Characterizing risk factors for pediatric lamp oil product exposures.

UNLABELLED: Poisonings from lamp oil ingestion continue to occur worldwide among the pediatric population despite preventive measures such as restricted sale of colored and scented lamp oils. This suggests that optimal prevention practices for unintentional pediatric exposures to lamp oil have yet to be identified and/or properly implemented. OBJECTIVE: To characterize demographic, health data, and potential risk factors associated with reported exposures to lamp oil by callers to poison centers (PCs) in the US and discuss their public health implications. STUDY DESIGN: This was a two part study in which the first part included characterizing all exposures to a lamp oil product reported to the National Poison Data System (NPDS) with regard to demographics, exposure, health, and outcome data from 1/1/2000 to 12/31/2010. Regional penetrance was calculated using NPDS data by grouping states into four regions and dividing the number of exposure calls by pediatric population per region (from the 2000 US census). Temporal analyses were performed on NPDS data by comparing number of exposures by season and around the July 4th holiday. Poisson regression was used to model the count of exposures for these analyses. In the second part of this project, in order to identify risk factors we conducted a telephone-based survey to the parents of children from five PCs in five different states. The 10 most recent lamp oil product exposure calls for each poison center were systematically selected for inclusion. Calls in which a parent or guardian witnessed a pediatric lamp oil product ingestion were eligible for inclusion. Data on demographics, exposure information, behavioral traits, and health were collected. A descriptive analysis was performed and Fisher's exact test was used to evaluate associations between variables. All analyses were conducted using SAS v9.3. RESULTS: Among NPDS data, 2 years was the most common patient age reported and states in the Midwestern region had the highest numbers of exposure calls compared to other regions. Exposure calls differed by season (p < 0.0001) and were higher around the July 4th holiday compared to the rest of the days in July (2.09 vs. 1.89 calls/day, p < 0.002). Most exposures occurred inside a house, were managed on-site and also had a "no effect" medical outcome. Of the 50 PC-administered surveys to parents or guardians, 39 (78%) met inclusion criteria for analysis. The majority of ingestions occurred in children that were 2 years of age, that were not alone, involved tiki torch fuel products located on a table or shelf, and occurred inside the home. The amount of lamp oil ingested did not appear to be associated with either the smell (p = 0.19) or the color of the oil (p = 1.00) in this small sample. Approximately half were asymptomatic (n = 18; 46%), and of those that reported symptoms, cough was the most common (n = 20, 95%) complaint. CONCLUSIONS: Lamp oil product exposures are most common among young children (around 2 years of age) while at home, not alone and likely as a result of the product being in a child-accessible location. Increasing parental awareness about potential health risks to children from these products and teaching safe storage and handling practices may help prevent both exposures and associated illness. These activities may be of greater benefit in Midwestern states and during summer months (including the period around the July 4th holiday).

Formaldehyde levels in FEMA-supplied travel trailers, park models, and mobile homes in Louisiana and Mississippi.

In 2006, area physicians reported increases in upper respiratory symptoms in patients living in U.S. Federal Emergency Management Agency (FEMA)-supplied trailers following Hurricanes Katrina and Rita. One potential etiology to explain their symptoms included formaldehyde; however, formaldehyde levels in these occupied trailers were unknown. The objectives of our study were to identify formaldehyde levels in occupied trailers and to determine factors or characteristics of occupied trailers that could affect formaldehyde levels. A disproportionate random sample of 519 FEMA-supplied trailers was identified in Louisiana and Mississippi in November 2007. We collected and tested an air sample from each trailer for formaldehyde levels and administered a survey. Formaldehyde levels among all trailers in this study ranged from 3 parts per billion (ppb) to 590 ppb, with a geometric mean (GM) of 77 ppb [95% confidence interval (CI): 70-85; range: 3-590 ppb]. There were statistically significant differences in formaldehyde levels between trailer types (P < 0.01). The GM formaldehyde level was 81 ppb (95% CI: 72-92) among travel trailers (N = 360), 57 ppb (95% CI: 49-65) among mobile homes (N = 57), and 44 ppb (95% CI: 38-53) among park models (N = 44). Among travel trailers, formaldehyde levels varied significantly by brand. While formaldehyde levels varied by trailer type, all types tested had some levels ≥ 100 ppb.

Exposure assessment of a mercury spill in a Nevada school -- 2004.

BACKGROUND: Although mercury is toxic, few studies have measured exposure in children who handled elemental mercury briefly. In 2004, a student spilled approximately 60 milliliters of mercury at a Nevada school. Within 12 hours, all students were removed from the source of exposure. We conducted an exposure assessment at the school. METHODS: We administered questionnaires and obtained urine samples from students. Using two-sample t-tests, we compared urine mercury levels from students who self-reported exposure to mercury levels of other students. RESULTS: Two-hundred students participated, including 55/62 (89%) who were decontaminated. The students' geometric mean urine mercury level was 0.36 microg/L (95% confidence interval 0.32-0.40 microg/L). The student who brought the mercury to school was the only one to have an elevated urine mercury level (11.4 microg/L). CONCLUSION: Despite environmental contamination, mercury exposure may have been minimized because of rapid identification of the elemental mercury spill and decontamination.

Investigation of systemic lupus erythematosus in Nogales, Arizona.

In 1996, a citizens group in Nogales, Arizona, reported to the Arizona Department of Health their concerns about a possible excess prevalence of systemic lupus erythematosus (SLE) due to exposure to environmental contamination in the area. The authors conducted a two-phase study in which the objectives of phase I were to identify potential SLE cases and to determine the prevalence of SLE and the objectives of phase II were to identify potential risk factors associated with the development of SLE and to evaluate the possible association between SLE and environmental exposure to pesticides and inorganic compounds. Participants included 20 confirmed cases and 36 controls. The authors found the prevalence of SLE to be 103 cases per 100,000 population (95 percent confidence interval: 56, 149), two to seven times higher than the prevalence in the US population. They detected elevated levels of 1,1-dichloro-2,2-bis-(p-chorophenyl)ethylene and organophosphate metabolites among cases and controls. In both, levels were higher than the reference mean for the US population. The authors found no statistical association between elevated levels of pesticides and disease status. Their results show that the prevalence of SLE in Nogales is higher than the reported prevalence in the US population and that both cases and controls had past exposure to chlorinated pesticides and have ongoing exposure to organophosphates.

Heat-related death and mental illness during the 1999 Cincinnati heat wave.

During a 1999 heat wave in Cincinnati, Ohio, the Hamilton County Coroner reported 18 heat-related deaths. The Centers for Disease Control and Prevention and the Cincinnati Department of Health conducted a case-control study using surrogate case information and first-person control information to identify risk factors for mortality during the heat wave. Surrogate data were supplemented by systematic death scene investigation reports and comprehensive toxicologic screens, important sources of data that are routinely collected by the Hamilton County Coroner's Office. The study included 17 case subjects and 34 controls from the decedents' neighborhood. Among 17 case subjects, 8 (47.1%) had mental illness (odds ratio [OR], 14.0; 95% confidence interval [CI], 1.8-633). There was a suggestion of an interaction between age and mental health. A working air-conditioner was the strongest protective factor (OR, 0.03; 95% CI, 0-0.2). Toxicologic screening indicated that case subjects with reported mental illness and a prescription for psychotropic drugs may not have been medication compliant. Three decedents lived in group homes for people with mental illness, indicating that opportunities for prevention may have been missed. Systematic death investigations, including toxicologic screening, provide valuable information about the circumstances of heat-related death, particularly the role of medication compliance as a risk factor. Prevention programs during heat waves should target people with mental illness, especially those who take psychotropic medication.

Exposure to persistent organochlorines among Alaska Native women.

OBJECTIVES: To report the levels of DDT, DDE, other chlorinated pesticides, and PCBs found in 131 Alaska Native women who had serum samples collected between 1980 and 1987 and to compare these levels to other published studies of DDE and PCB exposure among U.S. women. STUDY DESIGN: Review of data collected during a case-control study of the relationship between organochlorine chemicals and breast cancer. Data for case and control women were pooled in this analysis because case-control differences were found to be minimal and because serum samples pre-dated cancer diagnoses by 3 to 10 years. RESULTS: More than 99% of the women had detectable levels of p,p-DDE (mean 9.10 ng/mL or ppb). Mean total PCB level was 7.56 ppb. Levels of exposure varied by geographical location and ethnic identification, which maybe a reflection of dietary differences. Five of the organochlorines were detected in at least half of the study population. Results were recalculated using detection limits corresponding to other published studies of DDE and PCB levels in U.S. women. Alaska women had levels similar to those reported from New York women collected in the 1980s. We compared the PCB congener levels measured in Alaska Native women with levels reported in Arctic animals and found similar PCB congener profiles. The six most frequently detected contaminants in Alaska Natives were also detected in the marine mammal samples reported by Becker et al (5). CONCLUSIONS: Our study identified widespread Alaska Native exposure to organochlorines that originated outside of the Arctic, a finding also seen in other studies. Our results provide a reference baseline for exposure levels during the 1980s, but further research is necessary to assess temporal trends in exposure among Alaska Natives. Further, the need for national and international inter-laboratory standardization for testing for persistent organochlorines to facilitate comparisons between Alaska Natives and other American populations is clearly demonstrated.

Blood lead levels of primary school children in Dhaka, Bangladesh.

Dhaka, Bangladesh, has one of the highest air lead levels in the world. In February 2000, we evaluated children at five primary schools in Dhaka to determine blood lead (BPb) levels, sources of environmental exposure, and potential risk factors for lead poisoning. Selected schools represented a range of geographic and socioeconomic strata. A total of 779 students 4-12 years of age participated. The mean BPb level was 15.0 microg/dL (range 4.2-63.1 microg/dL). Most students (87.4%) had BPb levels above the Centers for Disease Control and Prevention's level of concern (10 microg/dL). Elevated BPb levels correlated with soil eating [odds ratio (OR) = 3.31; 95% confidence interval (CI), 1.30-8.39], low parental education (OR = 2.72; 95% CI, 1.97-3.75), living close to major roads (OR = 2.30; 95% CI, 1.23-4.29), and increasing age (OR = 1.11; 95% CI, 1.06-1.16). BPb levels measured were similar to those in other countries that use leaded gasoline. No other potential sources of lead exposure were consistently identified. Combustion of leaded gasoline is the main source of lead exposure in Dhaka, resulting in ubiquitous contamination of the environment. The increase in BPb levels with age, a finding contrary to observations in the United States and Australia, may be related to increased outdoor activities. The Bangladeshi government recently announced a plan to eliminate leaded gasoline. Baseline BPb surveys are critical to develop and evaluate intervention policies. Strategies to reduce BPb levels need to address variations in socioeconomic status, construction type and location of housing, and levels of hygiene.

Estimated prevalence of noise-induced hearing threshold shifts among children 6 to 19 years of age: the Third National Health and Nutrition Examination Survey, 1988-1994, United States.

OBJECTIVE: This analysis estimates the first nationally representative prevalence of noise-induced hearing threshold shifts (NITS) among US children. Historically, NITS has not been considered a common cause of childhood hearing problems. Among children, NITS can be a progressive problem with continued exposure to excessive noise, which can lead to high-frequency sound discrimination difficulties (eg, speech consonants and whistles). METHODS: The Third National Health and Nutrition Examination Survey (NHANES III) was conducted from 1988 to 1994. NHANES III is a national population-based cross-sectional survey with a household interview, audiometric testing at 0.5 to 8 kHz, and compliance testing. A total of 5249 children aged 6 to 19 years completed audiometry and compliance testing for both ears in NHANES III. The criteria used to assess NITS included audiometry indicating a noise notch in at least 1 ear. RESULTS: Of US children 6 to 19 years old, 12.5% (approximately 5.2 million) are estimated to have NITS in 1 or both ears. In the majority of the children meeting NITS criteria, only 1 ear and only 1 frequency are affected. In this analysis, all children identified with NITS passed compliance testing, which essentially rules out middle ear disorders such as conductive hearing loss. The prevalence estimate of NITS differed by sociodemographics, including age and sex. CONCLUSIONS: These findings suggest that children are being exposed to excessive amounts of hazardous levels of noise, and children's hearing is vulnerable to these exposures. These data support the need for research on appropriate hearing conservation methods and for NITS screening programs among school-aged children. Public health interventions such as education, training, audiometric testing, exposure assessment, hearing protection, and noise control when feasible are all components of occupational hearing conservation that could be adapted to children's needs with children-specific research.

Household exposures to drinking water disinfection by-products: whole blood trihalomethane levels.

Exposure to drinking water disinfection by-products (DBPs), such as trihalomethanes (THMs), has been associated with bladder and colorectal cancer in humans. Exposure to DBPs has typically been determined by examining historical water treatment records and reconstructing study participants' water consumption histories. However, other exposure routes, such as dermal absorption and inhalation, may be important components of an individual's total exposure to drinking water DBPs. In this study, we examined individuals' exposure to THMs through drinking, showering, or bathing in tap water. Thirty-one adult volunteers showered with tap water for 10 min (n = 11), bathed for 10 min in a bathtub filled with tap water (n = 10), or drank 1 l of tap water during a 10 min time period (n = 10). Participants provided three 10 ml blood samples: one sample immediately before the exposure; one sample 10 min after the exposure ended; and one sample 30 min (for shower and tub exposure) or 1 h ( for ingestion) after the exposure ended. A sample of the water (from the tap, from the bath, or from the shower) was collected for each participant. We analyzed water samples and whole blood for THMs (bromoform, bromodichloromethane, dibromochloromethane, and chloroform) using a purge-and-trap/gas chromatography/mass spectrometry method with detection limits in the parts-per-quadrillion range. The highest levels of THMs were found in the blood samples from people who took 10 min showers, whereas the lowest levels were found in the blood samples from people who drank 1 l of water in 10 min. The results from this study indicate that household activities such as bathing and showering are important routes for human exposure to THMs.

Paternal concentrations of dioxin and sex ratio of offspring.

BACKGROUND: 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD or dioxin), is commonly considered the most toxic man-made substance. We have previously shown that high serum concentrations of TCDD in parents from Seveso, Italy, were linked to their having a relative increase in the number of female births after the parents exposure to a release of dioxin in 1976. We have continued the study to determine whether the parents' sex and/or age at exposure affected the sex ratio of their children. METHODS: We measured the TCDD concentrations in serum samples from potentially exposed parents collected in 1976 and 1977, and investigated the sex ratio of their offspring. FINDINGS: Serum samples were collected from 239 men and 296 women. 346 girls and 328 boys were born to potentially exposed parents between 1977 and 1996, showing an increased probability of female births (lower sex ratio) with increasing TCDD concentrations in the serum samples from the fathers (p=0.008). This effect starts at concentrations less than 20 ng per kg bodyweight. Fathers exposed when they were younger than 19 years of age sired significantly more girls than boys (sex ratio 0.38 [95% CI 0.30-0.47]). INTERPRETATION: Exposure of men to TCDD is linked to a lowered male/female sex ratio in their offspring, which may persist for years after exposure. The median concentration of dioxin in fathers in this study is similar to doses that induce epididymal impairments in rats and is about 20 times the estimated average concentration of TCDD currently found in human beings in industrialised countries. These observations could have important public-health implications.

Red blood cell transfusions for elective hip and knee arthroplasty: opportunity to improve quality of care and documentation.

OBJECTIVES: To assess current practice for red blood cell transfusion relative to the American College of Physicians guideline for red blood cell transfusion; to determine comparative rates and relative appropriateness of autologous versus allogeneic blood use; and, to assess cost implications of current transfusion practices. DESIGN: Computerized quality-of-care algorithm applied retrospectively to medical-record and blood-bank data. SETTING: Twenty-six hospitals in Colorado, Connecticut, Georgia, Oklahoma, and Virginia. PATIENTS: Medicare beneficiaries (2,137) who were hospitalized in 1993 for two elective surgical procedures: total hip arthroplasty and total knee arthroplasty. Of the 1,195 patients who received a preoperative or postoperative transfusion, 728 were excluded from the analysis because the hospital medical record did not contain the clinical documentation necessary to apply the American College of Physicians guideline to each unit transfused. The remaining 467 patients comprised the sample. RESULTS: For 467 patients who underwent these two procedures and received a total of 651 units of preoperative or postoperative blood, there were 256 excess units transfused. Two hundred four of these units were autologous, and 52 were allogeneic. These excess units accounted for $48,200 of the total $121,000 direct cost of transfused units. CONCLUSIONS: These findings demonstrate that current medical records lack the documentation necessary to evaluate transfusion practice for the majority of Medicare beneficiaries undergoing elective hip and knee arthroplasty. The direct costs of preoperative and postoperative blood transfusion for these two procedures could be reduced by nearly 40% through adherence to the American College of Physicians guideline. The majority of this cost saving would be realized through reduction in unnecessary collection and use of autologous blood.

A comparison of the Charlson comorbidity index derived from medical record data and administrative billing data.

The objective of this article is to compare the Charlson comorbidity index derived from medical record data (Chart Index) with the same index derived from billing data (ICD-9 Index) to determine how well each predicted inpatient and 30-day mortality, length of stay, and complications among Medicare beneficiaries hospitalized for carotid endarterectomy. Economic and time constraints have increased the need for risk adjusters derived from administrative data, yet few studies have compared these measures with those derived from chart review. Using logistic regression, the Chart Index was found to be a significant predictor of inpatient mortality, 30-day mortality, length of stay, and complications, after controlling for age, gender, and neurologic and medical risk factors (P values = 0.004, 0.056, 0.0001, and 0.042, respectively). The ICD-9 Index approached significance as a predictor of the outcomes (P values = 0.092, 0.100, 0.093, and 0.080, respectively). The Chart Index was shown to be superior to the ICD-9 Index within this patient sample.

Serum follicle-stimulating hormone and luteinizing hormone levels in women aged 35-60 in the U.S. population: the Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994).

OBJECTIVE: The objective of this study was to examine age-specific population-based values for serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels in women in the U.S. population. DESIGN: Data were collected from a nationally representative cross-sectional health examination survey that included measurements of follicle-stimulating hormone and luteinizing hormone and information from a personal interview. A total of 3388 women aged 35 to 60 years were examined during the third National Health and Nutrition Examination Survey, 1988-1994. RESULTS: Among U.S. women aged 35-60 years, median FSH and LH levels began to increase for women in their late 40s and reached a plateau for women in their early 50s. This study supports the previously reported association between serum FSH and age (i.e., serum FSH and LH levels increase with age) and smoking (i.e., current smoking was associated with an increased level of serum FSH). At FSH levels of > or = 15 IU/L or > or = 20 IU/L. 70 and 73% of women, respectively, were postmenopausal. Our study also found an interaction between age and oophorectomy. In addition, the present data suggest that women with only one ovary may have higher FSH levels than women with both of their ovaries. CONCLUSIONS: NHANES III provides population-based data that support previously reported associations between serum FSH level and age, smoking, and menopausal status.

Prevalence of hearing loss among children 6 to 19 years of age: the Third National Health and Nutrition Examination Survey.

CONTEXT: Hearing loss in children influences the development of communication and behavioral skills, but few studies in the United States have used pure-tone audiometry to derive hearing loss prevalence estimates for children. OBJECTIVE: To describe the prevalence of hearing loss among US children by sociodemographic characteristics, reported hearing loss, and audiometric screening factors. DESIGN: National population-based cross-sectional survey with an in-person interview and audiometric testing at 0.5 to 8 kHz. SETTING/PARTICIPANTS: A total of 6166 children aged 6 to 19 years completed audiometry in the mobile examination center of the Third National Health and Nutrition Examination Survey conducted between 1988 and 1994. MAIN OUTCOME MEASURE: Hearing loss, defined as audiometric threshold values of at least 16-dB hearing level based on a low or high pure-tone average. RESULTS: A total of 14.9% of children had low-frequency or high-frequency hearing loss of at least 16-dB hearing level, 7.1% had low-frequency hearing loss of at least 16-dB hearing level, and 12.7% had high-frequency hearing loss of at least 16-dB hearing level. Most hearing loss was unilateral and slight in severity (16- to 25-dB hearing level). Of those with measured hearing loss, 10.8% were reported to have current hearing loss during the interview. CONCLUSIONS: This analysis indicates that 14.9% of US children have low-frequency or high-frequency hearing loss of at least 16-dB hearing level in 1 or both ears. Among children in elementary, middle, and high school, audiometric screening should include low-frequency and high-frequency testing to detect hearing loss.

Informatics, imaging, and healthcare quality management: imaging quality improvement opportunities and lessons learned form HCFA's Health Care Quality Improvement Program.

This article examines the use of population-based healthcare data at the interface among radiology, healthcare informatics, and health services research for the purposes of healthcare quality management. To illustrate these concepts, we draw on experience with Health Care Financing Administration's Medicare Health Care Quality Improvement Program (HCQIP). We present two HCQIP efforts that have identified opportunities to improve the delivery of imaging services, specifically studies of the diagnosis and management of congestive heart failure and cerebrovascular disease. The examples demonstrate from a population-level perspective that there are opportunities to enhance the quality of imaging practice by reducing the magnitude of imaging practice variability, implementing evidence-based guidelines, and optimizing the communication of imaging study findings to physicians who are responsible for subsequent diagnostic and therapeutic decisions. Additional research is required in specific clinical domains of radiology to determine if implementation of evidence-based imaging guidelines and enhanced clarity in the interpretation and communication of diagnostic imaging will improve health outcomes.

The American College of Rheumatology preliminary core set of disease activity measures for rheumatoid arthritis clinical trials. The Committee on Outcome Measures in Rheumatoid Arthritis Clinical Trials.

OBJECTIVE: To develop a set of disease activity measures for use in rheumatoid arthritis (RA) clinical trials, as well as to recommend specific methods for assessing each outcome measure. This is not intended to be a restrictive list, but rather, a core set of measures that should be included in all trials. METHODS: We evaluated disease activity measures commonly used in RA trials, to determine which measures best met each of 5 types of validity: construct, face, content, criterion, and discriminant. The evaluation consisted of an initial structured review of the literature on the validity of measures, with an analysis of data obtained from clinical trials to fill in gaps in this literature. A committee of experts in clinical trials, health services research, and biostatistics reviewed the validity data. A nominal group process method was used to reach consensus on a core set of disease activity measures. This set was then reviewed and finalized at an international conference on outcome measures for RA clinical trials. The committee also selected specific ways to assess each outcome. RESULTS: The core set of disease activity measures consists of a tender joint count, swollen joint count, patient's assessment of pain, patient's and physician's global assessments of disease activity, patient's assessment of physical function, and laboratory evaluation of 1 acute-phase reactant. Together, these measures sample the broad range of improvement in RA (have content validity), and all are at least moderately sensitive to change (have discriminant validity). Many of them predict other important long-term outcomes in RA, including physical disability, radiographic damage, and death. Other disease activity measures frequently used in clinical trials were not chosen for any one of several reasons, including insensitivity to change or duplication of information provided by one of the core measures (e.g., tender joint score and tender joint count). The committee also proposes specific ways of measuring each outcome. CONCLUSION: We propose a core set of outcome measures for RA clinical trials. We hope this will decrease the number of outcomes assessed and standardize outcomes assessments. Further, we hope that these measures will be found useful in long-term studies.