Longitudinal changes in inflammatory markers in nasal lavage of cotton workers. Relation to endotoxin exposure and lung function changes

Bcl2 like protine-12 (Bcl2L12) facilitates experimental airway allergic inflammation by inducing autocrine eotaxin in eosinophils

BACKGROUND

The pathogenesis of airway allergic disorders (AAD) needs to be further investigated. Eosinophils (Eos) are the canonical effector cells in AAD attacks. Bcl2 like protein-12 (Bcl2L12) is an apoptosis inhibitor and an immune regulator. Eos have the defects of apoptosis. This study aims to investigate the role of Bcl2L12 in the AAD pathogenesis by regulating Eo activities.

METHODS

Human nasal lavage fluids (NLF) and mouse bronchoalveolar lavage fluids (BALF) was collected. Eos in NLF and BALF were analyzed by flow cytometry. A murine AAD model was developed with ovalbumin as a specific antigen.

RESULTS

We found that Eos isolated from NLF or BALF of AAD subjects expressed high levels of Bcl2L12 and showed defects of apoptosis. The Bcl2L12 expression in Eos was positively correlated with the AAD response. High lipopolysaccharide levels were detected in the AAD airways, that promoted the Bcl2L12 expression in Eos. Bcl2L12 mediated the LPS-induced autocrine eotaxin 1 expression in Eos through activating the MAPK p38/STAT6/NF-κB signal pathway. Depletion of Bcl2L12 in Eos suppressed experimental AAD in mice.

CONCLUSIONS

AAD Eos express high levels of Bcl2L12, the latter is associated with AAD response by regulating the autocrine eotaxin 1 in Eos. Depletion of Bcl2L12 in Eos attenuates experimental AAD, suggesting that to suppress the Bcl2L12 Eos has the translational potential in the treatment of AAD.

Personal inhalable dust and endotoxin exposure among workers in an integrated textile factory

The aim of this study was to determine personal exposure to inhalable dust and endotoxin levels among workers in an integrated cotton-processing textile factory and exposure variability across the different work sections. Full shift measurements were carried out using inhalable conical samplers with 37 mm glass-fiber filters. Personal inhalable dust was determined gravimetrically, and endotoxin levels were analyzed by kinetic chromogenic Limulus Amebocytes Lysate assay. The geometric means of personal dust and endotoxin concentrations were 0.75 mg·m^-3 and 831 EU·m^-3, respectively. The highest dust and endotoxin concentrations were observed in carding section (1.34 mg·m^-3 and 6,381 EU·m^-3, respectively). Altogether, 11% of dust and 89% of endotoxin samples exceeded workplace exposure limits. This study showed a moderate correlation between inhalable dust and endotoxin (r = 0.450, p < 0.001). Our findings indicate that low dust exposure does not guarantee a low exposure to endotoxin.

Effect of wearing cotton towel Ihram and plain Ihram on lung function among Hajj Pilgrims

Objectives:

Hajj is the world’s largest gathering to Makkah, Saudi Arabia. Wearing cotton made Ihram is a basic and an essential component of Hajj. The aim of this study was to investigate the lung functions among Hajj pilgrims who were wearing cotton towel ihram (ihram with fibers) compared to those who were wearing plain cotton ihram (ihram without fibers).

Methods:

Ninety male, non-smoker, Hajj pilgrim volunteers with age ranged 20-60 years were selected. Forty five of them wore cotton towel ihram and 45 wore plain ihram. A day before leaving for Hajj and wearing ihram (6^th Dhu-al-Hijjah) lung function base line parameters of Hajj pilgrims were determined. Hajj Pilgrims continuously wear ihram from 7-10^th Dhu-al-Hijjah. In the afternoon of 10^th Dhu-al-Hijjah, after removal of ihram, all parameters were repeated and at the completion of Hajj when all pilgrims return to their homes at Riyadh, all parameters were recorded again.

Results:

Before wearing Ihram, anthropometric and lung function baseline parameters were recorded, no significant difference was found between the study population. After wearing Ihram on the 7^th Dhu-al-Hijjah and its removal on the 10^th Dhu-al-Hijjah significant decline in the lung function test parameters was observed among Hajj pilgrims who were wearing cotton towel ihram. Forced Vital Capacity (FVC) 4.30±1.18 vs. 5.03±1.41 (p=0.01); Forced Expiratory Flow 25% (FEF-25%) 4.39±1.94 vs. 5.69±2.84 (p=0.03); Forced Expiratory Flow-50% (FEF-50%) 2.93±1.65 vs. 4.07±2.08 (p=0.01); Forced Expiratory Flow-75% (FEF-75%) 1.02±0.70 vs. 1.66±0.94 (p=0.002) compared to those who were wearing plain ihram.

Conclusions:

Lung function test parameters were decreased among the Hajj pilgrims who were wearing cotton towel ihram compared to those who were wearing plain cotton ihram. The pattern of impairment of lung function shows an obstructive peripheral airway lung involvement. It is suggested to conduct further large sample size studies to confirm the present study observations and reach at better conclusions.

Investigating the potential for interaction between the components of PM(10)

The adverse health effects of elevated exposures to PM(10) (particulate matter collected through a size selective inlet with an efficiency of 50% for particles with an aerodynamic diameter of 10 μm) in relation to morbidity and mortality, especially in susceptible individuals, are now well recognised. PM(10) consists of a variable cocktail of components differing in chemical composition and size. Epidemiological and toxicological data suggest that transition metals and ultrafine particles are both able to drive the cellular and molecular changes that underlie PM(10)-induced inflammation and so worsen disease status. Toxicological evidence also suggest roles for the biological components of PM(10) including volatile organic compounds (VOC's), allergens and bacterial-derived endotoxin. Many of these components, in particular transition metals, ultrafine particles, endotoxin and VOC's induce a cellular oxidative stress which initiates an intracellular signaling cascade involving the activation of phosphatase and kinase enzymes as well as transcription factors such as nuclear factor kappa B. Activation of these signaling mechanisms results in an increase in the expression of proinflammatory mediators, and hence enhanced inflammation. Given that many of the components of PM(10) stimulate similar or even identical intracellular signaling pathways, it is conceivable that this will result in synergistic or additive interactions so that the biological response induced by PM(10) exposure is a response to the composition rather than the mass alone. A small number of studies suggest that synergistic interactions occur between ultrafine particles and transition metals, between particles and allergens, and between particles and VOC's. Elucidation of the consequences of interaction between the components of PM(10) in relation to their biological activity implies huge consequences for the methods used to monitor and to legislate pollution exposure in the future, and may drive a move from mass based measurements to composition.

Effect of vitamin supplementation on lung injury and running performance in a hot, humid, and ozone-polluted environment

In this study, the effect of vitamin C and E supplementation on lung injury and performance of runners were analyzed. Using a randomized, double-blinded, crossover design, nine runners participated in two experimental trials: a 2-week Vitamin trial (vitamin C = 500  mg/day + vitamin E = 100  IU/day) and a 2-week Placebo trial. At the end of each supplementation period the runners performed an 8-km time-trial run in a hot (31°C), humid (70% rh), and ozone-polluted (0.10  ppm O(3)) environmental chamber. Nasal lavage and blood samples were collected pre-, post-, and 6-h post-exercise to assess antioxidant status and CC16 as lung injury marker. Higher plasma (pre- and post-exercise) and nasal lavage (post-exercise) antioxidant concentration were found for the Vitamin trial. Nevertheless, this did not result in performance differences (Vitamin trial: 31:05  min; Placebo trial: 31:54  min; P = 0.075) even though significant positive correlations were found between antioxidant concentration and improvement in time to complete the run. CC16 was higher post-exercise in the Placebo trial (P < 0.01) in both plasma and nasal lavage. These findings suggest that antioxidant supplementation might help to decrease the lung injury response of runners when exercising in adverse conditions, but has little effect on performance.

Endotoxin exposure and childhood wheeze and asthma: a meta-analysis of observational studies

BACKGROUND

Exposure to endotoxin has been widely investigated as a potential factor for asthma and associated symptoms in children with different results. To clarify a potential relationship, we performed the present meta-analysis to integrate the results of studies examining the association of endotoxin exposure with wheeze and asthma in children.

METHODS

A search for relevant studies and reviews was conducted in MEDLINE, Highwire, CINAHL, and The Cochrane Library databases. Adjusted odds ratio (OR) with corresponding 95% confidence interval (CI) for endotoxin exposure and wheeze or asthma were retrieved and pooled to generate summary effect estimates in STATA 11.1.

RESULTS

Nineteen studies were included in the meta-analysis. The summary estimates suggested that endotoxin was positively associated with wheeze in infants and toddlers (meta-OR: 1.48, 95% CI: 1.10-1.98), but negatively related to asthma in school-aged children (meta-OR: 0.82, 95% CI: 0.69-0.97 for endotoxin concentration and 0.68, 95% CI: 0.50-0.93 for endotoxin load).

CONCLUSIONS

Based on the studies evaluated, endotoxin is a risk factor for wheeze in younger children, but a protective factor for asthma in older children. Thus, this study supports the "hygiene hypothesis."

Exposure to dust and endotoxin in textile processing workers

BACKGROUND

Inhalation of cotton-based particulate has been associated with respiratory symptoms and overt lung disease related to endotoxin exposure in some studies. This cross-sectional study measures personal exposure to inhalable dust and endotoxin in the textile industry of Nepal.

METHODS

This study was conducted in four sectors (garment making, carpet making, weaving, and recycling) of the textile industry in Kathmandu, Nepal. Personal exposure to inhalable dust and airborne endotoxin was measured during a full-shift for 114 workers.  

RESULTS

Personal exposure to cotton dust was generally low [geometric mean (GM) 0.81 mg m(-3)) compared to the UK workplace exposure limit (WEL) (2.5 mg m(-3)) but with nearly 18% (n = 20) of the workers sampled exceeding the limit. Exposures were lowest in the weaving and the garment sector (GM = 0.30 mg m(-3)), higher in the carpet sector (GM = 1.16 mg m(-3)), and highest in the recycling sector (GM = 3.36 mg m(-3)). Endotoxin exposures were high with the overall data (GM = 2160 EU m(-3)) being more than 20-fold higher than the Dutch health-based guidance value of 90 EU m(-3). The highest exposures were in the recycling sector (GM = 5110 EU m(-3)) and the weaving sector (GM = 2440 EU m(-3)) with lower levels in the garment sector (GM = 157 EU m(-3)). The highest endotoxin concentrations expressed as endotoxin units per milligram inhalable dust were found in the weaving sector (GM = 165 EU mg(-1)). There was a statistically significant correlation between inhalable dust concentrations and endotoxin concentrations (r = 0.37; P < 0.001) and this was particularly strong in the garment (r = 0.82; P = 0.004) and the carpet sector (r = 0.81; P < 0.001).  

CONCLUSIONS

Inhalable dust exposures measured in the weaving, carpet, and garment sectors were all below the UK WEL for cotton dust. A significant proportion of the measurements from the cotton recycling sector were above the UK WEL suggesting that better hygiene control measures are required. Airborne endotoxin concentrations in all sectors were found to exceed the Dutch health-based guidance limit of 90 EU m(-3) and may be associated with respiratory health effects.

Angiostatic versus angiogenic chemokines in IPF and EAA

BACKGROUND

Extrinsic allergic alveolitis (EAA) and idiopathic pulmonary fibrosis (IPF) share the presence of varying degree interstitial involvement and fibrosis. Vascular changes were often reported to accompany the development of fibrosis.

OBJECTIVES

The aim of our study was to examine the differences in angiostatic and angiogenic chemokine milieu in both diseases. Correlations between chemokine levels in bronchoalveolar lavage fluid (BALF), expression of chemokine receptors on CD4+ T cells (CXCR2, CXCR3) in BALF and HRCT pattern of the diseases were investigated.

METHODS

Sixteen patients with chronic EAA and 8 with IPF were enrolled to the study. Concentrations of interleukin (IL)-8, epithelial neutrophil activating protein (ENA)-78, interferon-gamma-inducible protein (IP)-10 and interferon-inducible T cell alpha chemoattractant (I-TAC) in BALF supernatants were quantified using Fluorokine MultiAnalyte profiling.

RESULTS

There was no significant difference in the BALF chemokine levels between the EAA and IPF group. IL-8 BALF concentrations correlate with the extent of fibrosis in both EAA and IPF (p<0.01). The IP-10 BALF concentrations do not correlate either with the HRCT alveolar or interstitial score and should be evaluated in the relationship with the disease course.

CONCLUSIONS

Both IL-8 and ENA-78 probably play a different role in IPF and chronic EAA pathogenesis. While we suggest ENA-78 as the marker of at least partial reversibility of the lung impairment in the EAA patients, IL-8 could be rather an indicator of continuous exposition to provoking agent in EAA patients. IL-8 might serve as a potential marker of early phase of IPF.

Fungal and endotoxin measurements in dust associated with respiratory symptoms in a water-damaged office building

We investigated the associations of fungal and endotoxin levels in office dust with respiratory health in 888 (67% participation) occupants of a water-damaged building. We analyzed floor and chair dusts from 338 workstations for culturable fungi and endotoxin. Based on averages, we ranked each floor of the building as low, medium, or high for occupants' exposure to each of these agents. Multivariate logistic regression models for building-related symptoms included this ranking of fungi and endotoxin, age, gender, race, smoking status, and duration of occupancy. Using floor dust measures, we found significantly increased odds for lower respiratory symptoms [wheeze, chest tightness, attacks of shortness of breath, and attacks of cough: odds ratios (OR) = 1.7 (95% confidence interval (CI): 1.02-2.77) to 2.4 (95% CI: 1.29-4.59)], throat irritation [OR = 1.7, (95% CI: 1.06-2.82)], and rash/itchy skin [OR = 3.0, (95% CI: 1.47-6.19)] in the highest fungal exposure group compared to the lowest, with generally linear exposure-response relationships. Nonlinear relationships were observed for many of these symptoms and endotoxin in floor dust. Interaction models showed that endotoxin modified effects of fungi on respiratory symptoms. Our findings of exposure interactions and exposure-response relationships of fungal and endotoxin with increased risk of building-related symptoms contribute to an understanding of the role of microbial agents in building-related asthma and respiratory and systemic symptoms.

PRACTICAL IMPLICATIONS

Our demonstration of exposure-response relationships between measurements of fungi and/or endotoxin in floor dusts and building-related symptoms implies that microbial agents in floor dust may be a good surrogate measure for dampness-related bioaerosol exposure, considering that measurements of microbial agents in air often fail to demonstrate the associations between exposure and health. In addition, our finding that endotoxin exposure may change the effect of fungal exposure (and vice versa) on respiratory heath suggests that exposure to both fungi and endotoxin should be assessed in epidemiological investigations examining the effect of fungal or endotoxin exposure on respiratory health in indoor environments.

Platinum levels in nasal lavage fluid as a biomarker for traffic-related exposure and inflammation in children

Platinum (Pt) is a well-known constituent of particles emitted by catalytic converters during car operation. To evaluate Pt as a potential marker for traffic related particle exposure, we investigated Pt content along with metals vanadium (V) and chromium (Cr) in coarse and fine particulate matter (PM), sampled in four areas with different traffic density, as well as in the nasal lavage (NAL) of 67 children (average age: 6 years) living in these areas. The different sites were characterised by significant differences in air pollutants including PM, NO, NO(2), CO and Cr, but differences in V or Pt were absent. No significant differences in neutrophil and epithelial cell counts or concentrations of the neutrophil chemoattractant interleukin-8 (IL-8) were found in the NAL of children living in the different areas. In addition, the concentrations of V, Cr and Pt, which were detectable in 64%, 73% and 93% of the individuals, respectively, did not differ between the different locations. However, in the NAL of the children, a significant correlation between Pt and the number of neutrophils/ml (r=0.40, p<0.001) as well as of epithelial cells/ml (r=0.41, p<0.001) was found. No relation was present between nasal inflammation and nasal Cr levels, whereas a relatively weak association was observed between V and epithelial cells counts (r=0.30, p=0.018). In conclusion, our data suggests a role for nasal lavage Pt as a candidate biomarker for traffic-related PM, which is able to induce inflammation in the upper respiratory tract.

Evaluation of exposure to man-made vitreous fibers by nasal lavage

The objectives of this study were to develop a biomonitoring method for the assessment of exposure to man-made vitreous fibers (MMVF), to examine the level of exposure to MMVF in the prefabricated house industry, and to study nasal inflammatory reactions and respiratory symptoms associated with MMVF among workers. Nasal lavage was performed on workers from two factories, and concentrations of MMVF were measured by electron microscopy. Cytokines (IL-6, IL-8, TNF-alpha, and IFN-gamma) were also assayed and inflammatory cells (lymphocytes, eosinophils, neutrophils, and macrophages) were counted microscopically. Concentrations of airborne fibers (longer than 5 microm) were measured for comparison. Moreover, the exposure to MMVF and the related symptoms were studied with a structured questionnaire. In nasal lavage samples, the mean concentration of MMVF (length >1.5 microm) was 3260 f/ mL in Factory 1, 1680 f/mL in Factory 2, and below 500 f/mL in the control group. About 52% of the retained fibers were longer than 100 microm. The group-specific mean concentrations of MMVF in nasal lavage samples correlated with production rates and airborne fiber levels in both plants. The airborne concentrations of MMVF both in the breathing zone and fixed-point samples were low (below 0.1 f/cm(3)). No significant differences in the biological response (inflammatory cells, cytokines) were found between the groups exposed and the control group. The workers complained of some irritation of the skin, eyes, and upper respiratory tract, which could be reduced by appropriate protective equipment. It is concluded that nasal lavage can be used as a biomonitoring method in the assessment of MMVF exposure.

Pulmonary toxicity of dust generated during weaving of carpets

The dust generated during weaving (carpet dust) tibbati, knotted and tuffted carpets in carpet industry was studied for its toxicity in vitro and in vivo. Carpet dust (0.5, 1.0, 2.5 and 5.0 mg/1 x 10(6) cells) caused in vitro cytotoxicity in rat alveolar macrophages (AM) in a concentration-dependent manner. The cytotoxic, inflammatory and oxidative responses were observed in bronchoalveolar lavage fluid (BALF) of rats at 1, 4, 8 and 16 days after exposure. Rats were intratracheally exposed at 5 mg/rat individually to all three types of carpet dust. All types of carpet dusts produced increased AM, lymphocytes (PMN) population in BALF suggesting their inflammatory reactions. Cytotoxic nature of carpet dust was shown by the increased activities of lactate dehydrogenase (LDH) and acid phosphatase (AP) in BALF. Increased AM population and in vitro cytotoxicity due to carpet dusts have shown some correlation with the levels of LDH and AP activities in BALF. The gradual enhanced profile of hydrogen peroxide (H2O2) and nitric oxide (NO) along with depletion of reduced glutathione (GSH) in AM due to these carpet dusts are suggestive of their oxidant nature. The enzyme activities of both glutathione peroxidase (GPx) and glutathione reductase (GR) in AM were marginally reduced in exposed rats. In conclusion, the data suggest the cytotoxic, inflammatory and oxidant nature of carpet dusts. It is extrapolated that health effects on carpet weavers would be associated with the concentration and nature of airborne dust generated during weaving of carpets.

A longitudinal analysis of wheezing in young children: the independent effects of early life exposure to house dust endotoxin, allergens, and pets

BACKGROUND

It has been postulated that exposure to bacterial endotoxins and animals early in life might confer protection against the development of asthma and allergies.

OBJECTIVE

We investigated the longitudinal effects of exposure to house dust endotoxin (HDE), allergen levels, and the presence of a dog in the home on wheezing in young children over a 4-year period.

METHODS

Two hundred twenty-six children younger than 5 years were followed for 4 years. Endotoxin and allergen levels were measured from house dust collected at baseline. Longitudinal associations were investigated by using a proportional hazards technique that allowed for multiple outcomes per subject.

RESULTS

Exposure to high concentrations of HDE of greater than the median level was associated with an increased risk for wheezing over the period of observation (multivariate relative risk, 1.52; 95 % CI, 1.07-2.14), but this risk rapidly decreased over time (P for trend =.005). Exposure to cockroach allergen was associated with increased risk for wheezing, whereas exposure to cat allergen and the presence of a dog in the home were both associated with decreased risk for wheezing. The risks associated with cockroach allergen, cat allergen, and dog did not change over the period of observation.

CONCLUSION

The negative associations between exposures to dogs and cat allergen and wheeze appear to be independent of the effects of endotoxin and suggest that separate mechanisms might mediate the effects of HDE exposure and pet exposure on the developing immune system.

Respiratory symptoms, lung function, and nasal cellularity in Indonesian wood workers: a dose-response analysis

OBJECTIVES

It was hypothesised that inflammation plays a dominant part in the respiratory effects of exposure to wood dust. The purpose of this study was to relate the nasal inflammatory responses of workers exposed to meranti wood dust to (a) levels of exposure, (b) respiratory symptoms and (c) respiratory function.

METHODS

A cross sectional study was carried out in 1997 in a woodworking plant that used mainly meranti, among 982 workers exposed to different concentrations of wood dust. Personal sampling (n=243) of inhalable dust measurements indicated mean exposure in specific jobs, and enabled classification of 930 workers in three exposure classes (<2, 2-5, and >5 mg/m(3)) based on job title. Questionnaires were used to screen respiratory symptoms in the entire population. Lung function was measured with two different techniques, conventional flow-volume curves and the forced oscillation technique. Nasal lavage was done to assess inflammation in the upper respiratory tract.

RESULTS

A negative trend between years of employment and most flow-volume variables was found in men, but not in women workers. Current exposure, however, was not related to spirometric outcomes, respiratory symptoms, or nasal cellularity. Some impedance variables were related to current exposure but also with better function at higher exposure.

CONCLUSIONS

Exposure to meranti wood dust did not cause an inflammation in the upper respiratory tract nor an increase of respiratory symptoms or decrease of lung function. These data do not corroborate the hypothesis that inflammation plays a part in airway obstruction induced by wood dust.

House dust endotoxin and wheeze in the first year of life

We examined endotoxin exposure and wheezing episodes during the first year of life in a birth cohort of 499 infants with one or both parents having a history of asthma or allergy. We measured endotoxin in settled dust from the baby's bed, bedroom floor, family room, and kitchen floor within the first 3 mo after birth. The primary outcomes were any wheeze (versus no wheeze), and repeated wheeze (versus one or no report of wheeze). We found a significant univariate association of elevated endotoxin (> or = 100 EU/ mg) in family room dust with increased risk of any wheeze (Relative Risk = 1.29, 95% CI = 1.03-1.62). The association was not confounded by cockroach allergen, lower respiratory illness (croup, bronchitis, bronchiolitis, and pneumonia), smoking during pregnancy, lower birth weight, maternal asthma, presence of dog, and race/ethnicity in a multivariate model; the multivariate relative risk (RR = 1.33) was marginally significant (95% CI: 1.00-1.76, p < 0.05). In a multivariate model, controlling for the above covariates, elevated endotoxin in family room dust was significantly associated with increased risk (RR = 1.56, 95% CI = 1.03-2.38) of repeated wheeze. These results suggest that home endotoxin exposure may independently increase risk of any wheeze and repeated wheeze during the first year of life for children with a familial predisposition to asthma or allergy.

Anemia and deficiencies of folate and vitamin B-6 are common and vary with season in Chinese women of childbearing age

Little is known about the micronutrient status of Chinese women of childbearing age. We assessed nonfasting plasma concentrations of folic acid, vitamin B-12, vitamin B-6 (as pyridoxal-5'-phosphate), hemoglobin (Hb), ferritin and transferrin receptor (TfR) in 563 nonpregnant textile workers aged 21-34 y from Anqing, China. All women had obtained permission to become pregnant and were participating in a prospective study of pregnancy outcomes. Mean (SD) plasma concentrations were 9.7 (4.1) nmol/L folic acid, 367 (128) pmol/L vitamin B-12, 40.2 (15.8) nmol/L vitamin B-6, 108 (12. 9) g/L Hb, 42.6 (34.2) microgram/L ferritin and 5.2 (2.7) mg/L TfR. Twenty-three percent of women had biochemical evidence of folic acid deficiency, 26% were deficient in vitamin B-6 and 10% had low vitamin B-12. Overall, 44% of women were deficient in at least one B vitamin. Although anemia (Hb < 120 g/L) was detected in 80% of women, only 17% had depleted iron stores (ferritin < 12 microgram/L); 11% had elevated TfR concentrations. Distinct seasonal trends were observed in the prevalence of moderate anemia (Hb < 100 g/L) and deficiencies of folic acid and vitamin B-6, with significantly lower concentrations of folate and Hb occurring in summer and lower concentrations of vitamin B-6 occurring in winter and spring than in other seasons. We conclude that deficiencies of folic acid, vitamin B-6 and iron were relatively common in this sample of Chinese women of childbearing age and were contributing to the high prevalence of anemia. Without appropriate supplementation, these deficiencies could jeopardize the women's health and increase their risk of adverse pregnancy outcomes.