Cleaning Products and Work-Related Asthma, 10 Year Update.

OBJECTIVE: To describe the frequency of work-related asthma (WRA) and characteristics of individuals with exposure to cleaning products 1998 to 2012, compared with 1993 to 1997. METHODS: Cases of WRA from products used for cleaning or disinfecting surfaces were identified from California, Massachusetts, Michigan (1998 to 2012), New Jersey (1998 to 2011), and New York (2009 to 2012). RESULTS: There were 1199 (12.4%) cleaning product cases among all 9667 WRA cases; 77.8% women, 62.1% white non-Hispanic, and average age of 43 years. The highest percentages worked in healthcare (41.1%), and were building cleaners (20.3%), or registered nurses (14.1%). CONCLUSIONS: The percentage of WRA cases from exposure to cleaning products from 1998 to 2012 was unchanged from 1993 to 1997 indicating that continued and additional prevention efforts are needed to reduce unnecessary use, identify safer products, and implement safer work processes.

Acute Illnesses and Injuries Related to Total Release Foggers - 10 States, 2007-2015.

Total release foggers (TRFs) (also known as "bug bombs") are pesticide products often used indoors to kill insects. After an earlier report found that TRFs pose a risk for acute illness (1), the Environmental Protection Agency required improved labels on TRFs manufactured after September 2012 (2). To examine the early impact of relabeling, the magnitude and characteristics of acute TRF-related illness were evaluated for the period 2007-2015. A total of 3,222 TRF-related illnesses were identified in 10 participating states, based on three data sources: Sentinel Event Notification System for Occupational Risk-Pesticides (SENSOR) programs, the California Department of Pesticide Regulation (CDPR) program, and poison control centers (PCCs) in Florida, Texas, and Washington. No statistically significant decline in the overall TRF-illness incidence rate was found. Failure to vacate treated premises during application was the most commonly reported cause of exposure. To reduce TRF-related illness, integrated pest management strategies (3) need to be adopted, as well as better communication about the hazards and proper uses of TRFs. Redesigning TRFs to prevent sudden, unexpected activation might also be useful.

Reports of adverse health effects related to synthetic cannabinoid use in New York State.

BACKGROUND/OBJECTIVES: We assessed synthetic cannabinoid (SC) outbreaks from 2011-2012 and 2015. METHODS: The National Poison Data System was utilized to collect reports of SC adverse effects in New York State from 2011-2012 and 2015 (N = 713). RESULTS: Cases from 2015 were more likely to be admitted to intensive care units and had different symptoms than those in 2011-2012. We identified two new SC structural classes from 2015 samples. DISCUSSION/CONCLUSIONS: The 2015 outbreak was associated with more severe SC-related illnesses than in 2011-2012. SCIENTIFIC SIGNIFICANCE: New SC compounds may pose a different or more severe risk than those previously identified. (Am J Addict 2017;26:772-775).

Managing Faecal INcontinence in people with advanced dementia resident in Care Homes (FINCH) study: a realist synthesis of the evidence.

BACKGROUND: Eighty per cent of care home residents in the UK are living with dementia. The prevalence of faecal incontinence (FI) in care homes is estimated to range from 30% to 50%. There is limited evidence of what is effective in the reduction and management of FI in care homes. OBJECTIVE: To provide a theory-driven explanation of the effectiveness of programmes that aim to improve FI in people with advanced dementia in care homes. DESIGN: A realist synthesis. This was an iterative approach that involved scoping of the literature and consultation with five stakeholder groups, a systematic search and analysis of published and unpublished evidence, and a validation of programme theories with relevant stakeholders. DATA SOURCES: The databases searched included PubMed, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Scopus, SocAbs, Applied Social Sciences Index and Abstracts, BiblioMap, Sirius, OpenGrey, Social Care Online and the National Research Register. RESULTS: The scoping identified six programme theories with related context-mechanism-outcome configurations for testing. These addressed (1) clinician-led support, assessment and review, (2) the contribution of teaching and support for care home staff on how to reduce and manage FI, (3) the causes and prevention of constipation, (4) how the cognitive and physical capacity of the resident affect outcomes, (5) how the potential for recovery, reduction and management of FI is understood by those involved and (6) how the care of people living with dementia and FI is integral to the work patterns of the care home and its staff. Data extraction was completed on 62 core papers with iterative searches of linked literature. Dementia was a known risk factor for FI, but its affect on the uptake of different interventions and the dementia-specific continence and toileting skills staff required was not addressed. Most care home residents with FI will be doubly incontinent and, therefore, there is limited value in focusing solely on FI or on single causes of FI such as constipation. Clinical assessment, knowledge of the causes of FI and strategies that recognise the individuals' preferences are necessary contextual factors. Valuing the intimate and personal care work that care home staff provide to people living with dementia and addressing the dementia-related challenges when providing continence care within the daily work routines are key to helping to reduce and manage FI in this population. LIMITATIONS: The synthesis was constrained by limited evidence specific to FI and people with dementia in care homes and by the lack of dementia-specific evidence on continence aids. CONCLUSIONS: This realist synthesis provides a theory-driven understanding of the conditions under which improvement in care for care home residents living with dementia and FI is likely to be successful. FUTURE WORK: Future multicomponent interventions need to take account of how the presence of dementia affects the behaviours and choices of those delivering and receiving continence care within a care home environment. STUDY REGISTRATION: This study is registered as PROSPERO CRD42014009902. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Influence of Intracranial Air on Electrode Position and Clinical Outcomes following Deep Brain Stimulation for Parkinson's Disease.

BACKGROUND: The introduction of intracranial air during deep brain stimulation (DBS) surgery is believed to negatively impact targeting accuracy and clinical outcomes. OBJECTIVE: To quantify the relationship between intracranial air (ICA) volumes, targeting accuracy, and clinical outcomes in patients undergoing subthalamic nucleus (STN) DBS for Parkinson's disease. METHODS: ICA in 73 consecutive STN DBS cases (146 leads) was measured by high-resolution CT and correlated with proximal lead bowing, electrode displacement, targeting accuracy, and clinical outcomes at 6 and 12 months. RESULTS: There was a statistically significant correlation of ICA volume (mean ± SEM: 21.3 ± 13.7 cm3) and proximal lead bowing (2.8 ± 1.4 mm, r = 0.34, p = 0.01). There was no significant correlation of ICA with targeting error (2.0 ± 1.2 mm), distal contact deviation (1.2 ± 0.7 mm), motor Movement Disorder Society-Unified Parkinson's Disease Rating Scale Part III improvement at 6 months (42.3 ± 4.5%) or 12 months (30.3 ± 7.7%), or dopaminergic medication reduction at 6 months (44.7± 4.2%) or 12 months (32.9 ± 5.9%). Comparison of top and bottom ICA quintile extremes also revealed no differences in these measures. CONCLUSIONS: Though the proximal DBS lead bends in association with ICA, movement of the distal contact, targeting error, and clinical outcomes are not affected by ICA. This unexpected finding is maintained at ICA quintile extremes.

Notes from the Field: Cardiac Dysrhythmias After Loperamide Abuse - New York, 2008-2016.

Loperamide is an over-the-counter antidiarrheal with opioid-receptor agonist properties. Recommended over-the-counter doses (range = 2-8 mg daily) do not produce opioid effects in the central nervous system because of poor oral bioavailability and P-glycoprotein efflux* of the medication (1); recent reports suggest that large doses (50-300 mg) of loperamide produce euphoria, central nervous system depression, and cardiotoxicity (2-4). Abuse of loperamide for its euphoric effect or for self-treatment of opioid withdrawal is increasing (5). Cases of loperamide abuse reported to the Upstate New York Poison Center and New York City Poison Control Center were analyzed for demographic, exposure, clinical, and laboratory characteristics. Cases of intentional loperamide abuse reported to the National Poison Database System (NPDS) also were analyzed for demographic, dose, formulation, and outcome information.

Atypical femur fractures in patients receiving bisphosphonate therapy: etiology and management.

Osteoporosis is a growing problem that is projected to affect more than 50% of American adults by 2020. Bisphosphonate therapy is currently the primary mode of treating osteoporosis in this population. While bisphosphonate therapy has been successful in increasing bone mineral density, data has shown an increased risk of atypical femur fractures with prolonged therapy. Atypical femur fractures are characterized by low-energy or atraumatic injuries that occur in the subtrochanteric region. They originate on the medial cortex, travel transversely, and typically have little or no comminution. Conservative therapy is indicated for patients with incomplete fractures without prodromal symptoms. Patients with incomplete fractures and significant prodromal symptoms or visible fracture line on radiographs, those who have failed conservative management, and those with complete fractures should be treated with intramedullary nail fixation. Evaluation should involve imaging of the contralateral femur. Teriparatide therapy may be considered for patients without contraindications. While the incidence of these fractures is low, it is likely that these rates will increase with the aging population and increased prevalence of patients being treated with bisphosphonate therapy.

Evaluating indirect subthalamic nucleus targeting with validated 3-tesla magnetic resonance imaging.

BACKGROUND/OBJECTIVES: Indirect targeting of the subthalamic nucleus (STN) is commonly utilized at deep brain stimulation (DBS) centers around the world. The superiority of either midcommissural point (MCP)-based or red nucleus (RN)-based indirect targeting remains to be established. METHODS: The location of the STN was determined and statistically compared to MCP- and RN-based predictions in 58 STN DBS patients, using a validated 3-tesla MRI protocol. The influence of additional neuroanatomical parameters on STN midpoint location was evaluated. Linear regression analysis was utilized to produce an optimized MCP/RN targeting model. Targeting coordinates at 1.5 T were compared to results at 3 T. RESULTS: Accuracy and precision for RN-based targeting was superior to MCP-based targeting to predict STN midpoint location for each coordinate dimension (p < 0.01 and p < 0.05, respectively). RN-based targeting was statistically equivalent to an optimized regression-based targeting strategy incorporating multiple neuroanatomical parameters, including third-ventricle width and overall brain size. RN-based targeting at 1.5 T yielded equivalent coordinates to targeting at 3 T. CONCLUSIONS: RN-based targeting is statistically superior to MCP-based STN targeting and accommodates broad variations in neuroanatomical parameters. Neurosurgeons utilizing indirect targeting of the STN may consider favoring RN-based over MCP-based indirect targeting methods.

Evaluation of a communications campaign to increase physician reporting to a surveillance system.

While all states have regulations requiring reporting of diseases from healthcare professionals and facilities, underreporting is substantial. To improve reporting to the New York State (NYS) Occupational Lung Disease Registry (OLDR), the NYS Department of Health's Bureau of Occupational Health initiated a multimedia campaign to increase case ascertainment and establish communication channels and partnerships for conducting prevention. The outreach campaign was successful in raising physician awareness about the OLDR, familiarizing physicians with reporting forms and procedures, and increasing physician reporting. It also raised awareness of the contribution of occupational factors to respiratory illness and other conditions. However, while our evaluation indicated it is possible to affect short-term outcomes, such as knowledge, attitudes, and behavior among health-care providers, the campaign was not as successful in promoting sustained reporting.

Surveillance of work-related asthma in new york state.

OBJECTIVE: The objective of this paper is to determine the percent of adults with asthma attributable to work and describe characteristics of the work-related asthma population in New York State. Sociodemographic and control characteristics of those with and without work-related asthma are compared. METHODS: Data from three population-based surveys and one case-based surveillance system were analyzed. Work-relatedness of asthma was determined by self-report for the population-based surveys and by physician report for the case-based system. Self-reported sociodemographic and control characteristics were analyzed for the population-based surveys by work-relatedness. RESULTS: The percent of work-relatedness among adults with current asthma in New York State ranged from 10.6% to 44.5%. Significantly more adults with work-related asthma had poorly controlled asthma than those without work-related asthma. More adults with work-related asthma also tended to be employed in the manufacturing, educational services, and public administration industries than the general population. The most frequently reported exposure was dust. CONCLUSIONS: Adults with work-related asthma have decreased control and adverse socioeconomic impacts compared to those with asthma that is not work-related. Increased recognition and physician reporting is necessary to further prevent the impact of work-related exposures.

Impulse oscillometry and respiratory symptoms in World Trade Center responders, 6 years post-9/11.

This study evaluated whether impulse oscillometry (IOS) testing revealed signs of respiratory disease in New York State (NYS) World Trade Center (WTC) responders in comparison with unexposed NYS employees. It also compared self-reported respiratory symptoms between the two groups, 6 years post-9/11. For this evaluation participants completed a self-administered questionnaire regarding respiratory symptoms. IOS testing included measures of resistance and reactance to assess for peripheral versus central airway effects. Two hundred forty-eight subjects (99 exposed and 149 unexposed) were included in the final analysis. Since September 11, 2001, NYS responders were more likely to report new or worsening cough in the absence of a respiratory infection, cough consistent with chronic bronchitis, current respiratory symptoms, or lower respiratory symptoms in the last 12 months. Significant associations were found between IOS indices and gender, smoking history, and obesity. When comparing exposed and unexposed participants, there were no significant differences in the geometric means of the IOS indices. Responders who used a respirator with canister demonstrated significantly lower respiratory resistance at 5 and 20 Hz (R5 and R20). While this study has provided no evidence of an association between WTC exposure and peripheral airways disease in this cohort of responders, results do suggest that use of a respirator with canister may be protective for central airways in responders exposed to dust and smoke. This emphasizes the importance of stressing proper respirator use in planning responses to future disasters. Our control data also provide useful reference values for future IOS research.

Long-term respiratory symptoms in World Trade Center responders.

BACKGROUND: New York State (NYS) employees who responded to the World Trade Center (WTC) disaster on or after 11 September 2001 potentially experienced exposures that might have caused persistent respiratory effects. NYS responders represent a more moderately exposed population than typical first responders. AIMS: To assess whether NYS employees who were WTC responders were more likely than controls to report lower respiratory symptoms (LRS) or a diagnosis of asthma 5 years post-9/11. Persistence and severity of symptoms were also evaluated. METHODS: Participants were initially mailed self-administered questionnaires (initial, Year 1, Year 2) and then completed a telephone interview in Year 3. Data were analysed using Poisson's regression models. RESULTS: WTC exposure was associated with LRS, including cough symptoms suggestive of chronic bronchitis, 5 years post-9/11. When exposure was characterized using an exposure assessment method, the magnitude of effect was greater in those with exposure scores above the mean. WTC exposure was associated with persistence of LRS over the 3 year study period. Results also suggest that participants with the highest exposures were more likely to experience increased severity of their asthma condition and/or LRS. CONCLUSIONS: Our findings suggest that even in a moderately exposed responder population, lower respiratory effects were a persistent problem 5 years post-9/11, indicating that some WTC responders require ongoing monitoring.

Health effects in New York State personnel who responded to the World Trade Center disaster.

OBJECTIVE: To conduct an evaluation of health effects in New York State personnel who responded to the World Trade Center disaster. METHODS: Data from a medical monitoring program, including questionnaire data, physical examination results, and clinical and laboratory test results were evaluated for 1423 participants. Descriptive statistics were reviewed and data were analyzed using logistic regression. RESULTS: Lower and upper respiratory symptoms were reported by nearly half of the study participants. One third reported a psychological symptom. Some health effects, including respiratory symptoms and symptoms suggestive of posttraumatic stress disorder, were associated with having been caught in the cloud of dust on September 11, 2001. CONCLUSIONS: This cohort probably experienced less overall exposure than other World Trade Center responder cohorts did. Results suggest that being present when the buildings collapsed was associated with reported symptoms.

Volar ligament release and distal radius dome osteotomy for correction of Madelung's deformity.

PURPOSE: Madelung's deformity is usually recognized near the completion of skeletal growth and corrective osteotomy of the radius is frequently performed to treat the deformity and reduce pain. This study reviewed the clinical and radiographic results of a volar approach, ligament release, and dome osteotomy technique for treatment of this deformity. METHODS: Between 1990 and 2000, 26 wrists in 18 patients were treated with a volar ligament release and dome osteotomy of the distal radius. The average age of the patients at the time of surgery was 13 years. All patients were available for review at an average of 23 months after surgery. Radiographs before surgery and at final follow-up evaluation were analyzed for the extent of correction. RESULTS: All patients treated with this corrective osteotomy reported a reduction in pain and improved appearance. Patients showed improvements in forearm supination and wrist extension, with no loss of pronation or flexion. Improvements in the radiographic parameters of radial inclination and lunate subsidence also were observed. Four wrists required concurrent ulnar-sided surgery, and 3 additional wrists required staged ulnar shortening. One patient required a Darrach resection 3 years after the index procedure. CONCLUSIONS: The results of volar dome osteotomy provide improved range of motion, improved appearance, radiographic correction, and pain relief while preserving soft-tissue support for radial rotation around the distal ulna. Long-term follow-up evaluation is ongoing.