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Cosselman KE, Allen J, Jansen KL, Stapleton P, Trenga CA, Larson TV, Kaufman JD. Acute exposure to traffic-related air pollution alters antioxidant status in healthy adults. ENVIRONMENTAL RESEARCH 2020; 191:110027. [PMID: 32810504 PMCID: PMC8568481 DOI: 10.1016/j.envres.2020.110027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 07/20/2020] [Accepted: 07/30/2020] [Indexed: 05/27/2023]
Abstract
BACKGROUND Exposure to traffic-related air pollution is associated with an increased risk of cardiovascular and respiratory disease. Evidence suggests that inhaled pollutants precipitate these effects via multiple pathways involving oxidative stress. OBJECTIVE Postulating that a decrease in circulating antioxidant levels reflect an oxidative response, we investigated the effect of inhaled diesel exhaust (DE) on the ratio of reduced to oxidized glutathione (GSH/GSSG) in healthy adults, and whether pre-exposure antioxidant supplementation blunted this response. We also examined exposure-related changes in antioxidant/stress response leukocyte gene expression (GCLc, HMOX-1, IL-6, TGFβ) and plasma IL-6 levels. METHODS Nineteen nonsmoking adults participated in a double-blind, randomized, four-way crossover study. Each subject completed 120-min exposures to filtered air and DE (200 μg/m3), with and without antioxidant pretreatment. Antioxidant comprised 1000 mg ascorbate for 7 days and 1200 mg N-acetylcysteine 1 day prior to exposure, with 1000 mg and 600 mg, respectively, administered 2 h prior to exposure. Whole blood glutathione was measured pre- and post-exposure; plasma IL-6 and mRNA expression were quantified pre, during and post exposure. RESULTS Diesel exhaust exposure was associated with significantly decreased GSH/GSSG (p = 0.001) and a 4-fold increase in IL-6 mRNA (p = 0.01) post exposure. Antioxidant pretreatment did not significantly mediate the effect of DE exposure on GSH/GSSG, though appeared to decrease the effect of exposure on IL-6 mRNA expression. CONCLUSIONS Acute DE inhalation induced detectable oxidative effects in healthy adults, which were not significantly attenuated by the selected antioxidant pre-treatment. This finding supports the premise that oxidative stress is one mechanism underlying the adverse effects of traffic-related air pollution.
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Affiliation(s)
| | - Jason Allen
- Department of Environmental and Occupational Health Sciences, USA
| | - Karen L Jansen
- Department of Environmental and Occupational Health Sciences, USA
| | | | - Carol A Trenga
- Department of Environmental and Occupational Health Sciences, USA
| | - Timothy V Larson
- Department of Environmental and Occupational Health Sciences, USA; Department of Civil and Environmental Engineering, USA
| | - Joel D Kaufman
- Department of Environmental and Occupational Health Sciences, USA; Department of Medicine, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
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Wang Q, Xu X, Zeng Z, Zheng X, Ye K, Huo X. Antioxidant alterations link polycyclic aromatic hydrocarbons to blood pressure in children. THE SCIENCE OF THE TOTAL ENVIRONMENT 2020; 732:138944. [PMID: 32434106 DOI: 10.1016/j.scitotenv.2020.138944] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 02/05/2023]
Abstract
Exposure to polycyclic aromatic hydrocarbons (PAHs) is associated with changes in blood pressure. However, the association is controversial in different studies, and antioxidants' roles involved in it remain unclear. To investigate the associations among PAH exposure, blood pressure, and antioxidant concentrations, we recruited 403 children (2-7 years old), of which 203 were from Guiyu, an e-waste-recycling area (exposed group), and 200 were from Haojiang, a nearby non-e-waste area (reference group). Levels of blood pressure, plasma vitamin E, serum superoxide dismutase (SOD), serum glutathione peroxidase (GPx), and eight urinary hydroxylated PAHs (OH-PAHs) were measured. Compared with Haojiang children, Guiyu children had higher urinary OH-PAH concentrations but lower systolic pressure, pulse pressure, serum SOD concentration, and serum GPx concentration (all P < 0.05). PAH exposure was associated with lower systolic pressure, pulse pressure, SOD (adjusted β = -0.091, -0.104 and -0.154, respectively, all P < 0.05, in all children), GPx (adjusted β∑7LMW-OH-PAHs-T3 = -0.332, only in Haojiang children) and vitamin E (adjusted OR∑7LMW-OH-PAHs = 0.838, 95% CI: 0.706, 0.995, only in Guiyu children). Serum SOD and GPx were associated with higher blood pressure (βSOD-T2 for diastolic pressure = 0.215 in all children, βSOD-T3 for systolic pressure = 0.193 in all children, βSOD-T3 for pulse pressure = 0.281 in high-∑8OH-PAHs children, βGPx-T2 = 0.283 and βGPx-T3 = 0.289 for diastolic pressure in Haojiang children, all P < 0.05). Interactions between PAHs and vitamin E were associated with lower systolic pressure and pulse pressure; simple effects of vitamin E to raise systolic pressure and pulse pressure were only significant in low-∑8OH-PAHs children. Our results indicate that PAH exposure, especially at high levels, and further antioxidant-decrease are potential risk factors for blood-pressure decrease in children; vascular function of PAH-exposed children may be impaired, manifesting as disordered blood pressure.
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Affiliation(s)
- Qihua Wang
- Laboratory of Environmental Medicine and Developmental Toxicology, Guangdong Key Laboratory of Environmental Pollution and Health, School of Environment, Jinan University, Guangzhou 511443, Guangdong, China
| | - Xijin Xu
- Laboratory of Environmental Medicine and Developmental Toxicology, Shantou University Medical College, Shantou 515041, Guangdong, China; Department of Cell Biology and Genetics, Shantou University Medical College, Shantou 515041, Guangdong, China
| | - Zhijun Zeng
- Laboratory of Environmental Medicine and Developmental Toxicology, Guangdong Key Laboratory of Environmental Pollution and Health, School of Environment, Jinan University, Guangzhou 511443, Guangdong, China; Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands
| | - Xiangbin Zheng
- Laboratory of Environmental Medicine and Developmental Toxicology, Guangdong Key Laboratory of Environmental Pollution and Health, School of Environment, Jinan University, Guangzhou 511443, Guangdong, China
| | - Kai Ye
- Laboratory of Environmental Medicine and Developmental Toxicology, Guangdong Key Laboratory of Environmental Pollution and Health, School of Environment, Jinan University, Guangzhou 511443, Guangdong, China
| | - Xia Huo
- Laboratory of Environmental Medicine and Developmental Toxicology, Guangdong Key Laboratory of Environmental Pollution and Health, School of Environment, Jinan University, Guangzhou 511443, Guangdong, China.
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Pardo M, Qiu X, Zimmermann R, Rudich Y. Particulate Matter Toxicity Is Nrf2 and Mitochondria Dependent: The Roles of Metals and Polycyclic Aromatic Hydrocarbons. Chem Res Toxicol 2020; 33:1110-1120. [PMID: 32302097 PMCID: PMC7304922 DOI: 10.1021/acs.chemrestox.0c00007] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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Particulate matter
(PM), an important component of air pollution,
induces significant adverse health effects. Many of the observed health
effects caused by inhaled PM are associated with oxidative stress
and inflammation. This association has been linked in particular to
the particles’ chemical components, especially the inorganic/metal
and the organic/polycyclic aromatic hydrocarbon (PAH) fractions, and
their ability to generate reactive oxygen species in biological systems.
The transcription factor NF-E2 nuclear factor erythroid-related factor
2 (Nrf2) is activated by redox imbalance and regulates the expression
of phase II detoxifying enzymes. Nrf2 plays a key role in preventing
PM-induced toxicity by protecting against oxidative damage and inflammation.
This review focuses on specific PM fractions, particularly the dissolved
metals and PAH fractions, and their roles in inducing oxidative stress
and inflammation in cell and animal models with respect to Nrf2 and
mitochondria.
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Affiliation(s)
- Michal Pardo
- Department of Earth and Planetary Sciences, Weizmann Institute of Science, Rehovot 76100, Israel
| | - Xinghua Qiu
- State Key Joint Laboratory for Environmental Simulation and Pollution Control, College of Environmental Sciences and Engineering, and Center for Environment and Health, Peking University, Beijing 100871, P.R. China
| | - Ralf Zimmermann
- Joint Mass Spectrometry Centre, University of Rostock, 18055 Rostock, Germany.,Joint Mass Spectrometry Centre, Comprehensive Molecular Analytics (CMA) Cooperation Group Helmholtz Zentrum, 81379 München, Germany
| | - Yinon Rudich
- Department of Earth and Planetary Sciences, Weizmann Institute of Science, Rehovot 76100, Israel
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Rhon Calderón EA, Galarza RA, Faletti AG. 3-Methylcholanthrene impacts on the female germ cells of rats without causing systemic toxicity. Toxicology 2020; 429:152328. [DOI: 10.1016/j.tox.2019.152328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/16/2019] [Accepted: 10/31/2019] [Indexed: 12/31/2022]
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Cory-Slechta DA, Sobolewski M, Marvin E, Conrad K, Merrill A, Anderson T, Jackson BP, Oberdorster G. The Impact of Inhaled Ambient Ultrafine Particulate Matter on Developing Brain: Potential Importance of Elemental Contaminants. Toxicol Pathol 2019; 47:976-992. [PMID: 31610749 DOI: 10.1177/0192623319878400] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Epidemiological studies report associations between air pollution (AP) exposures and several neurodevelopmental disorders including autism, attention deficit disorder, and cognitive delays. Our studies in mice of postnatal (human third trimester brain equivalent) exposures to concentrated ambient ultrafine particles (CAPs) provide biological plausibility for these associations, producing numerous neuropathological and behavioral features of these disorders, including male-biased vulnerability. These findings raise questions about the specific components of AP that underlie its neurotoxicity, which our studies suggest could involve trace elements as candidate neurotoxicants. X-ray fluorescence analyses of CAP chamber filters confirm contamination of AP exposures by multiple elements, including iron (Fe) and sulfur (S). Correspondingly, laser ablation inductively coupled plasma mass spectrometry of brains of male mice indicates marked postexposure elevations of Fe and S and other elements. Elevations of brain Fe and S in particular are consistent with potential ferroptotic, oxidative stress, and altered antioxidant capacity-based mechanisms of CAPs-induced neurotoxicity, supported by observations of increased serum oxidized glutathione and increased neuronal cell death in nucleus accumbens with no corresponding significant increase in caspase-3, in male brains following postnatal CAP exposures. Understanding the role of trace element contaminants of particulate matter AP as a source of neurotoxicity is critical for public health protection.
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Affiliation(s)
| | - Marissa Sobolewski
- Department of Environmental Medicine, University of Rochester Medical Center, NY, USA
| | - Elena Marvin
- Department of Environmental Medicine, University of Rochester Medical Center, NY, USA
| | - Katherine Conrad
- Department of Environmental Medicine, University of Rochester Medical Center, NY, USA
| | - Alyssa Merrill
- Department of Environmental Medicine, University of Rochester Medical Center, NY, USA
| | - Tim Anderson
- Department of Environmental Medicine, University of Rochester Medical Center, NY, USA
| | - Brian P Jackson
- Department of Earth Sciences, Dartmouth College, Hanover, NH, USA
| | - Gunter Oberdorster
- Department of Environmental Medicine, University of Rochester Medical Center, NY, USA
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Single-Nucleotide Polymorphisms and Markers of Oxidative Stress in Healthy Women. PLoS One 2016; 11:e0156450. [PMID: 27271305 PMCID: PMC4896456 DOI: 10.1371/journal.pone.0156450] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 05/13/2016] [Indexed: 12/22/2022] Open
Abstract
Purpose There is accumulating evidence that oxidative stress is an important contributor to carcinogenesis. We hypothesized that genetic variation in genes involved in maintaining antioxidant/oxidant balance would be associated with overall oxidative stress. Methods We examined associations between single nucleotide polymorphisms (SNPs) in MnSOD, GSTP1, GSTM1, GPX1, GPX3, and CAT genes and thiobarbituric acid-reactive substances (TBARS), a blood biomarker of oxidative damage, in healthy white women randomly selected from Western New York (n = 1402). We used general linear models to calculate age-adjusted geometric means of TBARS across the variants. We also examined the associations within strata of menopausal status. Results For MnSOD, being heterozygous was associated with lower geometric means of TBARS (less oxidative stress), 1.28 mg/dL, compared to homozygous T-allele or homozygous C-allele,1.35 mg/dL, and 1.31 mg/dL correspondingly (p for trend = 0.01). This difference remained among postmenopausal women, 1.40 mg/dL for TT, 1.32 mg/dL for TC, and 1.34mg/dL for CC (p for trend 0.015); it was attenuated among premenopausal women. SNPs in the other genes examined (GSTP1, GSTM1, GPX1, GPX3, and CAT) were not associated with TBARS. Conclusions Our findings suggest that genetic variation in MnSOD gene may be associated with oxidative status, particularly among postmenopausal women.
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Kamal A, Cincinelli A, Martellini T, Malik RN. Linking mobile source-PAHs and biological effects in traffic police officers and drivers in Rawalpindi (Pakistan). ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2016; 127:135-143. [PMID: 26827277 DOI: 10.1016/j.ecoenv.2016.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 11/12/2015] [Accepted: 01/11/2016] [Indexed: 06/05/2023]
Abstract
The aim of this study was to evaluate the effect of traffic related polycyclic aromatic hydrocarbons (PAHs) on blood parameters of subjects, including traffic police officers (TP), drivers (DR) and control subjects (CN) with presumably different levels of exposure. We quantified the urinary 1-hydroxypyrene (1-OHPyr), α-naphthol and β-naphthol (α- and β-naph) as biomarkers of exposure to PAHs in relation with biomarkers of effect (Hb, MCV, PCV, PLT, RBCs), biomarkers of inflammation/infection (CRP, WBCs), oxidative stress (SOD) and oxidative DNA damage i.e. 8-hydroxy-2-deoxyguanosine (8-OHdG). Results showed that mean 1-OHPyr, α-naph and β-naph concentrations were significantly higher in TPs (0.98, 1.55, and 1.9µmolmol-Cr(-1), respectively, p<0.05) than CNs (0.7, 0.6; 0.67µmolmol-Cr(-1), respectively, P<0.05). Furthermore, WBC and CRP were found in higher concentrations in TPs than CNs (7.04×10(3)µL(-1) and 0.95mgL(-1) vs. 5.1×10(3)µL(-1) and 0.54mgL(-1), respectively). The urinary 8-OHdG level, a biomarker of oxidative DNA damage, was higher in TPs than both CN and DR subjects (48ngmg-Cr(-1), 24ngmg-Cr(-1) and 33ngmg-Cr(-1), respectively). Self-reported health assessment indicates that, on the basis of daily time spent in the middle of heavy traffic, TPs and DRs more frequently suffered from adverse head and respiratory symptoms. The PCA analysis evidenced the impact of traffic pollution on exposure biomarkers and DNA damage. The study suggests that traffic pollution may be associated with important health risk, in particular on the respiratory system, not only for workers exposed to traffic exhausts but also for general public. Finally, vehicular air pollution in the city of Rawalpindi should be a high-priority concern for the Pakistan Government that needs to be addressed.
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Affiliation(s)
- Atif Kamal
- Environmental Biology and Ecotoxicology Laboratory, Department of Environmental Sciences, Faculty of Biological Sciences, Quaid-i-Azam University, Islamabad 45320, Pakistan
| | - Alessandra Cincinelli
- Department of Chemistry, University of Florence, Via della Lastruccia, 3, Sesto Fiorentino, 50019 Florence, Italy; CNR, Istituto per la Dinamica dei Processi Ambientali, Via Dorsoduro 2137, 30123 Venezia, Italy
| | - Tania Martellini
- Department of Chemistry, University of Florence, Via della Lastruccia, 3, Sesto Fiorentino, 50019 Florence, Italy
| | - Riffat Naseem Malik
- Environmental Biology and Ecotoxicology Laboratory, Department of Environmental Sciences, Faculty of Biological Sciences, Quaid-i-Azam University, Islamabad 45320, Pakistan.
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Kamal A, Cincinelli A, Martellini T, Malik RN. A review of PAH exposure from the combustion of biomass fuel and their less surveyed effect on the blood parameters. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2015; 22:4076-4098. [PMID: 25410307 DOI: 10.1007/s11356-014-3748-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 10/17/2014] [Indexed: 06/04/2023]
Abstract
Many epidemiological studies from all over the world have reported that populations of rural and urban environments differ in their health issues due to the differences in the countrywide pollution pattern. In developing countries, various occupational cohorts and subsections of the population in urban and rural areas are routinely exposed to several environmentally widespread contaminants. Polycyclic aromatic hydrocarbons (PAHs) are a group of over hundred different compounds and have ubiquitous presence in rural and urban environments. Smoke from the combustion of biomass fuel contains a high concentration of carcinogenic PAHs, which are related with several human morbidities. The sources and types of biomass fuel are diverse and wide in distribution. Limited numbers of literature reports have focused the significant impact of PAHs on several components of blood, both in human and wildlife. The toxicity of PAHs to rapidly dividing cells (e.g., bone marrow cells) and other tissues is largely attributed to their reactive oxygenated metabolites, potential of causing oxidative stress, and the adducts of their metabolites with DNA. This review aims to encompass the blood-related effects of PAHs and associated human health risks-an aspect that needs further research-on the population of developing countries of the world in particular.
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Affiliation(s)
- Atif Kamal
- Environmental Biology and Ecotoxicology Laboratory, Department of Environmental Sciences, Faculty of Biological Sciences, Quaid-i-Azam University, Islamabad, 45320, Pakistan,
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Positive relationship between total antioxidant status and chemokines observed in adults. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2014; 2014:693680. [PMID: 25254081 PMCID: PMC4164799 DOI: 10.1155/2014/693680] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 08/10/2014] [Accepted: 08/11/2014] [Indexed: 12/24/2022]
Abstract
Objective. Human evidence is limited regarding the interaction between oxidative stress biomarkers and chemokines, especially in a population of adults without overt clinical disease. The current study aims to examine the possible relationships of antioxidant and lipid peroxidation markers with several chemokines in adults. Methods. We assessed cross-sectional associations of total antioxidant status (TAS) and two lipid peroxidation markers malondialdehyde (MDA) and thiobarbituric acid reactive substances (TBARS) with a suite of serum chemokines, including CXCL-1 (GRO-α), CXCL-8 (IL-8), CXCL-10 (IP-10), CCL-2 (MCP-1), CCL-5 (RANTES), CCL-8 (MCP-2), CCL-11 (Eotaxin-1), and CCL-17 (TARC), among 104 Chinese adults without serious preexisting clinical conditions in Beijing before 2008 Olympics. Results. TAS showed significantly positive correlations with MCP-1 (r = 0.15751, P = 0.0014), MCP-2 (r = 0.3721, P = 0.0001), Eotaxin-1 (r = 0.39598, P < 0.0001), and TARC (r = 0.27149, P = 0.0053). The positive correlations remained unchanged after controlling for age, sex, body mass index, smoking, and alcohol drinking status. No associations were found between any of the chemokines measured in this study and MDA or TBARS. Similar patterns were observed when the analyses were limited to nonsmokers. Conclusion. Total antioxidant status is positively associated with several chemokines in this adult population.
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Beyea J, Stellman SD, Teitelbaum S, Mordukhovich I, Gammon MD. Imputation method for lifetime exposure assessment in air pollution epidemiologic studies. Environ Health 2013; 12:62. [PMID: 23919666 PMCID: PMC3751034 DOI: 10.1186/1476-069x-12-62] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Accepted: 07/24/2013] [Indexed: 05/21/2023]
Abstract
BACKGROUND Environmental epidemiology, when focused on the life course of exposure to a specific pollutant, requires historical exposure estimates that are difficult to obtain for the full time period due to gaps in the historical record, especially in earlier years. We show that these gaps can be filled by applying multiple imputation methods to a formal risk equation that incorporates lifetime exposure. We also address challenges that arise, including choice of imputation method, potential bias in regression coefficients, and uncertainty in age-at-exposure sensitivities. METHODS During time periods when parameters needed in the risk equation are missing for an individual, the parameters are filled by an imputation model using group level information or interpolation. A random component is added to match the variance found in the estimates for study subjects not needing imputation. The process is repeated to obtain multiple data sets, whose regressions against health data can be combined statistically to develop confidence limits using Rubin's rules to account for the uncertainty introduced by the imputations. To test for possible recall bias between cases and controls, which can occur when historical residence location is obtained by interview, and which can lead to misclassification of imputed exposure by disease status, we introduce an "incompleteness index," equal to the percentage of dose imputed (PDI) for a subject. "Effective doses" can be computed using different functional dependencies of relative risk on age of exposure, allowing intercomparison of different risk models. To illustrate our approach, we quantify lifetime exposure (dose) from traffic air pollution in an established case-control study on Long Island, New York, where considerable in-migration occurred over a period of many decades. RESULTS The major result is the described approach to imputation. The illustrative example revealed potential recall bias, suggesting that regressions against health data should be done as a function of PDI to check for consistency of results. The 1% of study subjects who lived for long durations near heavily trafficked intersections, had very high cumulative exposures. Thus, imputation methods must be designed to reproduce non-standard distributions. CONCLUSIONS Our approach meets a number of methodological challenges to extending historical exposure reconstruction over a lifetime and shows promise for environmental epidemiology. Application to assessment of breast cancer risks will be reported in a subsequent manuscript.
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Affiliation(s)
- Jan Beyea
- Consulting in the Public Interest (CIPI), Lambertville, NJ
| | - Steven D Stellman
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Susan Teitelbaum
- Department of Preventive Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - Irina Mordukhovich
- Department of Epidemiology, University of North Carolina at Chapel Hill, Raleigh, North Carolina, USA
| | - Marilie D Gammon
- Department of Epidemiology, University of North Carolina at Chapel Hill, Raleigh, North Carolina, USA
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