Per- and Polyfluoroalkyl Substance and Cardio Metabolic Markers in Firefighters.

OBJECTIVE: To evaluate if serum polyfluoroalkyl substances (PFAS) were associated with cardiometabolic markers. METHODS: Serum PFAS were evaluated in 38 Arizona firefighters and 49 participants from the 2009 to 2010 National Health and Nutrition Examination Survey (NHANES). Cardiometabolic markers including carotid intima-medial thickness (CIMT) were measured in the firefighters. RESULTS: Firefighters had elevated perfluorohexane sulfonic acid (PFHxS) and lower perfluorononanoic acid (PFNA) and perfluoroundecanoic acid (PFUA) compared to NHANES participants; for nine of the other 12 PFAS the values were not significantly different. There were significant negative associations among firefighters between perfluorodecanoic acid (PFDeA) and total cholesterol and PFUA and interleukin-6. PFAS concentrations were not associated with CIMT. CONCLUSION: PFHxS levels were elevated in firefighters compared to NHANES subjects. Serum PFAS concentrations were not associated with increased cardiometabolic risk measures in this population of firefighters.

The Value Proposition for Pathologists: A Population Health Approach.

The transition to a value-based payment system offers pathologists the opportunity to play an increased role in population health by improving outcomes and safety as well as reducing costs. Although laboratory testing itself accounts for a small portion of health-care spending, laboratory data have significant downstream effects in patient management as well as diagnosis. Pathologists currently are heavily engaged in precision medicine, use of laboratory and pathology test results (including autopsy data) to reduce diagnostic errors, and play leading roles in diagnostic management teams. Additionally, pathologists can use aggregate laboratory data to monitor the health of populations and improve health-care outcomes for both individual patients and populations. For the profession to thrive, pathologists will need to focus on extending their roles outside the laboratory beyond the traditional role in the analytic phase of testing. This should include leadership in ensuring correct ordering and interpretation of laboratory testing and leadership in population health programs. Pathologists in training will need to learn key concepts in informatics and data analytics, health-care economics, public health, implementation science, and health systems science. While these changes may reduce reimbursement for the traditional activities of pathologists, new opportunities arise for value creation and new compensation models. This report reviews these opportunities for pathologist leadership in utilization management, precision medicine, reducing diagnostic errors, and improving health-care outcomes.

Increased risk of respiratory diseases in adults with Type 1 and Type 2 diabetes.

AIMS: Diabetes is linked with decreases in lung elasticity and in capacity to transfer carbon monoxide. Systemic inflammation, a common concern with diabetes, may contribute to airflow obstruction. We examined the association of self-reported diabetes with self-reported respiratory diseases (RDs) among 53,146 adults from the C8 Health Project. METHODS: Participants were categorized into three groups: Type 1 (T1D, n = 781), Type 2 (T2D, n = 4277), or no diabetes (n = 48,088). ORs (95% CIs) for the association of diabetes with four RDs were computed: emphysema, chronic obstructive pulmonary disease (COPD), chronic bronchitis (CB), and asthma. Covariates controlled for were age, sex, estimated glomerular filtration rate, C-reactive protein, smoking history, BMI, and perfluorooctonaoic acid (C8). RESULTS: RDs were present in 26%, 21% and 13% of persons with T1D, T2D, and no diabetes, respectively. In multivariable analyses, persons with T1D were 62% more likely to have any RD (OR: 1.62, CI: (1.36-1.93)), while those with T2D were 1.3 times as likely (OR: 1.26, CI: 1.15-1.37)). Compared to those without diabetes, in those with T1D and T2D diabetes respectively, ORs (CIs) for COPD were 1.89 (1.38-2.57), 1.45 (1.23-1.71), asthma: 1.51 (1.21-1.87), 1.38 (1.24-1.53), CB: 1.96 (1.57-2.45), 1.35 (1.20-1.52) and emphysema: 1.25 (0.85-1.82), 1.31 (1.10-1.56). Population attributable risks for any RDs associated with a history of smoking were 19%, 30%, and 26% for those with Type 1, Type 2, and no diabetes respectively. CONCLUSIONS: Diabetes, more so in T1D, appears to increase RD risk. Smoking is an important risk factor, but not as informative in Type 1 diabetes.

Quality Improvement Intervention for Reduction of Redundant Testing.

Laboratory data are critical to analyzing and improving clinical quality. In the setting of residual use of creatine kinase M and B isoenzyme testing for myocardial infarction, we assessed disease outcomes of discordant creatine kinase M and B isoenzyme +/troponin I (-) test pairs in order to address anticipated clinician concerns about potential loss of case-finding sensitivity following proposed discontinuation of routine creatine kinase and creatine kinase M and B isoenzyme testing. Time-sequenced interventions were introduced. The main outcome was the percentage of cardiac marker studies performed within guidelines. Nonguideline orders dominated at baseline. Creatine kinase M and B isoenzyme testing in 7496 order sets failed to detect additional myocardial infarctions but was associated with 42 potentially preventable admissions/quarter. Interruptive computerized soft stops improved guideline compliance from 32.3% to 58% (P < .001) in services not receiving peer leader intervention and to >80% (P < .001) with peer leadership that featured dashboard feedback about test order performance. This successful experience was recapitulated in interrupted time series within 2 additional services within facility 1 and then in 2 external hospitals (including a critical access facility). Improvements have been sustained postintervention. Laboratory cost savings at the academic facility were estimated to be ≥US$635 000 per year. National collaborative data indicated that facility 1 improved its order patterns from fourth to first quartile compared to peer norms and imply that nonguideline orders persist elsewhere. This example illustrates how pathologists can provide leadership in assisting clinicians in changing laboratory ordering practices. We found that clinicians respond to local laboratory data about their own test performance and that evidence suggesting harm is more compelling to clinicians than evidence of cost savings. Our experience indicates that interventions done at an academic facility can be readily instituted by private practitioners at external facilities. The intervention data also supplement existing literature that electronic order interruptions are more successful when combined with modalities that rely on peer education combined with dashboard feedback about laboratory order performance. The findings may have implications for the role of the pathology laboratory in the ongoing pivot from quantity-based to value-based health care.

Tetryl exposure: forgotten hazards of antique munitions.

BACKGROUND: Older yet still abundant munitions such as tetryl present easily forgotten health hazards and associated needs for worker protection. CASE PRESENTATION: Symptoms and findings from 22 workers who were exposed to tetryl are summarized. CONCLUSIONS: This study highlights the health hazards from exposure to tetryl. Occupational health professionals need to maintain vigilance to protect workers from the risks of handling older munitions.

Use of Pathology Data to Improve High-Value Treatment of Cervical Neoplasia.

We investigated the influence of pathology data to improve patient outcomes in the treatment of high-grade cervical neoplasia in a joint pathology and gynecology collaboration. Two of us (B.S.D. and M.D.) reviewed all cytology, colposcopy and surgical pathology results, patient history, and pregnancy outcomes from all patients with loop electrosurgical excision procedure specimens for a 33-month period (January 2011-September 2013). We used this to determine compliance to 2006 consensus guidelines for the performance of loop electrosurgical excision procedure and shared this information in 2 interprofessional and interdisciplinary educational interventions with Obstetrics/Gynecology and Pathology faculty at the end of September 2013. We simultaneously emphasized the new 2013 guidelines. During the postintervention period, we continued to provide follow-up using the parameters previously collected. Our postintervention data include 90 cases from a 27-month period (October 2013-December 2015). Our preintervention data include 331 cases in 33 months (average 10.0 per month) with 76% adherence to guidelines. Postintervention, there were 90 cases in 27 months (average 3.4 per month) and 96% adherence to the 2013 (more conservative) guidelines (P < .0001, χ2 test). Preintervention, the rate of high-grade squamous intraepithelial lesion in loop electrosurgical excision procedures was 44%, whereas postintervention, there was a 60% high-grade squamous intraepithelial lesion rate on loop electrosurgical excision procedure (P < .0087 by 2-tailed Fisher exact test). The duration between diagnosis of low-grade squamous intraepithelial lesion and loop electrosurgical excision procedure also increased significantly from a median 25.5 months preintervention to 54 months postintervention (P < .0073; Wilcoxon Kruskal-Wallis test). Postintervention, there was a marked decrease of loop electrosurgical excision procedure cases as well as better patient outcomes. We infer improved patient safety, and higher value can be achieved by providing performance-based pathologic data.

Urinary polycyclic aromatic hydrocarbon biomarkers and diabetes mellitus.

OBJECTIVE: The aim of the current study is to investigate the association of polycyclic aromatic hydrocarbons (PAHs), a group of environmental pollutants, with diabetes mellitus. Animal studies link PAHs to inflammation and subsequent development of diabetes mellitus. In addition, occupational studies suggest that exposure to other aromatic hydrocarbons such as dioxins may be associated with diabetes risk in humans. DESIGN: We examined participants from the merged National Health and Nutrition Examination Survey 2001-2002, 2003-2004 and 2005-2006. Exposures of interest were eight urinary monohydroxy-PAHs. Our outcome was diabetes mellitus defined as a glycohemoglobin level (HbA1c) ≥6.5%, a self-reported physician diagnosis of diabetes or use of oral hypoglycaemic medication or insulin. Analyses were adjusted for age, sex, body mass index, race, alcohol consumption, poverty-income ratio, total cholesterol and serum cotinine. RESULTS: We observed a positive association between urinary biomarkers of 1 and 2-hydroxynapthol, 2-hydroxyphenanthrene and summed low molecular weight (LMW) PAH biomarkers, and diabetes mellitus. Compared with participants with summed LMW PAH biomarkers in the lowest quartile, the multivariable-adjusted OR of diabetes mellitus among those in the highest quartile was 3.1 (95% CI 1.6 to 5.8). CONCLUSIONS: Urinary biomarkers of 1 and 2-hydroxynapthol, 2-hydroxyphenanthrene and summed LMW PAH biomarkers are associated with diabetes mellitus in US adults 20-65 years of age. The association of a one-time biomarker of PAH exposure has limitations commonly associated with cross-sectional studies, yet is consistent with experimental animal data and is worthy of additional consideration.

Inverse association of colorectal cancer prevalence to serum levels of perfluorooctane sulfonate (PFOS) and perfluorooctanoate (PFOA) in a large Appalachian population.

BACKGROUND: Perfluorooctanoate (PFOA) and perfluorooctane sulfonate (PFOS) are persistent environmental contaminants that affect metabolic regulation, inflammation, and other factors implicated in the development and progression of colorectal cancer (CRC). However, the link between these compounds and CRC remains unknown. In this cross-sectional study, we investigated the association of CRC diagnosis to PFOA and PFOS blood levels in a large Appalachian population. METHODS: Participants were 47,359 adults ≥ 21 years of age and residing in six PFOA-contaminated water districts in the mid-Ohio Valley (N = 47,151 cancer-free adults, 208 cases of primary CRC). All participants completed a comprehensive health survey between 2005 and 2006; serum levels of PFOA, PFOS, and a range of other blood markers were also measured. Medical history was assessed via self report and cancer diagnosis confirmed via chart review. RESULTS: CRC showed a strong inverse, dose-response association with PFOS serum levels (odds ratio (OR) adjusted for potential confounders = 0.2, 95% confidence interval (CI) 0.2,0.3) for highest vs. lowest quartile of PFOS, P-trend < 0.00001) and a significant, but more modest inverse association with PFOA (adjusted OR = 0.6 (CI 0.4, 0.9) for highest vs. lowest quartile, P-trend = 0.001). These inverse associations were stronger in those diagnosed within the previous 6 years and resident in the same water district for a minimum of 10-15 years preceding assessment. The relationship between PFOA and CRC was also more pronounced in men and leaner adults, and showed a stronger linear trend at lower exposure levels. CONCLUSIONS: In this large cross-sectional study, we found a strong, inverse association between PFOS and likelihood of CRC diagnosis and a significant, although more modest inverse association between PFOA and CRC. If confirmed in prospective investigations, these findings may aid in identifying new strategies for CRC prevention and treatment and inform future studies regarding mechanisms underlying CRC pathogenesis.

Circulating maternal perfluoroalkyl substances during pregnancy in the C8 Health Study.

Perfluoroalkyl substances are manmade chemicals used in many consumer products and have become ubiquitous in the environment. Animal studies and a limited number of human studies have demonstrated developmental effects in offspring exposed to perfluoroalkyl substances in utero, but the implications of timing of in utero exposure have not been systematically investigated. The present study investigated variation in perfluorocarbon levels of 9952 women of childbearing age who had been exposed to perfluorooctanoic acid (PFOA) in drinking water contaminated by industrial waste. An analysis of variance with contrast was performed to compare the levels of PFOA and perfluorooctanesulfonic acid (PFOS) in pregnant and nonpregnant women overall and during each trimester of pregnancy. We found that pregnant women had lower circulating PFOA and PFOS concentrations in peripheral blood than nonpregnant women and that PFOA levels were consistently lower throughout all trimesters for pregnancy, suggesting transfer to the fetus at an early stage of gestation. These results are discussed in the context of the endocrine-disrupting properties of perfluoroalkyl substances that have been characterized in animal and human studies. Our conclusion is that further, systematic study of the potential implications of intrauterine perfluorocarbon exposure during critical periods of fetal development is urgently needed.

Adult tooth loss for residents of US coal mining and Appalachian counties.

OBJECTIVES: The authors compared rates of tooth loss between adult residents of Appalachian coal-mining areas and other areas of the nation before and after control for covariate risks. METHODS: The authors conducted a cross-sectional secondary data analysis that merged 2006 national Behavioral Risk Factor Surveillance System data (BRFSS) (N = 242 184) with county coal-mining data and other county characteristics. The hypothesis tested was that adult tooth loss would be greater in Appalachian mining areas after control for other risks. Primary independent variables included main effects for coal-mining present (yes/no) residence in Appalachia (yes/no), and their interaction. Data were weighted using the BRFSS final weights and analyzed using SUDAAN Proc Multilog to account for the multilevel complex sampling structure. The odds of two measures of tooth loss were examined controlling for age, race\ethnicity, drinking, smoking, income, education, supply of dentists, receipt of dental care, fluoridation rate, and other variables. RESULTS: After covariate adjustment, the interaction variable for the residents of Appalachian coal-mining counties showed a significantly elevated odds for any tooth loss [odds ratio (OR) = 1.19, 95% CI = 1.02, 1.38], and greater tooth loss measured by a 4-level edentulism scale (OR = 1.20, 95% CI = 1.05, 1.36). The main effect for Appalachia was also significant for both measures, but the main effect for coal mining was not. CONCLUSIONS: Greater risk of tooth loss among adult residents of Appalachian coal-mining areas is present and is not explained by differences in reported receipt of dental care, fluoridation rates, supply of dentists or other behavioral or socioeconomic risks. Possible contributing factors include mining-specific disparities related to access, behavior or environmental exposures.

Left atrial volume by echocardiography in patients with false positive myocardial perfusion scans.

A stress-induced myocardial perfusion abnormality (MPS), in the absence of angiographically significant epicardial coronary artery disease, is considered a "false-positive" test result. We hypothesized that echocardiography would provide complementary prognostic and pathophysiologic data relevant to the management of patients with MPS and normal coronary angiograms. Accordingly, left atrial volume index (LAVi) was assessed by echocardiography in 38 patients with false positive MPS as defined by normal coronary angiograms and 26 patients with true negative MPS from a total of 1,356 patients stressed from July 2006-May 2008. Pathologically abnormal elevation of LAVi (≥ 32 mL/m(2)) was observed in 16 of 19 women (84%) and 11 of 19 men (58%) in the false positive MPS (FPMPS) group while none of the patients in the true negative MPS (TNMPS) group had elevated LAVi. In the FPMPS group mean LAVi was significantly higher in women than men (40.64 ± 11.4 mL/m(2) versus 32.6 ± 10.5 mL/m(2), P = 0.01). The mean LAVi in the FPMPS group was significantly different from the TNMPS group (36.6 ± 11.6 versus 21 ± 7 mL/m(2), P = 0.000). A stepwise logistic regression determined BSA, LAV and LAVi as useful in predicting false positive and true negative MPS. All three were significant predictors (P < 0.01) and the area under the ROC curve was 0.91. Our findings in this relatively small cohort suggest that patients with false positive MPS have a greater increased LAVi.

Serum perfluorooctanoate (PFOA) and perfluorooctane sulfonate (PFOS) concentrations and liver function biomarkers in a population with elevated PFOA exposure.

BACKGROUND: Perfluorooctanoate (PFOA) and perfluorooctane sulfonate (PFOS) persist in the environment and are found in relatively high concentrations in animal livers. Studies in humans have reported inconsistent associations between PFOA and liver enzymes. OBJECTIVES: We examined the cross-sectional association between serum PFOA and PFOS concentrations with markers of liver function in adults. METHODS: The C8 Health Project collected data on 69,030 persons; of these, a total of 47,092 adults were included in the present analysis. Linear regression models were fitted for natural log (ln)-transformed values of alanine transaminase (ALT), γ-glutamyltransferase (GGT), and direct bilirubin on PFOA, PFOS, and potential confounders. Logistic regression models were fitted comparing deciles of PFOA or PFOS in relation to high biomarker levels. A multilevel analysis comparing the evidence for association of PFOA with liver function at the individual level within water districts to that at the population level between water districts was also performed. RESULTS: ln-PFOA and ln-PFOS were associated with ln-ALT in linear regression models [PFOA: coefficient, 0.022; 95% confidence interval (CI): 0.018, 0.025; PFOS: coefficient, 0.020; 95% CI: 0.014, 0.026] and with raised ALT in logistic regression models [with a steady increase in the odds ratio (OR) estimates across deciles of PFOA and PFOS; PFOA: OR = 1.10; 95% CI: 1.07, 1.13; PFOS: OR = 1.13; 95% CI: 1.07, 1.18]. There was less consistent evidence of an association of PFOA and GGT or bilirubin. The relationship with bilirubin appears to rise at low levels of PFOA and to fall again at higher levels. CONCLUSIONS: These results show a positive association between PFOA and PFOS concentrations and serum ALT level, a marker of hepatocellular damage.

Tabletop scenarios for realism in bioterrorism and threat preparedness.

Five realistic tabletop scenarios were designed to facilitate threat preparedness training of Medical, Public Health, Nursing, Emergency Services, Mental Health, Allied Health, and Pharmacy personnel. Training scenarios were (1) student contaminates lettuce (Act) in a state university with Shigella sonnei (Agent), (2) dismissed athlete contaminates ice (Act) at the basketball tournament with Escherichia coli (Agent), (3) workers fail to report abandoned backpacks (Act) at a state fair that contain smallpox virus (Agent), (4) terrorists expose county residents (Act) to Pneumonic plague bacterium (Agent), and (5) infected birds expose field-trip participants (Act) to Avian influenza virus (Agent). Evaluation of the tabletops yielded positive ratings of educational outcomes in these domains: well-structured, organized, plausible, realistic, engaging, on-target, useful, and multidisciplinary. Attendees with previous blended-learning courses on bioterrorism and threat preparedness enhanced performance in the tabletop exercises. Evaluative data indicated a new level of competence and self-confidence about being part of a coordinated, local-level, interdisciplinary response.

The relationship between gamma-glutamyl transferase levels and chronic kidney disease among Appalachian adults.

BACKGROUND: Serum gamma-glutamyl transferase (GGT), a marker of oxidative stress has been associated with diabetes and hypertension, which are risk factors for chronic kidney disease (CKD). However, it is unclear whether serum GGT is independently associated with CKD. METHODS: We analyzed data from a population-based study of Appalachian adults residing in six communities in Ohio and West Virginia, who were aged > or = 18 years (n = 55,187, 52% women). Serum GGT was examined as gender-specific quintiles (quintiles 1-5 in women: 0-11 U/L, 12-14 U/L, 15-19 U/L, 20-29 U/L and > 29 U/L; quintiles 1-5 in men: 0-17 U/L, 18-23 U/L, 24-30 U/L, 31-45 U/L, and > 45 U/L). The main outcome of interest was CKD (n = 4482), defined as an estimated glomerular filtration rate of < 60 mL/ min/1.73 m2 from serum creatinine. RESULTS: Higher serum GGT levels were not found to be associated with CKD after adjusting for age, education, smoking, alcohol intake, body mass index (BMI), diabetes, hypertension and total cholesterol. In women, compared to quintile 1 of GGT, the odds ratio (OR) (95% confidence interval [CI]) of CKD associated with quintile 5 was 0.93 (0.82-1.06); p-trend = 0.3102. Similarly, in men, compared to quintile 1 of GGT, the odds ratio (OR) (95% confidence interval [CI]) of CKD associated with quintile 5 was 0.94 (0.80-1.10); p-trend = 0.4372. Subgroup analyses that examined the relation between GGT and CKD by alcohol intake and BMI categories also showed a consistent null association. CONCLUSION: In a community-based sample of Appalachian adults, higher serum GGT was not found to be independently associated with CKD.

Perfluorocarbon exposure, gender and thyroid function in the C8 Health Project.

Perfluorocarbons from common household products such as food containers, stain- resistant protection for clothing, furniture and carpets, paints, and fire-fighting foams are found in soil, water, plants, animal and human serum worldwide. Previous research has shown a significant association between these chemicals and thyroid disease in women. The present data from the C8 Health Project assessed thyroid function in a cross-sectional analysis of 52,296 adults with a year or more of exposure to perfluorooctanoate (PFOA) from drinking water. Outcomes were: thyroxine, T3 uptake, and thyroid stimulating hormone (TSH). Analyses were stratified by gender and age group (< 20 - < 50 years and > 50). Both PFOA and perfluorooctane sulfonate (PFOS) were associated with significant elevations in serum thyroxine and a significant reduction in T3 uptake in all participants. There were also significant gender/PFOS interactions for T3( )uptake and thyroxine, as well as gender/PFOA interactions for T3 uptake. Results provide evidence for disruption of thyroid function related to these common chemicals and possible mechanisms are discussed.

Association of osteoarthritis with serum levels of the environmental contaminants perfluorooctanoate and perfluorooctane sulfonate in a large Appalachian population.

Perfluorooctanoate (PFOA) and perfluorooctane sulfonate (PFOS) are persistent environmental contaminants that affect metabolic regulation, inflammation, and other factors implicated in the pathogenesis of osteoarthritis (OA). However, the link between these compounds and OA remains unknown. In this study, the authors investigated the association of OA with PFOA and PFOS in a population of 49,432 adults from 6 PFOA-contaminated water districts in the mid-Ohio Valley (2005-2006). Participants completed a comprehensive health survey; serum levels of PFOA, PFOS, and a range of other blood markers were also measured. Medical history, including physician diagnosis of osteoarthritis, was assessed via self-report. Analyses included adjustment for demographic and lifestyle characteristics, body mass index, and other potential confounders. Reported OA showed a significant positive association with PFOA serum levels (for highest quartile of PFOA vs. lowest, adjusted odds ratio = 1.3, 95% confidence interval: 1.2, 1.5; P-trend = 0.00001) and a significant inverse association with PFOS (for highest quartile vs. lowest, adjusted odds ratio = 0.8, 95% confidence interval: 0.7, 0.9; P-trend = 0.00005). The relation between PFOA and OA was significantly stronger in younger and nonobese adults. Although the cross-sectional nature of this large, population-based study limits causal inference, the observed strong, divergent associations of reported OA with PFOA and PFOS may have important public health and etiologic implications and warrant further investigation.

Implications of early menopause in women exposed to perfluorocarbons.

CONTEXT: Perfluorocarbons (PFC) are man-made chemicals used in numerous household products. They have a long half-life in humans and complex animal toxicity, and accumulating evidence points toward associations with multiple human health endpoints. OBJECTIVE: Our objective was to investigate whether PFC are associated with endocrine disruption in women. DESIGN: Cross-sectional analyses were made between quintiles of serum PFC, serum estradiol, and menopause onset. SETTING: The C8 Health Project, with cohort of 69,030 adults and children, was conducted due to PFC contamination of drinking water from six water districts in two states. PARTICIPANTS: Participants included 25,957 women aged 18-65 yr. MAIN OUTCOME MEASURES: Serum estradiol levels and onset of menopause were assessed. The survey was the result of a class action suit, and survey designers (an independent corporation) had no a priori hypotheses. All hypotheses have been formulated by other investigators after data collection. RESULTS: After excluding women who reported hysterectomy and adjusting for age within the group, smoking, alcohol consumption, body mass index, and exercise, the odds of having experienced menopause were significantly higher in the highest quintile relative to the lowest quintile of perfluorooctanoate (PFOA) and perfluorooctane sulfonate (PFOS) in the perimenopausal [PFOS odds = 1.4, confidence interval (CI) = 1.1-1.8; PFOA odds =1.4, CI = 1.1-1.8] and menopausal age groups (PFOS odds = 2.1, CI=1.6-2.8; PFOA odds = 1.7, CI = 1.3-2.3). After appropriate exclusions and adjustment for covariates, there was a significant inverse association between PFOS and estradiol in perimenopausal (ß = -3.65; P < 0.0001) and menopausal age groups (ß = -0.83; P = 0.007) but not between PFOA and estradiol. CONCLUSIONS: These data suggest that PFC are associated with endocrine disruption in women and that further research on mechanisms is warranted.

A survey study of occupational pain and injury in ophthalmic plastic surgeons.

PURPOSE: To determine factors associated with pain/injury related to practicing ophthalmic plastic and reconstructive surgery. METHODS: A 29-question electronic survey was sent to the American Society of Ophthalmic Plastic and Reconstructive Surgery's listserv. The Chi-Squared Automatic Interaction Detector technique was used to generate a decision tree using SPSS software. The levels of dendograms were limited to 8. Significance was pre-established at α = 0.05. RESULTS: One hundred thirty surveys were completed, and 72.5% reported pain associated with operating, 80.9% reported use of loupe magnification, 68.7% reported use of a headlight, 42.5% reported modification of their operating room practice, and 9.2% reported stopping operating due to pain or spine injury. Most respondents regularly exercise, with 55.7% characterizing the amount of exercise as less than necessary; 60.8% and 57.3% agreed that loupe use and headlamp use, respectively, can lead to spine problems.Chi-Squared Automatic Interaction Detector analysis found that 62.7% (n = 47) with neck pain had modified their operating room practice, compared with 13.5% (n = 7) without pain (χ = 30.42; df = 1; p < 0.001); All surgeons that had to stop operating (n = 9) had tried modifying their operating room practice; over half (57.6%, n = 38) of practicing surgeons had changed their operating room practice (χ = 6.09; df = 1; p = 0.014). The majority who exercised 5 hours or less had modified their operating room practice (70.2%, n = 33), compared with 26.3% (n = 5) who exercised more. CONCLUSIONS: Many oculoplastic surgeons experience discomfort due to operating, and an alarming minority have stopped operating due to pain or neck injury. Participants identified loupe and headlamp use as a special concern.

Suicide and unintentional poisoning mortality trends in the United States, 1987-2006: two unrelated phenomena?

BACKGROUND: Two counter trends in injury mortality have been separately reported in the US in recent times - a declining suicide rate and a rapidly rising unintentional poisoning mortality rate. Poisoning suicides are especially difficult to detect, and injury of undetermined intent is the underlying cause-of-death category most likely to reflect this difficulty. We compare suicide and poisoning mortality trends over two decades in a preliminary assessment of their independence and implications for suicide misclassification. METHODS: Description of overall and gender- and age-specific trends using national mortality data from WISQARS, the Web-based Injury Statistics Query and Reporting System, maintained by the Centers for Disease Control and Prevention (CDC). Subjects were the 936,633 residents dying in the 50 states and the District of Columbia between 1987 and 2006 whose underlying cause of death was classified as suicide, unintentional poisoning, or injury mortality of undetermined intent. RESULTS: The official US suicide rate declined 18% between 1987 and 2000, from 12.71 to 10.43 deaths per 100,000 population. It then increased to 11.15 deaths per 100,000 by 2006, a 7% rise. By contrast to these much smaller rate changes for suicide, the unintentional poisoning mortality rate rose more than fourfold between 1987 and 2006, from 2.19 to 9.22 deaths per 100,000. Only the population aged 65 years and older showed a sustained decline in the suicide rate over the entire observation period. Consistently highest in gender-age comparisons, the elderly male rate declined by 35%. The elderly female rate declined by 43%. Unlike rate trends for the non-elderly, both declines appeared independent of corresponding mortality trends for unintentional poisoning and poisoning of undetermined intent. The elderly also deviated from younger counterparts by having a smaller proportion of their injury deaths of undetermined intent classified as poisoning. Poisoning manifested as a less common method of suicide for this group than other decedents, except for those aged 15-24 years. Although remaining low, the undetermined poisoning mortality rate increased over the observation period. CONCLUSIONS: The official decline in the suicide rate between 1987 and 2000 may have been a partial artifact of misclassification of non-elderly suicides within unintentional poisoning mortality. We recommend in-depth national, regional, and local population-based research investigations of the poisoning-suicide nexus, and endorse calls for widening the scope of the definition of suicide and evaluation of its risk factors.