EHR) provide an unprecedented opportunity to conduct large, cost-efficient, population-based studies. However, the studies of heterogeneous diseases, such as chronic obstructive pulmonary disease (COPD), often require labor-intensive clinical review and testing, limiting widespread use of these important resources. To develop a generalizable and efficient method for accurate identification of large COPD cohorts in EHRs, a COPD datamart was developed from 3420 participants meeting inclusion criteria in the Mass General Brigham Biobank. Training and test sets were selected and labeled with gold-standard COPD classifications obtained from chart review by pulmonologists. Multiple classes of algorithms were built utilizing both structured (e.g. ICD codes) and unstructured (e.g. medical notes) data via elastic net regression. Models explicitly including and excluding spirometry features were compared. External validation of the final algorithm was conducted in an independent biobank with a different EHR system. The final COPD classification model demonstrated excellent positive predictive value (PPV; 91.7%), sensitivity (71.7%), and specificity (94.4%). This algorithm performed well not only within the MGBB, but also demonstrated similar or improved classification performance in an independent biobank (PPV 93.5%, sensitivity 61.4%, specificity 90%). Ancillary comparisons showed that the classification model built including a binary feature for FEV1/FVC produced substantially higher sensitivity than those excluding. This study fills a gap in COPD research involving population-based EHRs, providing an important resource for the rapid, automated classification of COPD cases that is both cost-efficient and requires minimal information from unstructured medical records.

Hearing conservation program for agricultural students: short-term outcomes from a cluster-randomized trial with planned long-term follow-up.

OBJECTIVES: (1) To conduct a contemporary analysis of historical data on short-term efficacy of a 3-year hearing conservation program conducted from 1992 to 1996 in Wisconsin, USA, with 753 high school students actively involved in farm work; (2) to establish procedures for assessment of hearing loss for use in a recently funded follow-up of this same hearing conservation program cohort. METHODS: We analyzed a pragmatic cluster-randomized controlled trial, with schools as the unit of randomization. Thirty-four rural schools were recruited and randomized to intervention or control. The intervention included classroom instruction, distribution of hearing protection devices, direct mailings, noise level assessments, and yearly audiometric testing. The control group received the audiometric testing. RESULTS: Students exposed to the hearing conservation program reported more frequent use of hearing protection devices, but there was no evidence of reduced levels of noise-induced hearing loss (NIHL). CONCLUSION: Our analysis suggests that, since NIHL is cumulative, a 3-year study was likely not long enough to evaluate the efficacy of this intervention. While improvements in reported use of hearing protection devices were noted, the lasting impact of these behaviors is unknown and the finding merits corroboration by longer term objective hearing tests. A follow-up study of the cohort has recently been started.

Use of an electronic medical record to characterize cases of intermediate statin-induced muscle toxicity.

Statin use can be accompanied by a variety of musculoskeletal complaints. The authors describe the clinical characteristics of case patients who experienced adverse statin-induced musculoskeletal symptoms within a large population-based cohort in Central Wisconsin. Case status was determined based on elevated serum creatine kinase (CK) levels and the presence of at least 1 physician note reflecting an increased index of suspicion for statin intolerance. From the medical records of nearly 2 million unique patients, the authors identified more than 20,000 potential study patients ( approximately 1%) having CK data and at least 1 exposure to a statin drug. Manual screening was completed on 2227 patients with CK levels in the upper 10th percentile. Of those screened, 267 met inclusion criteria (12.0% eligibility) and 218 agreed to participate in a retrospective study characterizing the risk determinants of statin-induced muscle toxicity. Three categoric pain variables were graded retrospectively (distribution, location, and severity of pain). The presenting complaints of the case patients were extremely heterogeneous. The number of patients with a compelling pain syndrome (diffuse, proximal muscle pain of high intensity) increased at higher serum CK levels; the number of patients with indeterminate pain variables decreased at higher serum CK levels. The lines reflecting these relationships cross at a CK level of approximately 1175 U/L, approximately half the threshold level needed to make a clinical diagnosis of "myopathy" (ie, CK >10-fold the upper limit of normal).

Heritability and genome-wide association study of benign prostatic hyperplasia (BPH) in the eMERGE network.

Benign prostatic hyperplasia (BPH) results in a significant public health burden due to the morbidity caused by the disease and many of the available remedies. As much as 70% of men over 70 will develop BPH. Few studies have been conducted to discover the genetic determinants of BPH risk. Understanding the biological basis for this condition may provide necessary insight for development of novel pharmaceutical therapies or risk prediction. We have evaluated SNP-based heritability of BPH in two cohorts and conducted a genome-wide association study (GWAS) of BPH risk using 2,656 cases and 7,763 controls identified from the Electronic Medical Records and Genomics (eMERGE) network. SNP-based heritability estimates suggest that roughly 60% of the phenotypic variation in BPH is accounted for by genetic factors. We used logistic regression to model BPH risk as a function of principal components of ancestry, age, and imputed genotype data, with meta-analysis performed using METAL. The top result was on chromosome 22 in SYN3 at rs2710383 (p-value = 4.6 × 10-7; Odds Ratio = 0.69, 95% confidence interval = 0.55-0.83). Other suggestive signals were near genes GLGC, UNCA13, SORCS1 and between BTBD3 and SPTLC3. We also evaluated genetically-predicted gene expression in prostate tissue. The most significant result was with increasing predicted expression of ETV4 (chr17; p-value = 0.0015). Overexpression of this gene has been associated with poor prognosis in prostate cancer. In conclusion, although there were no genome-wide significant variants identified for BPH susceptibility, we present evidence supporting the heritability of this phenotype, have identified suggestive signals, and evaluated the association between BPH and genetically-predicted gene expression in prostate.

Adult supervision and pediatric injuries in the agricultural worksite.

Appropriate supervision is recommended as a strategy to prevent pediatric farm injuries, yet virtually nothing is known about the quality of adult supervision on farms. We therefore explored the nature of adult supervision among pediatric farm injury cases using three theoretically relevant dimensions of supervision: (1) attention, (2) proximity, and (3) continuity. We examined a retrospective case series of 334 pediatric farm injury cases from Canada and the United States that resulted in death or required hospitalization. Patterns of supervision were coded according to the three dimensions. Approximately two-thirds of the injured children (231/334; 69%) had an adult supervisor available (attention). The supervisor was in close proximity of the child in only about half the cases (169/334; 51%) and it was even less common for the supervision to be continuous (37%). Thus, many injuries occurred when children were inadequately supervised. However, approximately one-third of the injured children (112/334; 34%) had what in other circumstances would be considered adequate adult supervision at the time of their injury event, defined theoretically as having supervision available, proximal, and continuous. Yet, children on farms were injured even in the presence of adequate adult supervision. These findings, along with a growing body of literature examining pediatric farm injuries, suggest a need to develop a new definition of adequate adult supervision within the context of the agricultural work environment, or to consider restricting the access of children, especially the very young, to this hazardous worksite.

A study paradigm integrating prospective epidemiologic cohorts and electronic health records to identify disease biomarkers.

Defining the full spectrum of human disease associated with a biomarker is necessary to advance the biomarker into clinical practice. We hypothesize that associating biomarker measurements with electronic health record (EHR) populations based on shared genetic architectures would establish the clinical epidemiology of the biomarker. We use Bayesian sparse linear mixed modeling to calculate SNP weightings for 53 biomarkers from the Atherosclerosis Risk in Communities study. We use the SNP weightings to computed predicted biomarker values in an EHR population and test associations with 1139 diagnoses. Here we report 116 associations meeting a Bonferroni level of significance. A false discovery rate (FDR)-based significance threshold reveals more known and undescribed associations across a broad range of biomarkers, including biometric measures, plasma proteins and metabolites, functional assays, and behaviors. We confirm an inverse association between LDL-cholesterol level and septicemia risk in an independent epidemiological cohort. This approach efficiently discovers biomarker-disease associations.

Changing the child labor laws for agriculture: impact on injury.

OBJECTIVE: The child labor laws are intended to protect young workers from the most dangerous jobs. However, children who work on their parents' farms are exempt from these laws. We evaluated the potential for preventing the occurrence of farm injuries among children by changing the US Federal Child Labor Laws, Hazardous Occupations Orders for Agriculture. METHODS: A retrospective case series of 1193 farm injuries among children from the United States and Canada was assembled. The Hazardous Occupations Orders were systematically applied to each case. Injury preventability was estimated. RESULTS: A total of 286 (24%) cases of injury involved immediate family members engaged in farm work. Among these children, 33% of those aged younger than 16 years and 36% of those aged 16 or 17 years were performing work prohibited under the Hazardous Occupations Orders. CONCLUSIONS: Removing the family farm exemption from the Hazardous Occupations Orders and raising the age restriction for performing hazardous agricultural work from 16 to 18 years would be efficacious in preventing the most serious injuries experienced by young family farm workers. Potential reductions in injury would meet Healthy People 2010 goals for reducing traumatic injury in the agricultural sector.

A new approach to understanding pediatric farm injuries.

The objective of this study was to apply a new conceptual approach to the study of pediatric farm injuries. A large case series of pediatric farm injuries in North America was evaluated to assess interactions between risk factors for injury. Information about pediatric farm injuries to children in three age groups (<6 years, 6-12 years, 13+ years) was coded with respect to children's behavior (did unexpected child behavior contribute to injury?), predictability of injury risk (based on what the child had been doing, was the nature or occurrence of injury unexpected?), environmental events (did unexpected environmental events contribute to injury?), and level of environmental risk (low, high). The reliability of coding between independent raters was excellent (kappa=.83) for the 330 cases providing complete data. Results revealed that, in high-risk environments, unexpected child behavior was coded more frequently when children under 6 years were injured than for older children, whereas in low-risk environments unexpected child behavior had less impact on injury risk and showed no such age variation. With increasing age, the predictability of injury increased in a high-risk context, suggesting that youth engage in increasingly hazardous activities as they develop. Consistent with this interpretation, unexpected environmental events increasingly contributed to injury in a high-risk context in the oldest age groups. The observed variations in risk factors suggest that interactions between behavioral and environmental factors are important to consider in studies of the etiology of pediatric farm injuries.