An Evaluation of the Relationship among Urine, Air, and Hand Measures of Exposure to Bisphenol A (BPA) in US Manufacturing Workers.

Background: Exposure to bisphenol A (BPA) can be assessed using external and internal exposure measures. We examined the relationship between two measures of external BPA exposure (air and hand-wipe samples) and one of internal exposure (total BPA in urine) for a group of US manufacturing workers. Methods: During 2013-2014, we recruited 78 workers from six US companies that made BPA or made products with BPA. We quantified BPA in seven urine samples, two full-shift air samples and in pre- and end-shift hand-wipe samples collected from workers over 2 consecutive days. We examined correlations between creatinine-corrected urinary concentrations of total BPA (total BPACR) and BPA levels in air and hand wipes using Pearson's correlation coefficient. We also applied mixed-effects regression models to examine the relationship between total BPACR with BPA in air (urine~air model) and with BPA in end-shift hand wipes (urine~hand model), separately and together (urine~air+hand model), after adjusting for covariates. Results: End-shift total BPACR strongly correlated with BPA in air (rp = 0.79, P < 0.0001) and nearly as strongly with BPA in end-shift hand wipes (rp = 0.75, P < 0.0001). In mixed-effect models, BPA air concentration and end-shift hand-wipe BPA level were significantly and positively associated with end-shift total BPACR (P < 0.0001 each). We found a significant effect of the Day 1 BPA air concentration on Day 2 total BPACR (P = 0.0104). When BPA air concentration and end-shift hand-wipe BPA level were in the same model, the air concentration (P < 0.0001) was more significant than the hand-wipe level (P = 0.0106). Conclusion: BPA levels in air and end-shift hand wipes strongly correlated with total BPACR, suggesting that both inhalation and dermal contract were likely exposure routes; however, inhalation, on average, appeared to be a more dominant exposure route than dermal contact for these manufacturing workers.

Air, hand wipe, and surface wipe sampling for Bisphenol A (BPA) among workers in industries that manufacture and use BPA in the United States.

For decades, bisphenol A (BPA) has been used in making polycarbonate, epoxy, and phenolic resins and certain investment casting waxes, yet published exposure data are lacking for U.S. manufacturing workers. In 2013-2014, BPA air and hand exposures were quantified for 78 workers at six U.S. companies making BPA or BPA-based products. Exposure measures included an inhalable-fraction personal air sample on each of two consecutive work days (n = 146), pre- and end-shift hand wipe samples on the second day (n = 74 each), and surface wipe samples (n = 88). Potential determinants of BPA air and end-shift hand exposures (after natural log transformation) were assessed in univariate and multiple regression mixed models. The geometric mean (GM) BPA air concentration was 4.0 µg/m3 (maximum 920 µg/m3). The end-shift GM BPA hand level (26 µg/sample) was 10-times higher than the pre-shift level (2.6 µg/sample). BPA air and hand exposures differed significantly by industry and job. BPA air concentrations and end-shift hand levels were highest in the BPA-filled wax manufacturing/reclaim industry (GMAir = 48 µg/m3, GMHand-End = 130 µg/sample) and in the job of working with molten BPA-filled wax (GMAir = 43 µg/m3, GMHand-End = 180 µg/sample), and lowest in the phenolic resins industry (GMAir = 0.85 µg/m3, GMHand-End = 0.43 µg/sample) and in the job of flaking phenolic resins (GMAIR = 0.62 µg/m3, GMHand-End = 0.38 µg/sample). Determinants of increased BPA air concentration were industry, handling BPA containers, spilling BPA, and spending ≥50% of the shift in production areas; increasing age was associated with lower air concentrations. BPA hand exposure determinants were influenced by high values for two workers; for all other workers, tasks involving contact with BPA-containing materials and spending ≥50% of the shift in production areas were associated with increased BPA hand levels. Surface wipe BPA levels were significantly lower in eating/office areas (GM = 9.3 µg/100 cm2) than in production areas (GM = 140 µg/100 cm2). In conclusion, worker BPA exposure was associated with tasks and conditions affecting both inhalation and dermal exposure. The potential for BPA-related health effects among these workers is unknown.

Foreign body impaction of the vertebral canal.

Foreign body impactions in the aerodigestive tract are common, but have the potential for serious complications. A foreign body may disrupt the mucosal lining and migrate regionally thereby risking impingement or injury to critical neurovascular structures in the cervical region. It is important to recognize potential complications that may arise from luminal compromise. In such cases, expeditious surgical treatment is warranted.

Otitis media in a new mouse model for CHARGE syndrome with a deletion in the Chd7 gene.

Otitis media is a middle ear disease common in children under three years old. Otitis media can occur in normal individuals with no other symptoms or syndromes, but it is often seen in individuals clinically diagnosed with genetic diseases such as CHARGE syndrome, a complex genetic disease caused by mutation in the Chd7 gene and characterized by multiple birth defects. Although otitis media is common in human CHARGE syndrome patients, it has not been reported in mouse models of CHARGE syndrome. In this study, we report a mouse model with a spontaneous deletion mutation in the Chd7 gene and with chronic otitis media of early onset age accompanied by hearing loss. These mice also exhibit morphological alteration in the Eustachian tubes, dysregulation of epithelial proliferation, and decreased density of middle ear cilia. Gene expression profiling revealed up-regulation of Muc5ac, Muc5b and Tgf-ß1 transcripts, the products of which are involved in mucin production and TGF pathway regulation. This is the first mouse model of CHARGE syndrome reported to show otitis media with effusion and it will be valuable for studying the etiology of otitis media and other symptoms in CHARGE syndrome.

Sh3pxd2b mice are a model for craniofacial dysmorphology and otitis media.

Craniofacial defects that occur through gene mutation during development increase vulnerability to eustachian tube dysfunction. These defects can lead to an increased incidence of otitis media. We examined the effects of a mutation in the Sh3pxd2b gene (Sh3pxd2b(nee)) on the progression of otitis media and hearing impairment at various developmental stages. We found that all mice that had the Sh3pxd2b(nee) mutation went on to develop craniofacial dysmorphologies and subsequently otitis media, by as early as 11 days of age. We found noteworthy changes in cilia and goblet cells of the middle ear mucosa in Sh3pxd2b(nee) mutant mice using scanning electronic microscopy. By measuring craniofacial dimensions, we determined for the first time in an animal model that this mouse has altered eustachian tube morphology consistent with a more horizontal position of the eustachian tube. All mutants were found to have hearing impairment. Expression of TNF-α and TLR2, which correlates with inflammation in otitis media, was up-regulated in the ears of mutant mice when examined by immunohistochemistry and semi-quantitative RT-PCR. The mouse model with a mutation in the Sh3pxd2b gene (Sh3pxd2b(nee)) mirrors craniofacial dysmorphology and otitis media in humans.

Lack of financial barriers to pediatric cochlear implantation: impact of socioeconomic status on access and outcomes.

OBJECTIVES: (1) To analyze if socioeconomic status influences access to cochlear implantation in an environment with adequate Medicaid reimbursement. (2) To determine the impact of socioeconomic status on outcomes after unilateral cochlear implantation. DESIGN: Retrospective cohort study. SETTING: University Hospitals Case Medical Center and Rainbow Babies and Children's Hospital (tertiary referral center), Cleveland, Ohio. PARTICIPANTS: Pediatric patients (age range, newborn to 18 years) who received unilateral cochlear implantation during the period 1996 to 2008. MAIN OUTCOME MEASURES: Access to cochlear implantation after referral to a cochlear implant center, postoperative complications, compliance with follow-up appointments, and access to sequential bilateral cochlear implantation. RESULTS: A total of 133 pediatric patients were included in this study; 64 were Medicaid-insured patients and 69 were privately insured patients. There was no statistical difference in the odds of initial cochlear implantation, age at referral, or age at implantation between the 2 groups. The odds of prelingual Medicaid-insured patients receiving sequential bilateral cochlear implantation was less than half that of the privately insured group (odds ratio [OR], 0.43; P = .03). The odds of complications in Medicaid-insured children were almost 5-fold greater than the odds for privately insured children (OR, 4.6; P = .03). There were 10 complications in 51 Medicaid-insured patients (19.6%) as opposed to 3 in 61 privately insured patients (4.9%). Medicaid-insured patients missed substantially more follow-up appointments overall (35% vs 23%) and more consecutive visits (1.9 vs 1.1) compared with privately insured patients. CONCLUSIONS: In an environment with adequate Medicaid reimbursement, eligible children have equal access to cochlear implantation, regardless of socioeconomic background. However, lower socioeconomic background is associated with higher rates of postoperative complications, worse follow-up compliance, and lower rates of sequential bilateral implantation, observed herein in Medicaid-insured patients. These findings present opportunities for cochlear implant centers to create programs to address such downstream disparities.

Photodynamic therapy of cottontail rabbit papillomavirus-induced papillomas in a severe combined immunodeficient mouse xenograft system.

OBJECTIVES/HYPOTHESIS: To evaluate the efficacy of photodynamic therapy (PDT) with the phthalocyanine photosensitizer Pc 4 for treating an animal model of recurrent respiratory papillomatosis (RRP). METHODS: Rabbit skin was grafted onto the dorsum of severe combined immunodeficient mice, two xenografts per animal. After the graft healed, it was inoculated with cottontail rabbit papillomavirus (CRPV). When papillomas developed, Pc 4 (0.6 or 1.0 mg/kg) was administered systemically, and 48 hours later, one papilloma of the two on each animal was exposed to 675-nm photoactivating light at either 100 or 150 J/cm(2). In addition to the contralateral tumors, which received Pc 4 but no light, other controls included animals receiving light only or neither agent. Response was assessed by measuring papilloma size with a caliper. Some papillomas and residual skin were harvested for histological assessment. RESULTS: For the lower-dose PDT regimens, papilloma growth rates were not significantly different from the controls. In contrast, 13 of 15 papillomas receiving the higher Pc 4 dose (1.0 mg/kg) and the higher light fluence (150 J/cm(2)) regressed completely and did not regrow within the observation period of up to 79 days. The response of these papillomas was significantly different from the controls (P < .001). Histological analysis confirmed the absence of residual tumor following complete response and replacement with near-normal epithelium. CONCLUSIONS: Pc 4-PDT is highly effective in treating virally induced (CRPV) papillomas in a murine model of RRP, and thus warrants further study as a treatment for HPV-induced papillomas.

An unusual case of ingestion of a moth cocoon in a 14-month-old girl.

We present a case report of a 14-month-old girl who ingested a moth cocoon, which resulted in dramatic symptoms of irritability, drooling, and anorexia. Direct laryngoscopy, bronchoscopy, and esophagoscopy under general anesthesia revealed copious, tenaciously adherent, barbed hairs embedded in her tongue and buccal mucosa. Removal of the hairs with irrigation, suction, and brushing was unsuccessful and was eventually abandoned. In the following 48 hours, the girl recovered uneventfully with supportive care. The hairs were subsequently identified as coming from the hickory tussock moth (Lepidoptera: Arctiidae: Lophocampa caryae), which is ubiquitously distributed throughout much of North America. This is the first detailed case report of ingestion of an L caryae cocoon.

Vestibular-evoked myogenic potentials in infancy and early childhood.

OBJECTIVE: Hearing impairment and the often concurrent loss of vestibular function, which is rarely assessed in infants, can both impair sensory integration critical to the development of normal motor coordination. This study demonstrates, for the first time, that vestibular function in infants can be noninvasively assessed using vestibular-evoked myogenic potentials (VEMPs). Our intentions were to demonstrate that VEMPs can be reliably recorded from neonates and to compare neonatal VEMPs with those obtained from normal adults. STUDY DESIGN: Prospective cohort study. METHODS: Myogenic evoked potentials induced by air- and bone-conducted auditory stimuli were recorded from the sternocleidomastoid muscles of 12 normal neonates and 12 neonates with various clinical findings. These included infants with bilateral atresia of the external auditory canals, Treacher-Collins syndrome, and neonates who failed universal neonatal screening. RESULTS: With the exception of one patient with hearing loss, reproducible biphasic VEMPs were recorded from the sternocleidomastoid muscle of all the infants using loud, short tone-burst sounds. CONCLUSIONS: The VEMP has characteristics that differentiate it from the postauricular response and the Jaw reflex. The VEMPs were dominant on the side ipsilateral to the stimulated ear. The overall morphology of the neonatal VEMP is quite similar to that of adults. The major neonatal differences are a shorter latency of the n23 peak and higher amplitude variability. Our results suggest that recording of the VEMP in neonates with various audio-vestibular problems provides useful information about vestibular function in this population and may provide information that leads to better care and rehabilitation for neonates at risk of developmental and motor system delay.

Anesthetic management for laser excision of recurrent respiratory papillomatosis in a third trimester parturient.

Recurrent respiratory papillomatosis (RRP) is characterized by the development of laryngeal papillomas, which can produce partial to complete upper airway obstruction. Patients with RRP often require intermittent surgical excision to treat symptoms such as hoarseness and stridor, and to control progression of the lesions. The anesthetic management of such patients is challenging, and it requires carefully coordinated care between an anesthesiologist and otolaryngologist. We present 2 cases of general anesthesia administration during surgical excision of laryngeal papillomas, both occurring during the third trimester of separate pregnancies in the same parturient. The complexity of management was amplified in these cases because of the physiological and anatomical changes associated with pregnancy, along with the need to monitor fetal well-being. Possible complications included complete airway obstruction, pulmonary aspiration of gastric contents, hypoxemia, fetal distress, and preterm labor. Because pregnancy may lead to activation of human papillomavirus, the causative organism of RRP, management guidelines are provided for anesthesiologists who may care for patients with RRP during pregnancy.

Age-, site-, and time-specific differences in pediatric deep neck abscesses.

OBJECTIVE: To clarify presentations, organisms, and locations of deep neck abscesses in children. DESIGN: Retrospective review. SETTING: Tertiary children's hospital. The study population comprised 169 patients younger than 19 years who were surgically treated for deep neck abscesses between 1989 and 1999. MAIN OUTCOME MEASURE: Resolution of abscess. RESULTS: Neck mass (91%), fever (86%), cervical adenopathy (83%), poor oral intake (66%), and neck stiffness (59%) were common in all ages. Patients younger than 4 years, compared with patients 4 years or older, presented with agitation (50% vs 14%), cough (35% vs 14%), drooling (27% vs 12%), lethargy (46% vs 33%), oropharyngeal abnormalities (45% vs 60%), respiratory distress (5% vs 2%), retractions (5% vs 2%), rhinorrhea (53% vs 15%), stridor (4% vs 2%), and trismus (14% vs 53%). Children younger than 1 year were infected with Staphylococcus aureus (79%) vs group A streptococcus (6%). Children 1 year or older were infected with group A streptococcus (29%) vs S aureus (16%). Retropharyngeal or parapharyngeal regions were involved in children 1 year or older (49%) vs younger than 1 year (21%). Anterior or posterior triangles and submandibular or submental regions were involved in 39% and 36%, respectively, of children younger than 1 year vs 30% and 23%, respectively, of children 1 year or older. Retropharyngeal and parapharyngeal abscesses yielded group A streptococcus (34%) vs S aureus (11%). Anterior and posterior triangle abscesses yielded S aureus (35%) vs group A streptococcus (19%), as did submandibular and submental abscesses (42% vs 19%). CONCLUSIONS: Abscesses in children younger than 1 year affected anterior or posterior triangles and submandibular or submental regions, yielding S aureus. Abscesses in children 1 year or older affected retropharyngeal or parapharyngeal regions, yielding group A streptococcus.

Presentation, diagnosis, and management of deep-neck abscesses in infants.

OBJECTIVE: To clarify the presenting signs and symptoms, clinical course, pathogenic organisms, and management of deep-neck-space abscesses in infants. DESIGN: Retrospective chart review. SETTING: Tertiary care academic children's hospital. PATIENTS: Records of 25 patients 9 months or younger with deep-neck-space abscesses from July 1989 through May 1999 were reviewed. MAIN OUTCOME MEASURE: Resolution of abscess. RESULTS: Presenting symptoms included neck mass, 92% (n = 23); fever, 60% (n = 15); and dysphagia and/or poor intake by mouth, 36% (n = 9). Overall, patients were symptomatic for a mean duration of 3.8 days before presenting to the hospital; 21 of 22 evaluated patients had elevated white blood cell counts. Imaging included 68% computed tomographic scan (n = 17) and 44% plain radiographs (n = 11). On the basis of radiology and operative findings, locations of the abscesses were as follows: anterior triangle, 8; parapharyngeal, 5; posterior triangle, retropharyngeal, and undefined, 3 each; submandibular, 2; and parotid, 1. Of 17 scanned patients, 13 had some degree of airway compromise evident on computed tomography. All were treated with incision and drainage, 3 of 25 intraorally and 22 of 25 externally. Pus was identified in all 25; 20 of these grew Staphylococcus aureus, 1 grew group A Streptococcus, and 4 grew no organism. All patients received intravenous antibiotics for a mean of 4.8 days and oral antibiotics for a mean of 11 days. Only 1 patient required a second procedure. CONCLUSIONS: Deep-neck-space abscesses in infants are rapidly progressive, often cause airway compromise, and usually present with fever and neck mass. The most common pathogen is S aureus. Patients are effectively treated with incision and drainage coupled with intravenous followed by oral antibiotics.