Adaptación transcultural y validación de la versión española del EUROQUEST / Transcultural adaptation and validation of the Spanish version of EUROQUEST

Introducción: El diagnóstico específico de la encefalopatía tóxica (TE) por exposición crónica a neurotóxicos presenta dificultades fundamentalmente por la carencia de criterios clínicos de diagnóstico consensuados. El EUROQUEST (EQ) es un instrumento multicultural propuesto para su uso en estudios epidemiológicos sobre la neurotoxicidad. El objetivo de este estudio ha sido la validación de la versión española de este cuestionario para su uso como instrumento de diagnóstico y prevención en el ámbito laboral. Métodos: Tras la traducción y adaptación transcultural se ha generado un cuestionario definitivo en español y se ha realizado la validación mediante el pase del cuestionario a un total de 759 personas: 292 trabajadores expuestos a disolventes neurotóxicos, 391 trabajadores no expuestos y 22 pacientes diagnosticados de alcoholismo crónico. Resultados: En el análisis de la fiabilidad el valor del α de Cronbach para la totalidad del cuestionario fue de 0,94, lo que indica una consistencia interna muy elevada. La prueba test-retest para el análisis de la reproducibilidad fue muy significativa (r = 0,91, p < 0,001). En el análisis de la validez la comparación para los 3 grupos de estudio de las puntuaciones medias de las preguntas incluidas en cada una de las dimensiones del test (ANOVA) detectó mayores diferencias en las dimensiones que valoran los síntomas cognitivos, depresivos, alteraciones del sueño y síntomas psicopatológicos. Tras el análisis factorial se han obtenido un total de 9 ejes, que permiten diferenciar claramente entre los 3 grupos de estudio

Introduction: The specific diagnosis of toxic encephalopathy (TE) by chronic exposure to neurotoxics presents difficulties, mainly due to lack of consensus of clinical diagnostic criteria. The EUROQUEST (EQ) is a multicultural tool proposed for using in epidemiological studies on neurotoxicity. The aim of this study was to validate the Spanish version of this questionnaire for using as a diagnostic and prevention tool in the workplace. Methods: After translation and cultural adaptation, leading to a final questionnaire in Spanish, validation was performed by asking a total of 759 people to complete the questionnaire, of whom 292 were workers exposed to neurotoxic solvents, 391 non-exposed workers, and 22 patients diagnosed with chronic alcoholism. Results: In the analysis of the reliability, the Cronbach α value for the questionnaire was 0.94, indicating very high internal consistency. The test-retest reproducibility analysis was highly significant (r = 0.91, P < .001). In the analysis of the validity, comparing the three study groups, the mean scores of the questions included in each of the dimensions of the test (ANOVA) detected major differences in the dimensions that assess cognitive symptoms, depressive disorders, sleep and psychopathological symptoms. After factor analysis obtained a total of nine axes, allowing a clear distinction between the three study groups

Transcultural adaptation and validation of the Spanish version of EUROQUEST.

INTRODUCTION: The specific diagnosis of toxic encephalopathy (TE) by chronic exposure to neurotoxics presents difficulties, mainly due to lack of consensus of clinical diagnostic criteria. The EUROQUEST (EQ) is a multicultural tool proposed for using in epidemiological studies on neurotoxicity. The aim of this study was to validate the Spanish version of this questionnaire for using as a diagnostic and prevention tool in the workplace. METHODS: After translation and cultural adaptation, leading to a final questionnaire in Spanish, validation was performed by asking a total of 759 people to complete the questionnaire, of whom 292 were workers exposed to neurotoxic solvents, 391 non-exposed workers, and 22 patients diagnosed with chronic alcoholism. RESULTS: In the analysis of the reliability, the Cronbach α value for the questionnaire was 0.94, indicating very high internal consistency. The test-retest reproducibility analysis was highly significant (r=0.91, P<.001). In the analysis of the validity, comparing the three study groups, the mean scores of the questions included in each of the dimensions of the test (ANOVA) detected major differences in the dimensions that assess cognitive symptoms, depressive disorders, sleep and psychopathological symptoms. After factor analysis obtained a total of nine axes, allowing a clear distinction between the three study groups.

Use of the CYP2E1 genotype and phenotype for the biological monitoring of occupational exposure to styrene.

The CYP2E1 has been identified as the main cytochrome P450 isoform involved in human styrene metabolism. CYP2E1 presents polymorphism in humans and the different genotypes may, at least partly, be related to the different levels of individual expression of enzyme activity. We studied whether the genetic polymorphisms and phenotype of CYP2E1 modulate the level of urinary styrene metabolites and if they can be used for assessing risks of occupational exposure to styrene. A population of 49 male workers exposed to styrene (average level 362.7mg/m(3)) and a control group were selected. Samples of urine, blood and buccal swab were taken to determine the urinary biological indicators (phenylglyoxylic acid and mandelic acid), to quantify mRNA of CYP2E1 in blood using RT-PCR and to analyse different polymorphisms of enzyme CYP2E1 from buccal swab. We found decreased expression of mRNA of the enzyme, as well as decreased excretion of the styrene metabolites in individuals carrying the CYP2E1*5B heterozygote allele (cl/c2) with respect to the wild-type homozygote (c1/c1), which indicates a reduction in the inducibility of the enzyme in the presence of this polymorphism. The results show that the combined effect of both the CYP2E1 phenotype, measured by the expression of the specific mRNA in blood samples, and the CYP2E1*5B allele genotype, may explain the variability of urinary excretion of the styrene metabolites.

Activation of soluble guanylate cyclase by nitric oxide is increased in lymphocytes from both rats chronically exposed to 2,5-hexanedione and workers chronically exposed to n-hexane.

Although occupational exposure to n-hexane induces neurotoxic effects in the central and peripheral nervous systems, the mechanisms of its neurotoxicity remain unclear. n-Hexane is metabolized to 2,5-hexanedione (2,5-HD), which is the neurotoxic agent and the indicator chosen for the biological monitoring of exposed workers. It has been previously reported that chronic exposure to 2,5-HD impairs the glutamate-nitric oxide-cyclic GMP pathway at the level of activation of soluble guanylate cyclase (sGC) enzyme by nitric oxide (NO), both in cultured neurons and in the cerebellum of rats in vivo. The aim of this study was to assess whether the activation of sGC by NO is also altered in lymphocytes from rats treated with 2,5-HD and/or workers chronically exposed to n-hexane. Lymphocytes were isolated from male Wistar rats treated with 2,5-HD in drinking water, and from blood samples from shoe-factory workers environmentally and chronically exposed to n-hexane. Urine samples were also collected from workers at the end of the shift in order to measure the urinary levels of 2,5-HD. Activation of sGC by NO was significantly higher (p<0.05) in lymphocytes from rats treated with 2,5-HD than in control rats. In isolated lymphocytes from exposed workers the activation of sGC by NO also increases (p<0.05) in contrast to the controls. The results presented here indicate that the activation of lymphocytes could be an indicator of the toxicity produced by being exposed to n-hexane, since the effects observed in workers chronically exposed to n-hexane are similar to those found in rats chronically treated with 2,5-HD in drinking water.

Free and total 2,5-hexanedione in biological monitoring of workers exposed to n-hexane in the shoe industry.

OBJECTIVES: To analyse the role of total 2,5-hexanedione (2,5-HD) compared with free 2,5-HD as a biological indicator of exposure to n-hexane at work. METHODS: One-hundred and thirty two workers in contact with this solvent during their occupation in the shoe industry in the province of Alicante (Spain) were studied. Environmental and biological tests were carried out analysing variations of the concentration of the metabolite in urine corresponding to different working conditions. Environmental exposure was evaluated in each work place using active personal monitors and measured by gas chromatography (GC). Dichloromethane extracts of the urine samples collected at the end of the working shifts were analysed, before (determining free 2,5-HD, the toxic metabolite) and after acid hydrolysis (pH 0.1) (yielding the total 2,5-HD) and also by GC. The concentration of conjugated metabolite 4,5-dihydroxy-2-hexanone was calculated from the difference between total and free 2,5-HD. RESULTS: Free 2,5-HD represented an average of 14.2% of the total 2,5-HD determined in urine, and this percentage increased significantly (P<0.01) with higher environmental levels of acetone. Other factors, such as absorption through the skin (depending on the use of gloves) and the day on which samples were taken also significantly affected the relation between the two indicators and their respective relationships with environmental concentrations of n-hexane. CONCLUSION: Although analyses of the relationship between the levels of atmospheric n-hexane and those of metabolites in urine show a greater correlation for total 2,5-HD than for free 2,5-HD, our results suggest that free 2,5-HD could be a better indicator in evaluating risk of exposure to n-hexane, since the concentration is directly related to the neurotoxic effect.

Analysis of styrene and its metabolites in blood and urine of workers exposed to both styrene and acetone.

A purge-and-trap gas chromatographic (PT-GC) method for determining styrene concentrations in urine and blood samples has been used in the biological monitoring of workers exposed to styrene and acetone. Blood and urine samples were collected from 34 individuals exposed to both solvents at the end of a 4-h shift and measured for styrene in urine (Su), blood (Sb), and the two major urinary metabolites, mandelic acid (MA) and phenylglyoxylic acid (PGA). A second urine sample was taken at the beginning of the next shift. Environmental exposure was measured using passive personal monitoring and GC. Urinary excretion of MA and PGA was measured by high-performance liquid chromatography. The average exposures to styrene and acetone were 70.5 mg/m3 and 370.5 mg/m3, respectively. In end-of-shift samples there was a significant correlation between concentrations of Su and Sb and the metabolites PGA, MA (r = 0.714 and 0.788, p < 0.001 for Su and r = 0.644 and 0.566, p < 0.005 for Sb). A high correlation between Sb and Su (r = 0.732, p < 0.001) also existed. Poor correlations were found between Su and metabolites in samples collected at the beginning of the next shift (r = 0.491 and 0.474 for PGA and MA, respectively, p < 0.05). There was a better correlation between the biological parameters at the end of the shift and the environmental styrene (r = 0.841 for PGA, r = 0.834 for MA, r = 0.788 for Su, and r = 0.698 for Sb; p < 0.001) compared with those at the start of the shift (r = 0.81 for PGA, 0.675 for MA, and 0.650 for Su; p < 0.001). We found that the concentration of excreted metabolites decreased significantly when environmental concentrations of acetone increased (p < 0.05), particularly at the end of the shift. Although the best correlation with environmental styrene was obtained with the sum of PGA and MA at the end of the shift (r = 0.862, p < 0.001), urine and blood styrene were shown to be more useful biological monitoring indicators because their concentrations were not affected by acetone co-exposure.

Purge-and-trap gas chromatographic determination of styrene in urine and blood. Application to exposed workers.

A simple purge-and-trap gas chromatographic method with flame ionization detection was developed for the determination of styrene in urine and blood. Styrene present in a 5 ml sample at room temperature was swept by helium at 40 ml/min for 11 min, trapped on a Tenax trap, desorbed by heating, cryofocused, and injected by flash heating into a DB-5 capillary GC column. The oven temperature program was from 80 degrees C, held for 8 min, to 120 degrees C at 5 degrees C/min, and then held for 2 min. The detector temperature was 250 degrees C. The calibration curves were linear in the range of 2.5-15 ppb styrene in urine and 25-150 ppb in blood. The detection limits calculated were 0.4 microg/l in urine and 0.6 microg/l in blood. The coefficients of variations within the day and day-to-day were 3 and 3.1%, respectively, for 2.5 ppb of styrene in urine, and 1 and 1.6% for 25 ppb of styrene in blood. The results obtained from samples taken from workers exposed to styrene were reported.

Biological monitoring of styrene exposure and possible interference of acetone co-exposure.

The object of this study is the evaluation of some of the toxicokinetic effects of exposure to low concentrations of styrene, and the possible influence of simultaneous exposure to acetone. To this end we studied 19 workmen simultaneously exposed to both solvents. During a week of 4-h work shifts, the workmen underwent daily personal environmental monitoring and the collection of urine samples, at both the beginning and the end of the work period, for the determination of mandelic acid (MA) and phenylglyoxylic acid (PGA). The presence of the solvents in the atmosphere was evaluated using passive personal monitoring and gas chromatography. Average exposure to styrene and acetone were respectively 72.2 mg/m3 and 225.7 mg/m3. MA and PGA were quantified by high-performance liquid chromatography (HPLC). The daily urinary concentration averages, both at commencement and at the end of work shifts, of both the metabolites studied and of the sum of the two were in statistically significant linear correlation with the average daily styrene exposure. Concentrations of MA and PGA in urine samples collected at the start of the work shift averaged 61.5 mg/g creatinine and 45.2 mg/g creatinine respectively, representing 41% and 72% of those at the endo of the work shift which were 148.3 and 62.6 mg/g creatinine, respectively. With equal exposure to styrene, the average urinary concentrations of MA and PGA at both the beginning and end of the work shift increased significantly (P < 0.001) during the working week. Moreover, we found that with equal exposure to styrene, urinary excretion of MA, PGA and MA + PGA at the end of the shift was inversely correlated with the intensity of acetone exposure (r = 0.4659, 0.3410 and 0.542 respectively, P < 0.001). In conclusion, these results express slower urinary kinetics of styrene metabolites than is usually described in the literature, and favor a tendency to accumulate MA and PGA in the organism as a consequence of the retardation of urinary excretion kinetics. Acetone apparently represents one of the determining factors in this interference.

Behaviour of urinary 2,5-hexanedione in occupational co-exposure to n-hexane and acetone.

We analysed the relationship between free 2,5-hexanedione (2,5-HD) and total 2,5-HD in the urine of 87 workers exposed to n-hexane and other solvents (hexane isomers, acetone and toluene), in relation to different working conditions. The concentration of free 2,5-HD in urine of workers exposed to n-hexane was about 12% of total urinary 2,5-HD. The most significant correlation (r = 0.936) was that of total 2,5-HD in urine with environmental n-hexane and exhaled air. With equal exposure to n-hexane, the concentrations in urine of free and total 2,5-HD increased when cutaneous absorption was involved (gloves not used), during the working week and with co-exposure to acetone. An analysis of the relationship between combined exposure to acetone and urinary concentrations of the various forms of 2,5-HD suggests that acetone might influence the toxicokinetics of n-hexane, increasing the proportion of free 2,5-HD.

Early diagnosis of n-hexane-caused neuropathy.

n-Hexane neuropathy was studied in 20 workers exposed for prolonged periods to this solvent, and with urinary 2,5-hexanedione concentrations exceeding the biological exposure index recommended by the American Conference of Governmental Industrial Hygienists (5 mg/L) with a mean of 11.02 mg/L (range 5.3-24.2 mg/L). Although neurological examination did not detect significant anomalies in any of the patients, and the conduction velocity and F waves of all the nerves tested were normal, neurographic studies revealed significant differences in the amplitude of sensory nerve action potentials (SNAP) recorded from the sural (mean 14.0 microV), median (mean 17.3 microV), and ulnar (mean 7.9 microV) nerves when compared with normal values from healthy adults of the same age range, examined under identical conditions. The amplitude of the SNAP in sural and median nerves correlated significantly with the number of years worked. The notable decrease in mean amplitude of the SNAP appeared to reflect the primary neurotoxic effects of 2,5-hexanedione.

Biological monitoring of occupational exposure to n-hexane by measurement of urinary 2,5-hexanedione.

Occupational exposure to n-hexane in shoe factory workers was monitored by measuring urinary 2,5-hexanedione, the major metabolite of this solvent and the probable cause of peripheral neuropathy in exposed workers. Solvent pollution was monitored in the work environments of 189 employees, of whom 123 (65%) worked in Alicante, Spain, and 66 (35%) in Veneto, Italy. 2,5-Hexanedione was measured in spot urine samples collected from workers at the end of the shift. Information on working conditions was obtained from a previous study. A significant linear correlation was found between mean environmental concentration of n-hexane and urinary concentration of 2,5-hexanedione. The variability in the correlation may have been due to the variable use of protective clothing (gloves), and to variations in exposure during the working week. In numerous workers, percutaneous absorption of n-hexane represented as much as 50% of the total absorbed dose. Urinary concentrations of 2,5-hexanedione tended to increase during the working week. Simultaneous exposure to n-hexane and toluene tended to reduce urinary excretion of 2,5-hexanedione, whereas exposure to n-hexane and methyl ethyl ketone tended to increase excretion of the metabolite.

Biological monitoring of occupational exposure to n-hexane by exhaled air analysis and urinalysis.

To compare two methods of biological monitoring for the evaluation of risk of occupational exposure to n-hexane, we analyze the relationship between environmental exposure to this solvent and urinary excretion of 2,5-hexanedione and n-hexane in exhaled air in 69 workers employed in the shoe industry. Environmental exposure to the solvent was monitored with personal diffusive samplers, which were desorbed with carbon sulfide and analyzed by gas chromatography. To measure 2,5-hexanedione, urine was subjected to acid hydrolysis, separation in octadecyl silane columns, elution with 5% aqueous acetonitrile solution and extraction with dichloromethane, followed by gas chromatography. In exhaled air, n-hexane was measured with a sampling system that permitted concentration of aliquots of end-exhaled air (alveolar air) from one or more exhalations in a tube packed with activated charcoal, which was then desorbed with carbon sulfide and analyzed by gas chromatography. Concentrations of n-hexane in breathing zone air were significantly correlated with urinary concentrations of 2,5-hexanedione (r = 0.88) and with exhaled air n-hexane (r = 0.86); in addition, the two biological indicators correlated significantly (r = 0.70). Analyses in both exhaled air and urine were thus considered useful for biological monitoring of the risk of exposure to n-hexane.