Proposed Mitigation and Adaptation Strategies Related to Climate Change: Guidance for OEM Professionals.

Climate change is an urgent challenge amplified by socioeconomic factors that demands thoughtful public health responses from OEM professionals. This guidance statement from the American College of Occupational and Environmental Medicine focuses on the different strategies that these health professionals can implement to protect workers from health impacts associated with climate change hazards, foster workplace resilience in the face of rapidly changing environments, and take the necessary steps to mitigate the effects of global climate change.

A Case Report of Cake Frosting as a Source of Copper Toxicity in a Pediatric Patient.

INTRODUCTION: Copper is an uncommon source of metal toxicity in children that requires a high index of suspicion for diagnosis. CASE REPORT: We describe the unique presentation of a 12-month-old girl who developed acute onset of vomiting and diarrhea after ingestion of a copper-contaminated birthday cake. CONCLUSION: This case highlights the presentation, evaluation, and management of the rare pediatric patient who presents with copper poisoning. This case also illuminates the public health implications of potential metal poisoning when using non-edible decorative products in homemade and commercially prepared baked goods.

Occupational Reproductive Hazards for Female Surgeons in the Operating Room: A Review.

Importance: Higher rates of infertility and pregnancy complications have been found for female surgeons compared with the general population. Several reproductive hazards are present in the operating room and may be associated with these findings. Hazards should be identified and controlled to minimize risks. Observations: Studies comparing surgeons with the general population show increased rates of infertility and pregnancy complications, including conditions affecting both mother and fetus, such as spontaneous abortion, preterm delivery, growth restriction, and congenital abnormalities. Attention has focused on older age and demanding working conditions of pregnant surgeons; however, there are reproductive hazards present in the operating room that might also be contributing. Relevant hazards include radiation, surgical smoke, working conditions, sharps injury, anesthetic gases, and intraoperative use of toxic agents. Published evidence is limited to retrospective studies. Robust data are often unavailable to guide specific dose-response relationships, making it difficult to quantify risk and create occupational safety guidelines. Nevertheless, regulatory agencies have set exposure limits for some agents, relying on limited evidence. Various workplace interventions have shown success in reducing exposure levels for many reproductive hazards and should be adopted by surgical workplaces. Conclusions and Relevance: Reproductive hazards exist in the operating room that may contribute to pregnancy complications and infertility in surgeons. Information and guidance should be given to female surgeons and trainees of reproductive age, and efforts should be made in the workplace to control exposures but not restrict female surgeons' activities unnecessarily.

Exploring exposure to Agent Orange and increased mortality due to bladder cancer.

BACKGROUND: During the Vietnam War, many veterans were exposed to Agent Orange (AO), a chemical defoliant containing varying levels of the carcinogen dioxin. The health effects of AO exposure have been widely studied in the VA population. Here we review and interpret data regarding the association between AO exposure and bladder cancer (BC) mortality. MAIN FINDINGS: Data evaluating the association between AO and BC is limited. Methods characterizing exposure have become more sophisticated over time. Several studies support the link between AO exposure and increased mortality due to BC, including the Korean Veterans Health Study. CONCLUSIONS: Available data suggest an association with exposure to AO and increased mortality due to BC. In patients exposed to AO, increased frequency of cystoscopic surveillance and potentially more aggressive therapy for those with BC may be warranted but utility of these strategies remains to be proven. Additional research is required to better understand the relationship between AO and BC.

Association of urinary phenolic compounds, inflammatory bowel disease and chronic diarrheal symptoms: Evidence from the National Health and Nutrition Examination Survey.

Endocrine disruptors such as phenolic compounds and parabens may be involved in chronic non-infective disease. While products incorporating these compounds are extensively utilized in consumer and personal products, little is known about their effect on bowel health. Inflammatory bowel disease (IBD) - consisting of the diseases ulcerative colitis and Crohn's disease - and irritable bowel syndrome are common chronic non-infectious diarrheal diseases. Despite limited knowledge on the etiology of IBD, these diseases have increased prevalence in industrialized countries and cause significant impairment to quality of life. In the present study we examine relationships between urinary environmental phenolic compounds, chronic diarrhea and inflammatory bowel disease. Data was obtained from the 2005-2010 US National Health and Nutrition Examination Survey (NHANES) including demographics, lifestyle factors, self-reported health conditions, inflammatory markers and urinary phenolic chemical concentrations. Only participants with complete environmental phenols & parabens component were included in our analysis. Chronic diarrheal symptoms were determined by using the 2009-2010 NHANES questionnaire which included questions pertaining to bowel health. We utilized chronic bowel leakage symptoms as a surrogate marker for chronic diarrhea. The presence of IBD was also analyzed from 2009 to 2010 NHANES data, as a sub-analysis for arthropathy directly querying the presence or absence of IBD. Among the subset of 5218 American adults aged 20-80 years in the NHANES study period who completed environmental phenols & parabens component, 25.5% reported chronic diarrheal symptoms. Abnormal markers of inflammation were present in 2200 (42.2%) of respondents. For IBD, 19 individuals with arthropathy confirmed a diagnosis of ulcerative colitis, and 1 person confirmed a Crohn's diagnosis. After adjustment for demographics, inflammatory and subsample weighing; lower paraben levels were associated with chronic bowel leakage (diarrheal) symptoms. Higher 4-tert-octylphenol levels was significantly associated with ulcerative colitis. Further study of underlying mechanisms should be considered.

Insect Repellants During Pregnancy in the Era of the Zika Virus.

Health care providers must be equipped to provide appropriate advice to reproductive-aged patients for protection against the potentially devastating consequences of prenatal Zika virus exposure. The goal of this commentary is to summarize what is known about the safety and toxicity of N,N-diethyl-meta-toluamide (DEET) as a topical insect repellant and the pyrethroid permethrin for treatment of fabric, endorsed in the fight against Zika virus. Reviews assessing the safety and toxicity of DEET conducted by the U.S. Environmental Protection Agency and the Canadian Pest Management Regulatory Agency conclude that DEET has low acute toxicity and does not appear to pose a significant health concern to humans when used as directed. Some experimental animal and limited epidemiologic data suggest that prenatal pyrethroid exposure may adversely affect learning and behavior, but this level of evidence pales in comparison to the known risks of Zika virus to the fetal brain. The available evidence has led to the strong recommendation by the Centers for Disease Control and Prevention for use of these products by pregnant women as personal protection against mosquito bites in the fight against Zika virus infection. This message has been affirmed by our obstetrics and gynecology professional organizations. Because Zika virus is unlikely to be the last disease requiring vector control, those with environmental health expertise must continue to join with infectious disease specialists to communicate the potential vulnerability of our youngest (fetuses, infants, and young children) to vector-borne disease, both to the disease itself and to the strategies employed to mitigate the spread of such disease.

Arsenic and skin cancer in the USA: the current evidence regarding arsenic-contaminated drinking water.

BACKGROUND: Studies carried out in developing countries, such as Bangladesh and Taiwan, have reported an association between exposure to arsenic in drinking water and increased rates of non-melanoma skin cancer. However, it is unclear whether this correlation can be extended to the populations of developed countries such as the USA, which have lower levels of arsenic exposure and differ in other factors, such as genetics, nutrition, sun exposure, and socioeconomic status. OBJECTIVES: This report examines the current evidence in an attempt to resolve whether populations in the USA have rates of skin cancer that correlate with higher arsenic concentrations. METHODS: A systematic literature search was conducted using the PubMed, EMBASE, CINAHL, and Cochrane databases. RESULTS: Six key studies were found and reviewed. Several studies conducted in US populations indicate an association between arsenic-contaminated water and skin cancer, which may in some cases occur at arsenic concentrations of <10 µg/l, the 2001 Environmental Protection Agency (EPA) maximum allowable concentration for municipal water. CONCLUSIONS: Private wells are not regulated by the EPA's rule, and many have concentrations above the EPA maximum. In order to help curb the rising incidence of skin cancer, arsenic contamination of water warrants the attention of policymakers. Greater testing of well water and increased education and skin cancer surveillance by dermatologists in arsenic-endemic areas may help to reduce exposure to arsenic and facilitate the early recognition of skin cancer.

Occupational handling of nickel nanoparticles: a case report.

A 26-year-old female chemist formulated polymers and coatings usually using silver ink particles. When she later began working with nickel nanoparticle powder weighed out and handled on a lab bench with no protective measures, she developed throat irritation, nasal congestion, "post nasal drip," facial flushing, and new skin reactions to her earrings and belt buckle which were temporally related to working with the nanoparticles. Subsequently she was found to have a positive reaction to nickel on the T.R.U.E. patch test, and a normal range FEV1 that increased by 16% post bronchodilator. It was difficult returning her to work even in other parts of the building due to recurrence of symptoms. This incident triggered the company to make plans for better control measures for working with nickel nanoparticles. In conclusion, a worker developed nickel sensitization when working with nanoparticle nickel powder in a setting without any special respiratory protection or control measures.

Wide variation in reference values for aluminum levels in children.

BACKGROUND: Some parents are requesting aluminum testing in their children with developmental issues. Although aluminum can be measured in plasma, serum, or urine, there is scant scientific information about normal ranges. We sought to determine the basis for laboratory reference ranges and whether these ranges are applicable to children. METHODS: From texts, published lists, and Internet sources, we obtained the names of 10 clinical laboratories that perform aluminum testing. Contact was made by telephone or e-mail, or Internet sites were viewed to obtain information regarding the establishment of aluminum reference ranges and testing methods in biological samples. Seven laboratories provided supporting literature that was reviewed regarding details of the study populations. RESULTS: For laboratories using the atomic absorption spectrometry method, aluminum reference ranges varied from <5.41 µg/L to <20 µg/L (serum), <7.00 µg/L to 0 to 10 µg/L (plasma) and 5 to 30 µg/L (urine). For those using the inductively coupled plasma mass spectroscopy methodology, ranges varied from 0 to 6 µg/L to <42 µg/L (serum), 0 to 10 µg/L to 0 to 15 µg/L (plasma), and 0 to 7 µg/L to 5 to 30 µg/L (urine). None of the reference ranges are known to be derived from studies of healthy children, but relied instead on small studies of adult populations, adult dialysis patients, workers, or sick children on aluminum-containing parenteral therapy. CONCLUSIONS: Aluminum reference ranges provided by laboratories are widely divergent, may not represent "normal" ranges of a healthy population, especially children, and thus it is difficult to interpret serum or urine aluminum ranges clinically. Further studies of aluminum in children are warranted and should be considered as part of the Centers for Disease Control and Prevention Biomonitoring Project.

Resetting our priorities in environmental health: an example from the South-North partnership in Lake Chapala, Mexico.

Lake Chapala is a major source of water for crop irrigation and subsistence fishing for a population of 300,000 people in central Mexico. Economic activities have created increasing pollution and pressure on the whole watershed resources. Previous reports of mercury concentrations detected in fish caught in Lake Chapala have raised concerns about health risks to local families who rely on fish for both their livelihood and traditional diet. Our own data has indicated that 27% of women of childbearing age have elevated hair mercury levels, and multivariable analysis indicated that frequent consumption of carp (i.e., once a week or more) was associated with significantly higher hair mercury concentrations. In this paper we describe a range of environmental health research projects. Our main priorities are to build the necessary capacities to identify sources of water pollution, enhance early detection of environmental hazardous exposures, and deliver feasible health protection measures targeting children and pregnant women. Our projects are led by the Children's Environmental Health Specialty Unit nested in the University of Guadalajara, in collaboration with the Department of Environmental Health of Harvard School of Public Health and Department of Pediatrics of the New York School of Medicine. Our partnership focuses on translation of knowledge, building capacity, advocacy and accountability. Communication will be enhanced among women's advocacy coalitions and the Ministries of Environment and Health. We see this initiative as an important pilot program with potential to be strengthened and replicated regionally and internationally.

Low-dose amitriptyline for treatment of persistent arm pain due to repetitive use.

Amitriptyline is sometimes used to treat arm pain related to repetitive use, but rigorous evidence of its benefit is lacking. This randomized controlled trial investigated whether amitriptyline provided greater pain relief or improved arm function than a placebo pill in adults with arm pain associated with repetitive use that had persisted for at least 3 months. Participants (N=118) were randomly assigned to receive 25mg of amitriptyline or a placebo pill for 6 weeks. The primary outcome was intensity of pain (10-point numerical rating scale) and secondary outcomes were arm symptoms, arm function, grip strength, mood, and sleep. Assessments were done at baseline, 3 and 6 weeks of treatment, and 1 month after the treatment ended. Changes in arm pain were not statistically significant. However, the amitriptyline group improved more than the placebo group in arm function (p=0.023) and sense of well being (p=0.034). In a longitudinal analysis, the amitriptyline group's arm function score improved 0.45 points per week faster than placebo after adjusting for subject characteristics (p=0.015). At the treatment's midpoint, the amitriptyline group reported more "troublesome side-effects" than the placebo group (52.5% vs. 27.1%, p=0.005), but this difference decreased by the end of the treatment (30.5% vs. 22.0%, p=0.30). The most frequent side effect was drowsiness. In conclusion, this study found that low-dose amitriptyline did not significantly decrease arm pain among these participants but did significantly improve arm function and well being. Future research is needed to explore the effects of higher doses and longer duration of treatment.

The impact of psychological factors on placebo responses in a randomized controlled trial comparing sham device to dummy pill.

OBJECTIVES: To explore to what extent psychological factors such as expectation, depression, anxiety and belief in alternative medicine impact placebo response and differential responses to separate placebo interventions. METHODS: We analysed data from a randomized controlled trial designed to compare the clinical response of two distinct placebo treatments (sham acupuncture device and placebo pill) in 119 participants with persistent distal upper arm pain due to repetitive stress injury. We used a multivariable linear regression model to identify potential correlates of self-reported upper extremity pain at the end of treatment in both placebo arms of the study combined. We also performed stratified analyses by placebo treatment. RESULTS: We did not find any of the psychological factors of interest to be associated with pain at the end of treatment in our combined analysis. We found higher baseline pain score and pain for longer than 1 year's duration to be significantly associated with higher pain scores at the end of treatment for the placebo treatments combined. In stratified analyses, for the sham acupuncture group, we found higher baseline depression score, higher baseline pain score and younger age to be independently correlated with higher pain score at the end of treatment. For the placebo pill group, only baseline pain was significantly correlated to pain score at the end of treatment. CONCLUSION: In this trial, neither expectancy nor psychological states were associated with response to placebo, with the exception of baseline depression score for the sham acupuncture arm.

Using seminar blogs to enhance student participation and learning in public health school classes.

OBJECTIVES: We evaluated whether "seminar blogs" enhanced learning in a large graduate-level introductory public health school class. METHODS: Sixty students were divided into 6 online blog groups. Students posted their assignments (case analyses, news commentaries), prompting comments from other students. Anonymous poll surveys of students were conducted at midpoint and at the end of the course. RESULTS: Sixty percent reported that blog participation enriched their learning quite a bit, 34% a small amount, and 6% not at all; 54% said that the blogs provided opportunities to learn from classmates. When comparing writing on the blog to speaking in class, 60% found it easier, 30% about the same, and 10% harder. About 65% said that skills attained by participating in blogs were useful for current or future work. Major criticisms involved time issues. CONCLUSIONS: Small seminar blogs offer opportunities for increased student participation, interaction, and learning. To be most effective and appealing, assignments for postings need to allow sufficient time for commentary. This educational technology has potential to expand the classroom experience and is worthy of further development and testing.

Acupuncture for treatment of persistent arm pain due to repetitive use: a randomized controlled clinical trial.

OBJECTIVE: To compare true and sham acupuncture in their abilities to relieve arm pain and improve arm function in individuals with arm pain due to repetitive use. METHODS: Participants with persistent arm pain (N=123) were randomly assigned to true or sham acupuncture groups and received 8 treatments over 4 weeks. The primary outcome was intensity of pain (10-point scale) and secondary outcomes were arm symptoms, arm function, and grip strength. Outcomes were measured during treatment (at 2 and 4 wk) and 1 month after treatment ended. RESULTS: Arm pain scores improved in both groups during the treatment period, but improvements were significantly greater in the sham group than in the true acupuncture group. This difference disappeared by 1 month after treatment ended. The true acupuncture group experienced more side effects, predominantly mild pain at time of treatments. DISCUSSION: Sham acupuncture reduced arm pain more than true acupuncture during treatment, but the difference did not persist after 1 month. Mild side effects from true acupuncture may have blunted any positive treatment effects. Overall, this study did not find evidence to support the effectiveness of true acupuncture in treatment of persistent arm pain due to repetitive use.

Elevated urine arsenic: un-speciated results lead to unnecessary concern and further evaluations.

The consumption of seafood within two to three days of testing can increase total urine arsenic concentrations. Few clinicians are familiar with this fact and often misinterpret elevated results. A retrospective chart review of all cases with arsenic testing seen between 1991 and 2004 at an occupational and environmental medicine referral clinic was performed. Urine arsenic results were classified as follows: total arsenic levels; speciated results (inorganic, ionic arsenic); and whether the patient abstained from seafood prior to the collection. Laboratory detection limits for total and for ionic arsenic were < or = 2 microg/L. Fifty-four patients with urine arsenic testing were identified. The total urine arsenic concentration exceeded 40 microg/L for 28 patients. On paired, speciated testing (n = 21), mean total arsenic was 122 +/- 227 microg/L, and ionic arsenic was not detected in any of these same samples (p = 0.023). On paired testing, before and after seafood abstention (n = 12), total urine arsenic without abstention was 291 +/- 267 microg/L, and it was only 9 +/- 12 microg/L after seafood abstention (p = 0.004). The total urine arsenic elevations observed in our series were due to benign organic arsenic compounds commonly found in seafood. Laboratories should reflexively perform speciation on most samples with elevated total arsenic concentrations prior to reporting the results. Reflexive speciation could reduce unnecessary referrals, further testing, and patient anxiety.

Sham device v inert pill: randomised controlled trial of two placebo treatments.

OBJECTIVE: To investigate whether a sham device (a validated sham acupuncture needle) has a greater placebo effect than an inert pill in patients with persistent arm pain. DESIGN: A single blind randomised controlled trial created from the two week placebo run-in periods for two nested trials that compared acupuncture and amitriptyline with their respective placebo controls. Comparison of participants who remained on placebo continued beyond the run-in period to the end of the study. SETTING: Academic medical centre. PARTICIPANTS: 270 adults with arm pain due to repetitive use that had lasted at least three months despite treatment and who scored > or =3 on a 10 point pain scale. INTERVENTIONS: Acupuncture with sham device twice a week for six weeks or placebo pill once a day for eight weeks. MAIN OUTCOME MEASURES: Arm pain measured on a 10 point pain scale. Secondary outcomes were symptoms measured by the Levine symptom severity scale, function measured by Pransky's upper extremity function scale, and grip strength. RESULTS: Pain decreased during the two week placebo run-in period in both the sham device and placebo pill groups, but changes were not different between the groups (-0.14, 95% confidence interval -0.52 to 0.25, P = 0.49). Changes in severity scores for arm symptoms and grip strength were similar between groups, but arm function improved more in the placebo pill group (2.0, 0.06 to 3.92, P = 0.04). Longitudinal regression analyses that followed participants throughout the treatment period showed significantly greater downward slopes per week on the 10 point arm pain scale in the sham device group than in the placebo pill group (-0.33 (-0.40 to -0.26) v -0.15 (-0.21 to -0.09), P = 0.0001) and on the symptom severity scale (-0.07 (-0.09 to -0.05) v -0.05 (-0.06 to -0.03), P = 0.02). Differences were not significant, however, on the function scale or for grip strength. Reported adverse effects were different in the two groups. CONCLUSIONS: The sham device had greater effects than the placebo pill on self reported pain and severity of symptoms over the entire course of treatment but not during the two week placebo run in. Placebo effects seem to be malleable and depend on the behaviours embedded in medical rituals.