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Woolf AD, Jackson JE, Corcoran P, Fritz MK, Kim SS, Maslak TM, Shah M, Hansen L. An Update on Pediatric Environmental Health Specialty Units: Activities and Impacts, 2015-19. Acad Pediatr 2024:S1876-2859(24)00108-6. [PMID: 38494060 DOI: 10.1016/j.acap.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 03/05/2024] [Accepted: 03/11/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVE Pediatric Environmental Health Specialty Units (PEHSUs) address health concerns impacting children and their families related to environmental hazards by providing consultation and education to families, communities, and health care professionals. This analysis evaluated the productivity of the national PEHSU program. METHODS PEHSUs reported data on services provided to US communities between October 1, 2014 and September 30, 2019. Descriptive statistics and qualitative analysis are presented. RESULTS During this period, 6102 consultations and 4644 educational outreach activities were recorded. PEHSU faculty and staff published 462 articles, reviews, book chapters, fact sheets, commentaries, short informational pieces, and other materials between 2014 and 2019. These included 190 articles in scientific peer-reviewed journals and 29 textbook chapters to increase professional capacity in pediatric and reproductive environmental health. Lead, other metals, substances of abuse, pesticides, mold, and air pollution were frequently reported as agents of concern and educational topics. Requests for an overview of pediatric environmental health and outdoor pollutants were other frequently reported topics. CONCLUSIONS PEHSUs work to decrease harmful exposures and improve children's health. They serve as expert resources for families, health care professionals, and communities on health effects related to environmental exposures. Data show the breadth and depth of concerns addressed and demonstrate the productivity and impact of this national program.
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Affiliation(s)
- Alan D Woolf
- Division of General Pediatrics (AD Woolf), Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Mass.
| | | | - Peter Corcoran
- Department of Healthy Resilient Children, Youth & Families (P Corcoran), American Academy of Pediatrics, Itasca, Ill
| | - Meredith K Fritz
- Health Economics & Outcomes Research (MK Fritz, SS Kim, and TM Maslak), Battelle, Columbus, Ohio
| | - Stephani S Kim
- Health Economics & Outcomes Research (MK Fritz, SS Kim, and TM Maslak), Battelle, Columbus, Ohio
| | - Tanya M Maslak
- Health Economics & Outcomes Research (MK Fritz, SS Kim, and TM Maslak), Battelle, Columbus, Ohio
| | - Manthan Shah
- US Environmental Protection Agency (M Shah), Office of Children's Health Protection, Environmental Protection Agency, Washington, DC
| | - Linda Hansen
- Office of Capacity Development and Applied Prevention Science (OCDAPS) (L Hansen), Agency for Toxic Substances and Disease Registry (ATSDR), Centers for Disease Control and Prevention (CDC), Atlanta, Ga
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Woolf AD, Jacobson J, Flanagan S, Weinstock P. Education on Preventing Early Childhood Injuries Using a Video Game: The VirtualSafeHome Platform. Clin Pediatr (Phila) 2024; 63:257-262. [PMID: 37082793 DOI: 10.1177/00099228231169262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Poisonings and household injuries are frequent events among toddlers. We developed VirtualSafeHome (VSH)-a novel self-contained, Internet-based home-safety learning tool-to improve awareness of household hazards. Study aims were to investigate VSH usage characteristics. A prototype, screen-based VSH kitchen was built in Unity and delivered through the web using 3DVista and Wix. Players spot and click 21 embedded hazards. A unique feature is the ability to capture the "child's perspective" in identifying hazards. We recruited a convenience sample of adults in 2021-2022. Outcomes included number of hazards discovered, session duration, and pretest/posttest knowledge scores. Twenty-four adults identified a median 15.5 hazards; median playing time was 1022 seconds. Players reported satisfaction with ease of navigation and game features. Mean pretest/posttest knowledge scores rose from 2.0 to 2.79 (P < .035). A web-enabled video game can provide easily accessed, enjoyable training on home safety.
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Affiliation(s)
- Alan D Woolf
- Division of General Pediatrics, Pediatric Environmental Health Center, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jeffrey Jacobson
- Immersive Design Systems (formerly SIMPeds), Boston Children's Hospital, Boston, MA, USA
| | - Shelby Flanagan
- Division of General Pediatrics, Pediatric Environmental Health Center, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Peter Weinstock
- Harvard Medical School, Boston, MA, USA
- Immersive Design Systems (formerly SIMPeds), Boston Children's Hospital, Boston, MA, USA
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
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3
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Woolf AD, Baum CR, Burns M. Poison Centers and Pediatric Environmental Health Specialty Units: Productive Two-Way Partnerships. J Med Toxicol 2023:10.1007/s13181-023-00942-6. [PMID: 36988816 DOI: 10.1007/s13181-023-00942-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/21/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Affiliation(s)
- Alan D Woolf
- Region 1 Pediatric Environmental Health Specialty Unit, Division of General Pediatrics, Boston Children's Hospital, Professor of Pediatrics, Harvard Medical School, 300 Longwood Ave, Boston, MA, USA.
| | - Carl R Baum
- Department of Emergency Medicine, Yale New Haven Hospital, Professor of Pediatrics, Yale School of Medicine, 20 York Street, New Haven, CT, USA
| | - Michele Burns
- Massachusetts/Rhode Island Poison Center, Department of Emergency Medicine, Boston Children's Hospital, Assistant Professor of Pediatrics, Harvard Medical School, 300 Longwood Ave, Boston, MA, USA
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Woolf AD, Stierman BD, Barnett ED, Byron LG. Drinking Water From Private Wells and Risks to Children. Pediatrics 2023; 151:190542. [PMID: 36995188 DOI: 10.1542/peds.2022-060645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2022] [Indexed: 02/04/2023] Open
Abstract
Drinking water for approximately 23 million US households is obtained from private wells. These wells can become contaminated by pollutant chemicals or pathogenic organisms, leading to significant illness. Although the US Environmental Protection Agency and all states offer guidance for construction, maintenance, and testing of private wells, most states only regulate the construction of new private water wells. With a few exceptions, there is little regulation after construction. Well owners are responsible for their own wells. Children may also drink well water at child care or when traveling. Illness resulting from children’s ingestion of contaminated water can be severe. This report reviews relevant aspects of groundwater and wells; describes the common chemical and microbiologic contaminants; gives an algorithm with recommendations for inspection, testing, and remediation for wells providing drinking water for children; and provides references and Internet resources for more information.
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Affiliation(s)
- Alan D Woolf
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bryan D Stierman
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elizabeth D Barnett
- Department of Pediatrics, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Lori G Byron
- Indian Health Service (retired), SCL Health, Billings, Montana
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Woolf AD, Stierman BD, Barnett ED, Byron LG. Drinking Water From Private Wells and Risks to Children. Pediatrics 2023; 151:190540. [PMID: 36995187 DOI: 10.1542/peds.2022-060644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2022] [Indexed: 01/31/2023] Open
Abstract
Drinking water for >23 million US households is obtained from private wells. These wells can become contaminated by chemicals, naturally occurring toxic substances, or pathogenic organisms that can cause illness in children. Although the US Environmental Protection Agency and most states offer some guidance for the construction, maintenance, and testing of private wells, most states only regulate the construction of new private water wells. With few exceptions, well owners are responsible for their own wells after the initial construction. Children may also drink well water at childcare or when traveling. This policy statement provides recommendations for the inspection, testing, and remediation of private wells to provide safe drinking water for children.
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Affiliation(s)
- Alan D Woolf
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bryan D Stierman
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elizabeth D Barnett
- Department of Pediatrics, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Lori G Byron
- Indian Health Service (retired), SCL Health, Billings, Montana
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Shah SH, Woolf AD, Manning K, Holder-Niles F, Tully B, Flanagan S, Spence MC, Hauptman M. The more you know: Insights from integrated pre-visit surveys in a pediatric environmental health center. Int Public Health J 2023; 15:297-306. [PMID: 38362063 PMCID: PMC10868725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
The Pediatric Environmental Health Center (PEHC) at Boston Children's Hospital is a specialty referral clinic that provides consultation for approximately 250 patients annually. Identifying environmental hazards is key for clinical management. Exposure concerns include lead, mold, pesticides, perfluoroalkyl substances (PFAS), impaired air quality, and more. Our goal was to identify concerns and visit priorities of our patient population to guide visits. A 47-question pre-visit survey was created exploring potential environmental hazards and administered prior to visits using a platform integrated into the electronic medical record (EMR). The study group was a convenience sample of patients from June 2021 to June 2022. Of 204 total visits, 101 surveys were submitted, yielding a response rate of 49.5%. 66/101 (65.3%) were surveys from initial consultations used for descriptive analysis. The majority of patients were seen for a chief complaint of lead exposure (90.1%). Most respondents had concerns about peeling paint (40.0%), and those reporting peeling paint were more likely to report additional concerns [75.0%, p < 0.001]. Other concerns highlighted were mold (15.2%), pests (15.2%), asbestos (10.6%), air pollution (9.1%), temperature regulation (7.6%), pesticides (6.1%), PFAS (4.5%), and formaldehyde (4.5%). A knowledge gap was identified; 45.5% (30/66) respondents responded "no" to the question asking if the Poison Control Center phone number was stored in their phone. This study illustrates how the implementation of a pre-visit EMR integrated survey engages families, informs clinical care, and serves as a point-of-care education tool for specific knowledge gaps. Findings will guide development of future environmental health screeners.
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Affiliation(s)
- Shalini H Shah
- Pediatric Environmental Health Center, Boston Children’s Hospital, Boston, Massachusetts, USA
- Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, Massachusetts, USA
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Alan D Woolf
- Pediatric Environmental Health Center, Boston Children’s Hospital, Boston, Massachusetts, USA
- Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, Massachusetts, USA
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberly Manning
- Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, Massachusetts, USA
| | - Faye Holder-Niles
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Bridget Tully
- Pediatric Environmental Health Center, Boston Children’s Hospital, Boston, Massachusetts, USA
- Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, Massachusetts, USA
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Shelby Flanagan
- Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, Massachusetts, USA
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew C Spence
- Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, Massachusetts, USA
| | - Marissa Hauptman
- Pediatric Environmental Health Center, Boston Children’s Hospital, Boston, Massachusetts, USA
- Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, Massachusetts, USA
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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Affiliation(s)
- Alan D Woolf
- Department of Pediatrics, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Region 1 New England Pediatric Environmental Health Unit, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Mary Jean Brown
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Johnson KM, Specht AJ, Hart JM, Salahuddin S, Erlinger AL, Hacker MR, Woolf AD, Hauptman M, Karumanchi SA, O'Brien K, Wylie BJ. Risk-Factor Based Lead Screening and Correlation with Blood Lead Levels in Pregnancy. Matern Child Health J 2022; 26:185-192. [PMID: 35020085 PMCID: PMC8826746 DOI: 10.1007/s10995-021-03325-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2021] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Lead exposure has devastating neurologic consequences for children and may begin in utero. The American College of Obstetricians and Gynecologists recommends prenatal lead screening using a risk factor-based approach rather than universal blood testing. The clinical utility of this approach has not been studied. We evaluated a risk-factor based questionnaire to detect elevated blood lead levels in pregnancy. METHODS We performed a secondary analysis of a cohort of parturients enrolled to evaluate the association of lead with hypertensive disorders of pregnancy. We included participants in this analysis if they had a singleton pregnancy ≥ 34 weeks' gestation with blood lead levels recorded. Participants completed a lead risk factor survey modified for pregnancy. We defined elevated blood lead as ≥ 2 μg/dL, as this was the clinically reportable level. RESULTS Of 102 participants enrolled in the cohort, 92 had blood lead measured as part of the study. The vast majority (78%) had 1 or more risk factor for elevated lead using the questionnaire yet none had clinical blood lead testing during routine visits. Only two participants (2.2%) had elevated blood lead levels. The questionnaire had high sensitivity but poor specificity for predicting detectable lead levels (sensitivity 100%, specificity 22%). CONCLUSIONS FOR PRACTICE Prenatal risk-factor based lead screening appears underutilized in practice and does not adequately discriminate between those with and without elevated blood levels. Given the complexity of the risk factor-based approach and underutilization, the benefit and cost-effectiveness of universal lead testing should be further explored.
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Affiliation(s)
- Katherine M Johnson
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA.
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA.
- Department of Obstetrics and Gynecology, University of Massachusetts Medical School/University of Massachusetts Memorial Medical Center, 119 Belmont Street, Worcester, MA, 01605, USA.
| | - Aaron J Specht
- Harvard T. H. Chan School of Public Health, Boston, MA, 02215, USA
| | - Jessica M Hart
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Saira Salahuddin
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Center for Vascular Biology Research, Beth Israel Deaconess Medical Center/Harvard Medical School, 99 Brookline Avenue, RN 359, Boston, MA, 02215, USA
| | - Adrienne L Erlinger
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Michele R Hacker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, 02215, USA
| | - Alan D Woolf
- Pediatric Environmental Health Center, Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, USA
- Region 1 Pediatric Environmental Health Specialty Unit, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Marissa Hauptman
- Pediatric Environmental Health Center, Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, USA
- Region 1 Pediatric Environmental Health Specialty Unit, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - S Ananth Karumanchi
- Center for Vascular Biology Research, Beth Israel Deaconess Medical Center/Harvard Medical School, 99 Brookline Avenue, RN 359, Boston, MA, 02215, USA
- Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Karen O'Brien
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Blair J Wylie
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Region 1 Pediatric Environmental Health Specialty Unit, Boston, MA, USA
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Erwin J, Enki DG, Woolf AD. Younger people with rheumatoid arthritis are at increased risk of fracture even before age 50 years: a population-based cohort study. Osteoporos Int 2021; 32:1651-1659. [PMID: 33569694 DOI: 10.1007/s00198-021-05862-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 01/27/2021] [Indexed: 11/30/2022]
Abstract
UNLABELLED Less is known about the risk of fracture in people with rheumatoid arthritis aged under 50 than those in older age groups. The study shows that the risk of fracture before age 50 remains significantly higher in those with rheumatoid arthritis than matched controls. This has implications for fracture risk management. INTRODUCTION To determine the risk of first and subsequent fracture occurring before age 50 in people diagnosed with rheumatoid arthritis (RA) before age 50. METHODS A retrospective observational cohort study of RA cases with matched controls using data from Clinical Practice Research Datalink (CPRD) of adults ≥ 18 years with diagnosis of RA recorded from 1992 to 2016 in the UK. Patients were followed from index date to the first fracture and subsequent fracture. A total of 36,858 cases were each matched to 3 controls. Incidence rates (IR) and incidence rate ratios (IRR) of first and subsequent fractures were calculated. A multivariate Cox's proportional hazards model was used to calculate the risk of first fracture and of subsequent fracture in the presence of different risk factors. RESULTS The IR of first and subsequent fractures at any age is significantly higher in cases than controls for patients with onset of RA at any age. This includes first fractures occurring before age 50 for those diagnosed with RA before this age. In women, the rate of first fracture before age 50 are significantly higher than matched controls (IRR 1.29 CI 1.12-1.49), the IRR for subsequent fracture is higher but not significantly so. For men, the IRRs of first and subsequent fractures below age 50 are also higher but not significantly so. Gender, previous fracture, glucocorticoid prescription, osteoporosis diagnosis, alcohol, smoking, and bisphosphonate prescription have a significant effect on the risk of first fracture at any age for RA patients; all these variables except osteoporosis diagnosis and alcohol have a significant effect on the risk of subsequent fracture and first fractures before age 50. CONCLUSIONS These results indicate an increased risk of first fracture before age 50 in people with RA diagnosed before this age. It is important that patients with RA of all ages are given timely support from the time of diagnosis to protect their bone health.
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Affiliation(s)
- J Erwin
- Research Development & Innovations, Royal Cornwall Hospitals NHS Trust, Truro, UK.
| | - D G Enki
- School of Medicine, University of Nottingham, Nottingham, UK
| | - A D Woolf
- Research Development & Innovations, Royal Cornwall Hospitals NHS Trust, Truro, UK
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Abstract
The coronavirus disease 2019 pandemic has dramatically altered the health and well-being of children, particularly as they have been isolated indoors and in their homes as a result of social distancing measures. In this article, we describe several of the environmental threats that are affecting the health of children during the pandemic. These include increased exposure to household cleaning products, chemicals and lead in dust, indoor air pollutants, screen time, family stress, and firearms, as well as decreased availability of food, social supports, and routine childhood screenings. Importantly, many of these threats disproportionately affect children of racial or ethnic minorities or who have low socioeconomic status. Pediatric health care providers will need to screen and treat children and counsel their parents and/or other caregivers during well-child visits with an eye for these new or worsened environmental threats. [Pediatr Ann. 2020;49(12):e537-e542.].
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11
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Johnson KM, Specht AJ, Hart JM, Salahuddin S, Erlinger AL, Hacker MR, Woolf AD, Hauptman M, Karumanchi SA, Wylie BJ, O'Brien K. Lead exposure and association with angiogenic factors and hypertensive disorders of pregnancy. Pregnancy Hypertens 2020; 22:93-98. [PMID: 32763807 DOI: 10.1016/j.preghy.2020.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 07/23/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVES Lead exposure has been associated with hypertensive disorders of pregnancy. Angiogenic factors, including soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PlGF), are aberrant in preeclampsia, but have not been correlated with lead levels. We evaluated the association of lead exposure with angiogenic factors. STUDY DESIGN This cross sectional study utilized a convenience sample of singleton pregnancies ≥34 weeks' gestation. Blood lead and angiogenic factors were measured before delivery; bone lead was measured postpartum. We dichotomized bone and blood lead into the top tertile versus the bottom tertiles and used log-binomial regression to assess the association between lead and a high angiogenic ratio. MAIN OUTCOME MEASURES The outcomes were high sFlt1 to PlGF ratio and development of a hypertensive disorder of pregnancy. RESULTS We enrolled 102 participants, of whom 98 had at least one lead measurement and an angiogenic factor result. Median bone lead was 3.8 ug/g (2.0 - 6.6) and median blood lead was 0.2 ug/dL (0.2 - 0.4). Incidence of hypertensive disorders of pregnancy was 31%. When comparing the highest tertile of bone lead to the bottom two tertiles, there was no association with a high sFlt1/PlGF ratio or hypertensive disorders of pregnancy. Similar results were observed for the exposure of blood lead. CONCLUSIONS Lead exposure was not an important contributor to an elevated angiogenic factor ratio or hypertensive disorders of pregnancy in our U.S. POPULATION However, lead exposure was modest in our population and we cannot exclude a relationship with hypertensive disorders of pregnancy.
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Affiliation(s)
- Katherine M Johnson
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.
| | - Aaron J Specht
- Harvard T. H. Chan School of Public Health, Boston, MA 02215, USA
| | - Jessica M Hart
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - Saira Salahuddin
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA; Center for Vascular Biology Research, Beth Israel Deaconess Medical Center/Harvard Medical School, 99 Brookline Avenue, RN 359, Boston, MA 02215, USA
| | - Adrienne L Erlinger
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Michele R Hacker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA; Harvard T. H. Chan School of Public Health, Boston, MA 02215, USA
| | - Alan D Woolf
- Pediatric Environmental Health Center, Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, USA; Region 1 Pediatric Environmental Health Specialty Unit, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Marissa Hauptman
- Pediatric Environmental Health Center, Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, USA; Region 1 Pediatric Environmental Health Specialty Unit, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - S Ananth Karumanchi
- Center for Vascular Biology Research, Beth Israel Deaconess Medical Center/Harvard Medical School, 99 Brookline Avenue, RN 359, Boston, MA 02215, USA; Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| | - Blair J Wylie
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA; Region 1 Pediatric Environmental Health Specialty Unit, Boston, MA, USA
| | - Karen O'Brien
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
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12
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Affiliation(s)
- Alan D Woolf
- Boston Children's Hospital, Boston, Massachusetts; and .,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Shannon F Manzi
- Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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Abstract
Cases of severe childhood lead poisoning (a blood lead level (BLL) ≥45 mcg/dL) in the United States have decreased with time. Clinicians will encounter such cases only rarely. When such cases arise, however, recognizing their complexities and identifying resources that can help in management are important. We present here a case of severe childhood lead poisoning, highlighting the variable presentation, the rebound phenomenon of BLL after chelation, the usefulness of the zinc protoporphyrin as an adjunctive monitoring parameter, and the importance of early involvement of an inter-professional team.
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Affiliation(s)
- Bryan Stierman
- Department of Pediatrics, Pediatric Environmental Health Center, Boston Children's Hospital; 300 Longwood Ave; Boston 02115, MA, United States; Department of Pediatrics, Harvard Medical School, United States; Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, MA, United States
| | - Marissa Hauptman
- Department of Pediatrics, Pediatric Environmental Health Center, Boston Children's Hospital; 300 Longwood Ave; Boston 02115, MA, United States; Department of Pediatrics, Harvard Medical School, United States; Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, MA, United States
| | - Alan D Woolf
- Department of Pediatrics, Pediatric Environmental Health Center, Boston Children's Hospital; 300 Longwood Ave; Boston 02115, MA, United States; Department of Pediatrics, Harvard Medical School, United States; Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, MA, United States.
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Bruccoleri RE, Woolf AD. Puberty and resultant increased bone turnover as a possible etiology of an increased lead concentration in a pre-adolescent girl. Clin Toxicol (Phila) 2019; 58:843-845. [PMID: 31724434 DOI: 10.1080/15563650.2019.1688340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: We present a case in which puberty likely resulted in an increased lead concentration in a pre-adolescent girl.Case report: A 12-year-old girl was referred to the pediatric environmental health clinic (PEHC) after her blood lead level (BLL) was found to be elevated to 30 µg/dL (reference <5 µg/dL). She had been seen in the PEHC 6 years previously for management of a BLL as high as 36 µg/dL. Fifteen months prior to her repeat PEHC referral, her BLL had been 10 µg/dL. In those intervening 15 months, she grew 10.42 cm. Thyroid studies were normal. Four months after re-referral, her osteocalcin concentration, a marker of bone turnover, was 212 ng/mL (normal 9-42 ng/mL in adults >18 years); 10.5 months after the peak BLL of 32 mcg/dL, her BLL was 16 µg/dL, osteocalcin was 69 ng/mL, and her rate of growth had declined to 0.20 cm/30 days (peak: 1.07 cm/30 days). No external source of her exposure was found.Discussion: Osteocalcin concentrations and plotting the changes in growth velocity over time may assist clinicians in determining if pubertal growth is playing a role in unexpectedly increased BLL discovered in adolescents for whom no external source of lead exposure can be found.
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Affiliation(s)
- Rebecca E Bruccoleri
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Tennessee Poison Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan D Woolf
- Harvard Medical School, Boston, MA, USA.,Pediatric Environmental Health Center, Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
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15
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Affiliation(s)
- Marissa Hauptman
- Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, MA, USA
| | - Bryan Stierman
- Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, MA, USA
| | - Alan D. Woolf
- Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, MA, USA
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16
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Landrigan PJ, Braun JM, Crain EF, Forman J, Galvez M, Gitterman BA, Halevi G, Karr C, Mall JK, Paulson JA, Woolf AD, Lanphear BP, Wright RO. Building Capacity in Pediatric Environmental Health: The Academic Pediatric Association's Professional Development Program. Acad Pediatr 2019; 19:421-427. [PMID: 30639371 DOI: 10.1016/j.acap.2019.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 12/18/2018] [Accepted: 01/08/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Environmental exposures contribute to multiple diseases in children; yet, few pediatricians have training in pediatric environmental health (PEH), and few academic health centers have PEH expertise. To build national capacity in PEH, the Academic Pediatric Association (APA) launched a professional development program that since 2002 has encouraged the establishment of post-residency/post-doctoral training programs, supported a special interest group, and convened an annual mentored retreat for PEH trainees. OBJECTIVE Describe the APA's professional development program in PEH and assess its impact by tracking careers of former trainees. METHODS Careers were tracked through interviews with trainees and program directors supplemented by searches of institutional websites. Publication listings were obtained through PubMed. Publication impact was assessed using bibliometric and altmetric measures. Grant histories were accessed through the National Institutes of Health RePORTER project. Information on advocacy work was obtained through interviews with program directors. RESULTS Fifty-five trainees (36 physicians and 19 health scientists) completed PEH training and attended the APA retreat between 2002 and 2017. Forty-one (75%) are pursuing academic careers, 11 are associate or full professors, 11 are practicing general pediatrics or a pediatric subspecialty, 2 are Centers for Disease Control and Prevention epidemiologists, and 1 is a data scientist. Forty-two former trainees (76%) listed "environment" or "environmental" in their job titles or on their websites. Former trainees have published 632 scientific papers. These papers have been cited 3094times, have a relative citation ratio of 2.97, and have been read or viewed 1,274,388times. Twenty-one former trainees have been awarded 43 National Institutes of Health grants. Trainees have developed education and advocacy skills by teaching medical students and residents, presenting grand rounds, preparing policy papers, presenting legislative testimony, and making presentations to public audiences. CONCLUSIONS The APA's professional development program has contributed to the expansion of national capacity in PEH. Former trainees are populating the field, generating new knowledge, and moving into leadership positions.
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Affiliation(s)
- Philip J Landrigan
- Icahn School of Medicine at Mount Sinai (PJ Landrigan, J Forman, M Galvez, G Halevi, and RO Wright), New York, NY.
| | - Joseph M Braun
- Brown University School of Public Health (JM Braun), Providence, RI
| | - Ellen F Crain
- Albert Einstein College of Medicine (EF Crain), Bronx, NY
| | - Joel Forman
- Icahn School of Medicine at Mount Sinai (PJ Landrigan, J Forman, M Galvez, G Halevi, and RO Wright), New York, NY
| | - Maida Galvez
- Icahn School of Medicine at Mount Sinai (PJ Landrigan, J Forman, M Galvez, G Halevi, and RO Wright), New York, NY
| | - Benjamin A Gitterman
- Children's National Medical Center, George Washington University (BA Gitterman and JA Paulson), Washington, DC
| | - Gali Halevi
- Icahn School of Medicine at Mount Sinai (PJ Landrigan, J Forman, M Galvez, G Halevi, and RO Wright), New York, NY
| | - Catherine Karr
- University of Washington School of Medicine and School of Public Health (C Karr), Seattle
| | | | - Jerome A Paulson
- Children's National Medical Center, George Washington University (BA Gitterman and JA Paulson), Washington, DC
| | - Alan D Woolf
- Boston Children's Hospital, Harvard Medical School (AD Woolf), Boston, Mass
| | | | - Robert O Wright
- Icahn School of Medicine at Mount Sinai (PJ Landrigan, J Forman, M Galvez, G Halevi, and RO Wright), New York, NY
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17
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Paulson JA, Lowry JA, Ahdoot S, Baum CR, Bernstein AS, Bole A, Byron LG, Landrigan PJ, Marcus SM, Pacheco SE, Spanier AJ, Woolf AD. Pediatric Considerations Before, During, and After Radiological or Nuclear Emergencies. Pediatrics 2018; 142:peds.2018-3000. [PMID: 30478240 DOI: 10.1542/peds.2018-3000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Infants, children, and adolescents can be exposed unexpectedly to ionizing radiation from nuclear power plant events, improvised nuclear or radiologic dispersal device explosions, or inappropriate disposal of radiotherapy equipment. Children are likely to experience higher external and internal radiation exposure levels than adults because of their smaller body and organ size and other physiologic characteristics, by picking up contaminated items, and through consumption of contaminated milk or foodstuffs. This policy statement and accompanying technical report update the 2003 American Academy of Pediatrics policy statement on pediatric radiation emergencies by summarizing newer scientific knowledge from studies of the Chernobyl and Fukushima Daiichi nuclear power plant events, use of improvised radiologic dispersal devices, exposures from inappropriate disposal of radiotherapy equipment, and potential health effects from residential proximity to nuclear plants. Policy recommendations are made for providers and governments to improve future responses to these types of events.
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Affiliation(s)
| | - Jennifer Ann Lowry
- Department of Pediatrics, School of Medicine and Health Sciences and Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Samantha Ahdoot
- Department of Pediatrics, School of Medicine and Health Sciences and Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Carl R. Baum
- Department of Pediatrics, School of Medicine and Health Sciences and Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Aaron S. Bernstein
- Department of Pediatrics, School of Medicine and Health Sciences and Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Aparna Bole
- Department of Pediatrics, School of Medicine and Health Sciences and Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Lori G. Byron
- Department of Pediatrics, School of Medicine and Health Sciences and Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Philip J. Landrigan
- Department of Pediatrics, School of Medicine and Health Sciences and Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Steven M. Marcus
- Department of Pediatrics, School of Medicine and Health Sciences and Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Susan E. Pacheco
- Department of Pediatrics, School of Medicine and Health Sciences and Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Adam J. Spanier
- Department of Pediatrics, School of Medicine and Health Sciences and Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Alan D. Woolf
- Department of Pediatrics, School of Medicine and Health Sciences and Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
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18
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Carpenter C, Potts B, von Oettingen J, Bonnell R, Sainvil M, Lorgeat V, Mascary MC, She X, Jean-Baptiste E, Palfrey S, Woolf AD, Palfrey J. Elevated Blood Lead Levels in Infants and Children in Haiti, 2015. Public Health Rep 2018; 134:47-56. [PMID: 30426830 DOI: 10.1177/0033354918807975] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Few studies have reported blood lead levels (BLLs) in Haitian children, despite the known presence of lead from environmental factors such as soil, water, leaded paint and gasoline, improperly discarded batteries, and earthquakes. We sought to determine the prevalence of elevated blood lead levels (EBLLs) among healthy Haitian children. METHODS We enrolled children aged 9 months to 6 years from 3 geographic areas in Haiti (coastal, urban, and mountain) from March 1 through June 30, 2015. We obtained anthropometric measurements, household income, potential sources of lead exposure, and fingerstick BLLs from 273 children at 6 churches in Haiti. We considered a BLL ≥5 μg/dL to be elevated. RESULTS Of 273 children enrolled in the study, 95 were from the coastal area, 78 from the urban area, and 100 from the mountain area. The median BLL was 5.8 μg/dL, with higher levels in the mountain area than in the other areas ( P < .001). BLLs were elevated in 180 (65.9%) children. The prevalence of EBLL was significantly higher in the mountain area (82 of 100, 82.0%; P < .001) than in the urban area (42 of 78, 53.8%) and the coastal area (56 of 95, 58.9%; P < .001). Twenty-eight (10.3%) children had EBLLs ≥10 μg/dL and 3 (1.1%) children had EBLLs ≥20 μg/dL. Exposure to improperly discarded batteries ( P = .006) and living in the mountain area ( P < .001) were significant risk factors for EBLLs. CONCLUSIONS More than half of Haitian children in our study had EBLLs. Public health interventions are warranted to protect children in Haiti against lead poisoning.
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Affiliation(s)
- Chris Carpenter
- 1 Boston Children's Hospital, Boston, MA, USA.,2 Kay Mackenson Center, Pierre Payen, Artibonite, Haiti.,3 Current affiliation: University of California, San Francisco Medical Center, San Francisco, CA, USA
| | - Brittany Potts
- 1 Boston Children's Hospital, Boston, MA, USA.,4 Akron's Children's Hospital, Akron, OH, USA
| | - Julia von Oettingen
- 2 Kay Mackenson Center, Pierre Payen, Artibonite, Haiti.,5 McGill University Health Center, Montreal, Quebec, Canada
| | - Ric Bonnell
- 2 Kay Mackenson Center, Pierre Payen, Artibonite, Haiti.,6 Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | | | | | | | - Xinshu She
- 1 Boston Children's Hospital, Boston, MA, USA
| | - Eddy Jean-Baptiste
- 7 Fondation Haïtienne de Diabète et de Maladies Cardio-Vasculaires, Port au Prince, Ouest, Haiti
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19
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Hauptman M, Woolf AD. Lead Poisoning and Children in Foster Care: Diagnosis and Management Challenges. Clin Pediatr (Phila) 2018; 57:988-991. [PMID: 28969453 PMCID: PMC6982421 DOI: 10.1177/0009922817734364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Marissa Hauptman
- Boston Children’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA,New England Pediatric Environmental Health Specialty Unit, Boston, MA, USA
| | - Alan D. Woolf
- Boston Children’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA,New England Pediatric Environmental Health Specialty Unit, Boston, MA, USA
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20
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Rodan LH, Hauptman M, D'Gama AM, Qualls AE, Cao S, Tuschl K, Al-Jasmi F, Hertecant J, Hayflick SJ, Wessling-Resnick M, Yang ET, Berry GT, Gropman A, Woolf AD, Agrawal PB. Novel founder intronic variant in SLC39A14 in two families causing Manganism and potential treatment strategies. Mol Genet Metab 2018; 124:161-167. [PMID: 29685658 PMCID: PMC5976541 DOI: 10.1016/j.ymgme.2018.04.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/04/2018] [Accepted: 04/04/2018] [Indexed: 01/06/2023]
Abstract
Congenital disorders of manganese metabolism are rare occurrences in children, and medical management of these disorders is complex and challenging. Homozygous exonic mutations in the manganese transporter SLC39A14 have recently been associated with a pediatric-onset neurodegenerative disorder characterized by brain manganese accumulation and clinical signs of manganese neurotoxicity, including parkinsonism-dystonia. We performed whole exome sequencing on DNA samples from two unrelated female children from the United Arab Emirates with progressive movement disorder and brain mineralization, identified a novel homozygous intronic mutation in SLC39A14 in both children, and demonstrated that the mutation leads to aberrant splicing. Both children had consistently elevated serum manganese levels and were diagnosed with SLC39A14-associated manganism. Over a four-year period, we utilized a multidisciplinary management approach for Patient 1 combining decreased manganese dietary intake and chelation with symptomatic management of dystonia. Our treatment strategy appeared to slow disease progression, but did not lead to a cure or reversal of already established deficits. Clinicians should consider testing for noncoding mutations in the diagnosis of congenital disorders of manganese metabolism and utilizing multidisciplinary approaches in the management of these disorders.
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Affiliation(s)
- Lance H Rodan
- Department of Neurology, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, United States.
| | - Marissa Hauptman
- Harvard Medical School, Boston, MA, United States; Pediatric Environmental Health Center, Division of General Pediatrics, Boston Children's Hospital, Boston, MA, United States; Region 1 New, England, Pediatric Environmental Health Specialty Unit (PEHSU), Boston, MA, United States
| | - Alissa M D'Gama
- Harvard Medical School, Boston, MA, United States; Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, United States
| | - Anita E Qualls
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States; The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, United States
| | - Siqi Cao
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, United States; Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States; The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, United States
| | - Karin Tuschl
- Department of Cell and Developmental Biology, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Fatma Al-Jasmi
- Department of Pediatrics, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Jozef Hertecant
- Department of Pediatrics, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Susan J Hayflick
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR, United States; Department of Pathology, Oregon Health & Science University, Portland, OR, United States
| | - Marianne Wessling-Resnick
- Department of Genetics and Complex Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Edward T Yang
- Department of Radiology, Boston Children's Hospital, Boston, MA, United States
| | - Gerard T Berry
- Harvard Medical School, Boston, MA, United States; Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, United States
| | - Andrea Gropman
- Division of Neurodevelopmental Disabilities and Neurogenetics, Children's National Health System, Washington, DC, United States
| | - Alan D Woolf
- Harvard Medical School, Boston, MA, United States; Pediatric Environmental Health Center, Division of General Pediatrics, Boston Children's Hospital, Boston, MA, United States; Region 1 New, England, Pediatric Environmental Health Specialty Unit (PEHSU), Boston, MA, United States
| | - Pankaj B Agrawal
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, United States; Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States; The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, United States
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21
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Daly ER, Chan BP, Talbot EA, Nassif J, Bean C, Cavallo SJ, Metcalf E, Simone K, Woolf AD. Per- and polyfluoroalkyl substance (PFAS) exposure assessment in a community exposed to contaminated drinking water, New Hampshire, 2015. Int J Hyg Environ Health 2018. [PMID: 29514764 DOI: 10.1016/j.ijheh.2018.02.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Per- and polyfluoroalkyl substances (PFAS) are synthetic chemicals used in manufacturing that resist environmental degradation, can leach into drinking water, and bioaccumulate in tissues. Some studies have shown associations with negative health outcomes. In May 2014, a New Hampshire public drinking water supply was found to be contaminated with PFAS from a former U.S. Air Force base. OBJECTIVES We established a serum testing program to assess PFAS exposure in the affected community. METHODS Serum samples and demographic and exposure information were collected from consenting eligible participants. Samples were tested for PFAS at three analytical laboratories. Geometric means and 95% confidence intervals were calculated and analyzed by age and exposure variables. RESULTS A total of 1578 individuals provided samples for PFAS testing; >94% were found to have perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), and perfluorohexane sulfonic acid (PFHxS) detectable in serum. Geometric mean serum concentrations of PFOS, PFOA, and PFHxS were 8.6 μg/L (95% CI:8.3-8.9), 3.1 μg/L (95% CI: 3.0-3.2), and 4.1 μg/L (95% CI: 3.9-4.3), respectively, which were statistically higher than the general U.S. POPULATION Significant associations were observed between PFAS serum concentrations and age, time spent in the affected community, childcare attendance, and water consumption. CONCLUSIONS PFOS, PFOA, and PFHxS were found in significantly higher levels in the affected population, consistent with PFAS drinking water contamination. Given increased recognition of PFAS contamination in the U.S, a coordinated national response is needed to improve access to biomonitoring and understand health impacts.
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Affiliation(s)
- Elizabeth R Daly
- New Hampshire Department of Health and Human Services, Concord, NH, United States.
| | - Benjamin P Chan
- New Hampshire Department of Health and Human Services, Concord, NH, United States
| | - Elizabeth A Talbot
- New Hampshire Department of Health and Human Services, Concord, NH, United States; Geisel School of Medicine at Dartmouth, Hanover, NH, United States
| | - Julianne Nassif
- New Hampshire Department of Health and Human Services, Concord, NH, United States
| | - Christine Bean
- New Hampshire Department of Health and Human Services, Concord, NH, United States
| | - Steffany J Cavallo
- New Hampshire Department of Health and Human Services, Concord, NH, United States
| | - Erin Metcalf
- New Hampshire Department of Health and Human Services, Concord, NH, United States
| | - Karen Simone
- Northern New England Poison Center, Portland, ME, United States; School of Medicine, Tufts University, Boston, MA, United States
| | - Alan D Woolf
- Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, MA, United States; Pediatric Environmental Health Center, Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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22
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Abstract
Infants and children are at higher risk than adolescents and adults for exposure to environmental toxins via ingestion for a number of reasons: their smaller size (and proportionately larger dose of ingested toxins), their closer proximity to the ground, dirt, and indoor dust, their boundless curiosity and oral exploratory behaviors, pica habits that may persist into school-age for children with autism or other developmental delays, their proportionately larger daily water and milk intake, and food preferences that differ markedly from adolescents and adults. Children depend on adults to protect them and keep their home environment safe. Pediatric care providers can integrate environmental health topics into their well-child care practices, offering guidance and resources to parents concerned with reducing the risks to their children posed by hazards in their homes, daycare centers, preschools, schools, and the other environments in which they spend time. [Pediatr Ann. 2017;46(12):e466-e471.].
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23
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Affiliation(s)
- Rose Hannah Goldman
- 1 Cambridge Health Alliance, Cambridge, MA, USA.,2 Harvard Medical School, Boston, MA, USA.,3 Harvard T.H. Chan School of Public Health, Boston, MA, USA.,4 Boston Children's Hospital, Boston, MA, USA
| | - Alan D Woolf
- 2 Harvard Medical School, Boston, MA, USA.,4 Boston Children's Hospital, Boston, MA, USA
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24
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Karwowski MP, Morman SA, Plumlee GS, Law T, Kellogg M, Woolf AD. Toxicants in folk remedies: implications of elevated blood lead in an American-born infant due to imported diaper powder. Environ Geochem Health 2017; 39:1133-1143. [PMID: 27704308 DOI: 10.1007/s10653-016-9881-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 09/26/2016] [Indexed: 06/06/2023]
Abstract
Though most childhood lead exposure in the USA results from ingestion of lead-based paint dust, non-paint sources are increasingly implicated. We present interdisciplinary findings from and policy implications of a case of elevated blood lead (13-18 mcg/dL, reference level <5 mcg/dL) in a 9-month-old infant, linked to a non-commercial Malaysian folk diaper powder. Analyses showed the powder contains 62 % lead by weight (primarily lead oxide) and elevated antimony [1000 parts per million (ppm)], arsenic (55 ppm), bismuth (110 ppm), and thallium (31 ppm). These metals are highly bioaccessible in simulated gastric fluids, but only slightly bioaccessible in simulated lung fluids and simulated urine, suggesting that the primary lead exposure routes were ingestion via hand-mouth transmission and ingestion of inhaled dusts cleared from the respiratory tract. Four weeks after discontinuing use of the powder, the infant's venous blood lead level was 8 mcg/dL. Unregulated, imported folk remedies can be a source of toxicant exposure. Additional research on import policy, product regulation, public health surveillance, and culturally sensitive risk communication is needed to develop efficacious risk reduction strategies in the USA. The more widespread use of contaminated folk remedies in the countries from which they originate is a substantial concern.
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Affiliation(s)
- Mateusz P Karwowski
- Department of Medicine, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, USA.
- Pediatric Environmental Health Center, Boston Children's Hospital, 1295 Boylston St, Suite 100, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, 22 Shattuck St, Boston, MA, USA.
| | | | | | - Terence Law
- Department of Laboratory Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Mark Kellogg
- Department of Laboratory Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Alan D Woolf
- Department of Medicine, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, USA
- Pediatric Environmental Health Center, Boston Children's Hospital, 1295 Boylston St, Suite 100, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, 22 Shattuck St, Boston, MA, USA
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25
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Abstract
Childhood lead poisoning is a multi-faceted, complex condition, which affects not only the child's health and well-being, but also the family's housing security, economic status, job security, and stress level. This review updates the emergency department clinician on the management of childhood lead poisoning. Infants and children are at higher risk than adults for lead exposure due to their smaller size and proportionately larger dose of ingested toxins, their proximity to ground dirt and indoor dust, their energy and curiosity, their oral exploratory and pica behaviors, their proportionately larger daily water and milk intake, and dietary preferences that differ markedly from those of adults. Pediatric health care providers working in the emergency department can provide medical management, as well as preventive counseling and guidance, to parents of children presenting with evidence of acute or chronic lead poisoning.
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Affiliation(s)
- Marissa Hauptman
- Pediatric Environmental Health Center, Division of General Pediatrics, Department of Medicine, Boston Children's Hospital
- Department of Pediatrics, Harvard Medical School
- Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, MA
| | - Rebecca Bruccoleri
- Pediatric Environmental Health Center, Division of General Pediatrics, Department of Medicine, Boston Children's Hospital
- Department of Pediatrics, Harvard Medical School
- Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, MA
- Program in Medical Toxicology, Boston Children's Hospital
| | - Alan D Woolf
- Pediatric Environmental Health Center, Division of General Pediatrics, Department of Medicine, Boston Children's Hospital
- Department of Pediatrics, Harvard Medical School
- Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, MA
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26
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Chehade MJ, Gill TK, Kopansky-Giles D, Schuwirth L, Karnon J, McLiesh P, Alleyne J, Woolf AD. Building multidisciplinary health workforce capacity to support the implementation of integrated, people-centred Models of Care for musculoskeletal health. Best Pract Res Clin Rheumatol 2017; 30:559-584. [PMID: 27886946 DOI: 10.1016/j.berh.2016.09.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/09/2016] [Indexed: 10/20/2022]
Abstract
To address the burden of musculoskeletal (MSK) conditions, a competent health workforce is required to support the implementation of MSK models of care. Funding is required to create employment positions with resources for service delivery and training a fit-for-purpose workforce. Training should be aligned to define "entrustable professional activities", and include collaborative skills appropriate to integrated and people-centred care and supported by shared education resources. Greater emphasis on educating MSK healthcare workers as effective trainers of peers, students and patients is required. For quality, efficiency and sustainability of service delivery, education and research capabilities must be integrated across disciplines and within the workforce, with funding models developed based on measured performance indicators from all three domains. Greater awareness of the societal and economic burden of MSK conditions is required to ensure that solutions are prioritised and integrated within healthcare policies from local to regional to international levels. These healthcare policies require consumer engagement and alignment to social, economic, educational and infrastructure policies to optimise effectiveness and efficiency of implementation.
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Affiliation(s)
- M J Chehade
- Chair International MSK Musculoskeletal Education Task Force Global Alliance for Musculoskeletal Health of the Bone and Joint Decade (GMUSC), Discipline of Orthopaedics and Trauma, Level 4 Bice Building, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia.
| | - T K Gill
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Level 7, South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA 5000, Australia
| | - D Kopansky-Giles
- Graduate Education and Research, Canadian Memorial Chiropractic College, Department of Family and Community Medicine, University of Toronto, 6100 Leslie Street, Toronto, ON M2H 3J1, Canada
| | - L Schuwirth
- Prideaux Centre for Research in Health Professions Education, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia
| | - J Karnon
- School of Public Health, The University of Adelaide, 178 North Terrace, Adelaide, SA 5000, Australia
| | - P McLiesh
- Australian and New Zealand Orthopaedic Nurses Association, School of Nursing, Faculty of Health Sciences, The University of Adelaide, Royal Adelaide Hospital, Eleanor Harrald Building, North Terrace, Adelaide, SA 5000, Australia
| | - J Alleyne
- University of Toronto, Department of Family and Community Medicine, Toronto Rehabilitation Institute, Musculoskeletal Program, Toronto, Canada
| | - A D Woolf
- Bone and Joint Research Group, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro TR1 3HD, England, United Kingdom
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von Friesendorff M, McGuigan FE, Wizert A, Rogmark C, Holmberg AH, Woolf AD, Akesson K. Hip fracture, mortality risk, and cause of death over two decades. Osteoporos Int 2016; 27:2945-53. [PMID: 27172936 DOI: 10.1007/s00198-016-3616-5] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 04/25/2016] [Indexed: 10/21/2022]
Abstract
UNLABELLED Men and women with hip fracture have higher short-term mortality. This study investigated mortality risk over two decades post-fracture; excess mortality remained high in women up to 10 years and in men up to 20 years. Cardiovascular disease (CVD) and pneumonia were leading causes of death with a long-term doubling of risk. INTRODUCTION Hip fractures are associated with increased mortality, particularly short term. In this study with a two-decade follow-up, we examined mortality and cause of death compared to the background population. METHODS We followed 1013 hip fracture patients and 2026 matched community controls for 22 years. Mortality, excess mortality, and cause of death were analyzed and stratified for age and sex. Hazard ratio (HR) was estimated by Cox regression. A competing risk model was fitted to estimate HR for common causes of death (CVD, cancer, pneumonia) in the short and long term (>1 year). RESULTS For both sexes and at all ages, mortality was higher in hip fracture patients across the observation period with men losing most life years (p < 0.001). Mortality risk was higher for up to 15 years (women (risk ratio (RR) 1.9 [95 % confidence interval (CI) 1.7-2.1]); men (RR 2.8 [2.2-3.5])) and until end of follow-up ((RR 1.8 [1.6-2.0]); (RR 2.7 [2.1-3.3])). Excess mortality by time intervals, censored for the first year, was evident in women (<80 years, up to 10 years; >80 years, for 5 years) and in men <80 years throughout. CVD and pneumonia were predominant causes of death in men and women with an associated higher risk in all age groups. Pneumonia caused excess mortality in men over the entire observation period. CONCLUSION In a remaining lifetime perspective, all-cause and excess mortality after hip fracture was higher even over two decades of follow-up. CVD and pneumonia reduce life expectancy for the remaining lifetime and highlights the need to further improve post-fracture management.
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Affiliation(s)
- M von Friesendorff
- Department of Clinical Sciences Malmö, Clinical and Molecular Osteoporosis Research Unit, Lund University, Malmö, Sweden
- Department of Orthopedics Malmö, Skåne University Hospital, 205 02, Malmö, Sweden
| | - F E McGuigan
- Department of Clinical Sciences Malmö, Clinical and Molecular Osteoporosis Research Unit, Lund University, Malmö, Sweden
- Department of Orthopedics Malmö, Skåne University Hospital, 205 02, Malmö, Sweden
| | - A Wizert
- ERC Syd - Epidemiology and Register Centre South, Skåne University Hospital, Lund, Sweden
| | - C Rogmark
- Department of Clinical Sciences Malmö, Clinical and Molecular Osteoporosis Research Unit, Lund University, Malmö, Sweden
- Department of Orthopedics Malmö, Skåne University Hospital, 205 02, Malmö, Sweden
| | - A H Holmberg
- Department of Clinical Sciences Malmö, Clinical and Molecular Osteoporosis Research Unit, Lund University, Malmö, Sweden
- Department of Orthopedics Malmö, Skåne University Hospital, 205 02, Malmö, Sweden
| | - A D Woolf
- Department of Rheumatology Royal Cornwall Hospital, Truro, UK
| | - K Akesson
- Department of Clinical Sciences Malmö, Clinical and Molecular Osteoporosis Research Unit, Lund University, Malmö, Sweden.
- Department of Orthopedics Malmö, Skåne University Hospital, 205 02, Malmö, Sweden.
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McLellan MC, Highfield ES, Woolf AD. Pediatric Health Care Providers’ Attitudes and Referral Predictors for Therapeutic Massage and Acupuncture. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/1533210105280645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this study was to assess pediatric health providers’ attitudes, experience, and referral patterns with respect to therapeutic massage and acupuncture (TM&A). A written survey of experience with and attitudes about TM&A was distributed to a convenience sample of pediatric health care providers attending a regional postgraduate course in April 2002. Bivariate analyses were performed using Fisher’s exact test and the chisquare statistic. Pediatric care providers’ practices of referring patients to TM&A were associated with their own familiarity with and prior use of TM&A as well as their professed comfort level in discussing these modalities. There were no significant differences by professional status, gender, or years in practice in 42% of the respondents who reported making TM&A referrals. Pediatric health care providers’practices in referring patients for TM&A are positively associated with their familiarity with and personal use of TM&A.
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Affiliation(s)
| | | | - Alan D. Woolf
- Harvard Medical School, Academy at Harvard Medical School, Program in Environmental Medicine, Children's Hospital, Boston
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Woolf AD, Sibrizzi C, Kirkland K. Pediatric Environmental Health Specialty Units: An Analysis of Operations. Acad Pediatr 2016; 16:25-33. [PMID: 26233834 DOI: 10.1016/j.acap.2015.05.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 05/05/2015] [Accepted: 05/07/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND In 1998 the Agency for Toxic Substances and Disease Registry (ATSDR) secured the first federal funding to develop an innovative network of public health-oriented entities: Pediatric Environmental Health Specialty Units (PEHSUs). PEHSU goals were to provide pediatric and environmental health education to health care providers and health profession students, to offer consultation to health care professionals, parents, and others regarding environmental health exposures, and to provide referrals to specialized medical resources when necessary. This report analyzes the productivity of US PEHSUs from 1999 to 2014. METHODS This was a retrospective analysis of federally mandated quarterly reports filed by each PEHSU. These reports document specific goal-related deliverables outlined under cooperative agreements awarded to the Association of Occupational and Environmental Clinics (AOEC) with funding from the Environmental Protection Agency (EPA) and ATSDR. Costs were obtained from grant budget information available from the administrator of the grants, AOEC. RESULTS Total EPA/ATSDR funding for PEHSUs paid to AOEC during 1999-2014 was $23,847,452. The average cost to the EPA/ATSDR of running each PEHSU in 2014 was $169,256. Through over 8000 consultations and educational activities, PEHSUs reached 702,506 people: 298,936 health professionals, 61,947 health professional trainees, 323,817 members of the public, and 17,806 public health officials and others. CONCLUSIONS PEHSUs have grown into an established, productive network of clinical and educational centers whose expertise and activities have benefited both the public and health care professionals alike. The federal contributions to the cost of operating these centers have been more than offset by the benefits PEHSUs have conferred on the communities they serve.
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Affiliation(s)
- Alan D Woolf
- Pediatric Environmental Health Center, Division of General Pediatrics, Boston Children's Hospital, Region 1 New England Pediatric Environmental Health Specialty Unit (PEHSU), and Harvard Medical School, Boston, Mass.
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Armbrecht G, Felsenberg D, Ganswindt M, Lunt M, Kaptoge SK, Abendroth K, Aroso A, Banzer D, Bhalla AK, Dequeker J, Eastell R, Hoszowski K, Lyritis G, Delmas PD, Masaryk P, Miazgowski T, Cannata J, Nuti R, Oei L, Poor G, Redlund-Johnell I, Reid DM, Reisinger W, Schatz H, Todd CJ, Woolf AD, Javaid K, Rivadeneira F, Silman AJ, Cooper C, O'Neill TW, Reeve J. Vertebral Scheuermann's disease in Europe: prevalence, geographic variation and radiological correlates in men and women aged 50 and over. Osteoporos Int 2015; 26:2509-19. [PMID: 26021761 DOI: 10.1007/s00198-015-3170-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 05/06/2015] [Indexed: 12/13/2022]
Abstract
UNLABELLED In 27 centres across Europe, the prevalence of deforming spinal Scheuermann's disease in age-stratified population-based samples of over 10,000 men and women aged 50+ averaged 8% in each sex, but was highly variable between centres. Low DXA BMD was un-associated with Scheuermann's, helping the differential diagnosis from osteoporosis. INTRODUCTION This study aims to assess the prevalence of Scheuermann's disease of the spine across Europe in men and women over 50 years of age, to quantitate its association with bone mineral density (BMD) and to assess its role as a confounder for the radiographic diagnosis of osteoporotic fracture. METHODS In 27 centres participating in the population-based European Vertebral Osteoporosis Study (EVOS), standardised lateral radiographs of the lumbar and of the thoracic spine from T4 to L4 were assessed in all those of adequate quality. The presence of Scheuermann's disease, a confounder for prevalent fracture in later life, was defined by the presence of at least one Schmorl's node or irregular endplate together with kyphosis (sagittal Cobb angle >40° between T4 and T12) or a wedged-shaped vertebral body. Alternatively, the (rare) Edgren-Vaino sign was taken as diagnostic. The 6-point-per-vertebral-body (13 vertebrae) method was used to assess osteoporotic vertebral shape and fracture caseness. DXA BMD of the L2-L4 and femoral neck regions was measured in subsets. We also assessed the presence of Scheuermann's by alternative published algorithms when these used the radiographic signs we assessed. RESULTS Vertebral radiographic images from 4486 men and 5655 women passed all quality checks. Prevalence of Scheuermann's varied considerably between centres, and based on random effect modelling, the overall European prevalence using our method was 8% with no significant difference between sexes. The highest prevalences were seen in Germany, Sweden, the UK and France and low prevalences were seen in Hungary, Poland and Slovakia. Centre-level prevalences in men and women were highly correlated. Scheuermann's was not associated with BMD of the spine or hip. CONCLUSIONS Since most of the variation in population impact of Scheuermann's was unaccounted for by the radiological and anthropometric data, the search for new genetic and environmental determinants of this disease is encouraged.
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Affiliation(s)
- G Armbrecht
- Department of Radiology and Nuclear Medicine, Free University, Berlin, Germany
| | - D Felsenberg
- Department of Radiology and Nuclear Medicine, Free University, Berlin, Germany
| | - M Ganswindt
- Department of Radiology and Nuclear Medicine, Free University, Berlin, Germany
| | - M Lunt
- ARC Epidemiology Unit, University of Manchester Musculoskeletal Biomedical Research Unit & Arthritis Research UK Centre for Epidemiology, Manchester, UK
| | - S K Kaptoge
- Department of Public Health and Primary Care, Strangeways Research Laboratory, Cambridge, UK
| | | | - A Aroso
- Hospital de San Joao, Oporto, Portugal
| | - D Banzer
- Röntgen u Nuklearmed, Krankenhaus Behring, Berlin, Germany
| | - A K Bhalla
- Royal National Hospital for Rheumatic Diseases, Bath, UK
| | | | - R Eastell
- Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | | | - G Lyritis
- Laboratory for Research on the Musculoskeletal System, University of Athens, Athens, Greece
| | - P D Delmas
- Centre de Médécine Specialisée Claude Gauthier, Montceau-les-Mines France & U Inserm 504, Lyon, France
| | - P Masaryk
- Institute of Rheumatic Diseases, Piestany, Slovakia
| | - T Miazgowski
- Department of Hypertension, Pomeranian Medical University, Szczecin, Poland
| | - J Cannata
- Asturias General Hospital, Oviedo, Spain
| | - R Nuti
- Institute of Clinical Medicine, University of Siena, Siena, Italy
| | - L Oei
- Departments of Epidemiology and Internal Medicine, Erasmus University, Rotterdam, Netherlands
| | - G Poor
- National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | | | - D M Reid
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - W Reisinger
- Charité Inst fur Rontgendiagnostik, Berlin, Germany
| | - H Schatz
- Med Klinik & Polyklinik Bochum, Bochum, Germany
| | - C J Todd
- Department of Public Health and Primary Care, Strangeways Research Laboratory, Cambridge, UK
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - K Javaid
- NIHR Musculo-skeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre & Institute of Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK
| | - F Rivadeneira
- Departments of Epidemiology and Internal Medicine, Erasmus University, Rotterdam, Netherlands
| | - A J Silman
- ARC Epidemiology Unit, University of Manchester Musculoskeletal Biomedical Research Unit & Arthritis Research UK Centre for Epidemiology, Manchester, UK
- Arthritis Research UK, Chesterfield, S41 7TD, UK
| | - C Cooper
- NIHR Musculo-skeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre & Institute of Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK
| | - T W O'Neill
- ARC Epidemiology Unit, University of Manchester Musculoskeletal Biomedical Research Unit & Arthritis Research UK Centre for Epidemiology, Manchester, UK
| | - J Reeve
- NIHR Musculo-skeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre & Institute of Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK.
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Zenlea IS, Billett A, Hazen M, Herrick DB, Nakamura MM, Jenkins KJ, Woolf AD, Kesselheim JC. Trainee and program director perceptions of quality improvement and patient safety education: preparing for the next accreditation system. Clin Pediatr (Phila) 2014; 53:1248-54. [PMID: 24928576 DOI: 10.1177/0009922814538701] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the current state of quality improvement and patient safety (QIPS) education at a large teaching hospital. METHODS We surveyed 429 trainees (138 residents, 291 clinical fellows) and 38 program directors (PDs; 2 were PDs of >1 program) from 39 Accreditation Council for Graduate Medical Education-accredited training programs. RESULTS Twenty-nine PDs (76.3%) and 259 trainees (60.3%) responded. Most trainees (68.8%) reported participation in projects culminating in scholarly products (39.9%) or clinical innovations (44%). Most PDs reported that teaching (88.9%) and project supervision (83.3%) are performed by expert faculty. Nearly half of the PDs (45.8%) and trainees (49.6%) perceived project-based learning to be of equal value to formal curricula. Compared with trainees, a greater proportion of PDs reported needs for funding for projects, teaching faculty to provide mentorship, and faculty development (P < .05). CONCLUSIONS Providing additional financial, administrative, and operational support could enhance the value of curricula and projects. Developing expert teaching faculty is paramount.
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Affiliation(s)
- Ian S Zenlea
- Boston Children's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - Amy Billett
- Boston Children's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA Dana-Farber/Children's Hospital Cancer Center, Boston, MA, USA
| | - Melissa Hazen
- Boston Children's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | | | - Mari M Nakamura
- Boston Children's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - Kathy J Jenkins
- Boston Children's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - Alan D Woolf
- Boston Children's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - Jennifer C Kesselheim
- Boston Children's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA Dana-Farber/Children's Hospital Cancer Center, Boston, MA, USA
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Affiliation(s)
- Alan D Woolf
- Pediatric Environmental Health Center, and Region 1 New England Pediatric Environmental Health Specialty Unit, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Christine Greco
- Harvard Medical School, Boston, Massachusetts Department of Anesthesiology, Boston Children's Hospital, Boston, Massachusetts
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Kesselheim JC, Sun P, Woolf AD, London WB, Boyer D. Balancing education and service in graduate medical education: data from pediatric trainees and program directors. Acad Med 2014; 89:652-657. [PMID: 24556769 PMCID: PMC4885597 DOI: 10.1097/acm.0000000000000174] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
PURPOSE To measure pediatric program directors' (PDs') and trainees' perceptions of and expectations for the balance of service and education in their training programs. METHOD In fall 2011, an electronic survey was sent to PDs and trainees at Boston Children's Hospital. Respondents described perceptions and expectations for service and education and rated the education and service inherent to 12 vignettes. Wilcoxon rank sum tests measured the agreement between PD and trainee perceptions and ratings of service and education assigned to each vignette. RESULTS Responses were received from 28/39 PDs (78%) and 223/430 trainees (52%). Seventy-five (34%) trainees responded that their education had been compromised by excessive service obligations; only 1 (4%) PD agreed (P < .0001). Although 132 (59%) trainees reported that service obligations usually/sometimes predominated over clinical education, only 3 (11%) PDs agreed (P < .0001). One hundred trainees (45%) thought rotations never/rarely/sometimes provided a balance between education and clinical demands compared with 2 PDs (7%) (P < .0001). Both groups agreed that service can, without formal teaching, be considered educational. Trainees scored 6 vignettes as having greater educational value (P ≤ .01) and 10 as having lower service content (P ≤ .04) than PDs did. CONCLUSIONS Trainees and medical educators hold mismatched impressions of their training programs' balance of service and education. Trainees are more likely to report an overabundance of service. These data may impact the interpretation of Accreditation Council for Graduate Medical Education survey results and should be incorporated into dialogue about future curricular design initiatives.
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Affiliation(s)
- Jennifer C Kesselheim
- Dr. Kesselheim is assistant professor of pediatrics, Department of Pediatric Oncology, Dana-Farber/Children's Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts. Ms. Sun is statistician, formerly with the Department of Pediatric Oncology, Dana-Farber/Children's Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts. Dr. Woolf is associate professor of pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts. Dr. London is statistician, Department of Pediatric Oncology, Dana-Farber/Children's Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts. Dr. Boyer is assistant professor of pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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van der Jagt-Willems HC, Vis M, Tulner CR, van Campen JPCM, Woolf AD, van Munster BC, Lems WF. Mortality and incident vertebral fractures after 3 years of follow-up among geriatric patients. Osteoporos Int 2013; 24:1713-9. [PMID: 23052933 DOI: 10.1007/s00198-012-2147-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 09/11/2012] [Indexed: 10/27/2022]
Abstract
UNLABELLED In a prospective cohort study of 395 geriatric outpatients, mortality after 3 years was associated with prevalent vertebral fractures at baseline. The mortality risk was independently associated with the presence of three or more vertebral fractures at baseline. In the surviving patients, the risk of incident fractures was noteworthy, occurring in 26 % of these patients. INTRODUCTION The purpose of this study is to determine mortality rate and the incidence of vertebral fractures in a geriatric outpatient group, during a 3-year follow-up period, in a teaching hospital in Amsterdam, The Netherlands. METHODS This study includes a prospective cohort study of 395 geriatric patients who had their baseline visit at a diagnostic day hospital in 2007 and 2008. They were invited for follow-up 3 years later. Lateral X-rays of the lumbar spine and chest were performed at baseline and after 3 years; vertebral fractures were scored in all patients according to the semi-quantitative method of Genant. RESULTS After 3 years, mortality was 46 % and associated with prevalent vertebral fractures at baseline (odds ratio (OR), 1.83; 95 % CI, 1.23-2.74). The presence of three or more vertebral fractures at baseline was an independent risk factor for mortality (OR, 3.32; 95 % CI, 1.56-7.07). Other independently associated risk factors were greater age, higher co-morbidity score, and having more prescriptions. Higher cognitive capacity protected against mortality after 3 years. In 72 patients, radiography was repeated. Nineteen patients (26 %) had an incident radiographic vertebral fracture: 16 in those with a prevalent fracture, and 3 in those without a prevalent vertebral fracture at baseline. CONCLUSIONS In geriatric outpatients, mortality after 3 years was associated with prevalent vertebral fractures at baseline, and the mortality risk was independently associated with 3 or more vertebral fractures at baseline. In survivors, the risk of incident fractures was noteworthy, since these occurred in 26 % of the patients, particularly in those with a prevalent vertebral fracture.
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Abstract
BACKGROUND Some parents are requesting aluminum testing in their children with developmental issues. Although aluminum can be measured in plasma, serum, or urine, there is scant scientific information about normal ranges. We sought to determine the basis for laboratory reference ranges and whether these ranges are applicable to children. METHODS From texts, published lists, and Internet sources, we obtained the names of 10 clinical laboratories that perform aluminum testing. Contact was made by telephone or e-mail, or Internet sites were viewed to obtain information regarding the establishment of aluminum reference ranges and testing methods in biological samples. Seven laboratories provided supporting literature that was reviewed regarding details of the study populations. RESULTS For laboratories using the atomic absorption spectrometry method, aluminum reference ranges varied from <5.41 μg/L to <20 μg/L (serum), <7.00 μg/L to 0 to 10 μg/L (plasma) and 5 to 30 μg/L (urine). For those using the inductively coupled plasma mass spectroscopy methodology, ranges varied from 0 to 6 μg/L to <42 μg/L (serum), 0 to 10 μg/L to 0 to 15 μg/L (plasma), and 0 to 7 μg/L to 5 to 30 μg/L (urine). None of the reference ranges are known to be derived from studies of healthy children, but relied instead on small studies of adult populations, adult dialysis patients, workers, or sick children on aluminum-containing parenteral therapy. CONCLUSIONS Aluminum reference ranges provided by laboratories are widely divergent, may not represent "normal" ranges of a healthy population, especially children, and thus it is difficult to interpret serum or urine aluminum ranges clinically. Further studies of aluminum in children are warranted and should be considered as part of the Centers for Disease Control and Prevention Biomonitoring Project.
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Affiliation(s)
- Michelle Zeager
- Division of General Pediatrics, Department of Pediatrics and Environmental Health, Children's Hospital Boston, Boston, MA 02115, USA.
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Harris ESJ, Cao S, Littlefield BA, Craycroft JA, Scholten R, Kaptchuk T, Fu Y, Wang W, Liu Y, Chen H, Zhao Z, Clardy J, Woolf AD, Eisenberg DM. Heavy metal and pesticide content in commonly prescribed individual raw Chinese Herbal Medicines. Sci Total Environ 2011; 409:4297-305. [PMID: 21824641 PMCID: PMC3163780 DOI: 10.1016/j.scitotenv.2011.07.032] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Revised: 07/14/2011] [Accepted: 07/14/2011] [Indexed: 04/15/2023]
Abstract
Heavy metal and pesticide contamination has previously been reported in Chinese Herbal Medicines (CHMs), in some cases at potentially toxic levels. This study was conducted to determine general patterns and toxicological significance of heavy metal and pesticide contamination in a broad sample of raw CHMs. Three-hundred-thirty-four samples representing 126 species of CHMs were collected throughout China and examined for arsenic, cadmium, chromium, lead, and mercury. Of the total, 294 samples representing 112 species were also tested for 162 pesticides. At least 1 metal was detected in all 334 samples (100%) and 115 samples (34%) had detectable levels of all metals. Forty-two different pesticides were detected in 108 samples (36.7%), with 1 to 9 pesticides per sample. Contaminant levels were compared to toxicological reference values in the context of different exposure scenarios. According to a likely scenario of CHM consumption, only 3 samples (1%) with heavy metals and 14 samples (5%) with pesticides were found with concentrations that could contribute to elevated background levels of contaminant exposure. According to the most conservative scenario of CHM consumption, 231 samples (69%) with heavy metals and 81 samples (28%) with pesticides had contaminants that could contribute to elevated levels of exposure. Wild collected plants had higher contaminant levels than cultivated samples. Cadmium, chromium, lead, and chlorpyrifos contamination showed weak correlations with geographic location. Based on our assumptions of the likely mode of consumption of raw CHMs, the vast majority (95%) of the 334 samples in this study contained levels of heavy metals or pesticides that would be of negligible concern. However, given the number of samples with detectable contaminants and the range between the more likely and more conservative scenarios of contaminant exposure, more research and monitoring of heavy metals (especially cadmium and chromium) and pesticide residues (especially chlorpyrifos) in raw CHMs are advised.
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Affiliation(s)
- Eric S J Harris
- Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, 240 Longwood Avenue, Boston, MA 02115, USA.
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Uhlig T, Lems W, Dijkmans BAC, Kvien TK, Woolf AD, OSTRA group. Differences in utility and other disease severity levels in patients with rheumatoid arthritis from three European countries. Scand J Rheumatol Suppl 2010; 39:433-4. [DOI: 10.3109/03009741003781993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Woolf AD, Law T, Yu HYE, Woolf N, Kellogg M. Lead poisoning from use of bronze drinking vessels during the late Chinese Shang dynasty: an in vitro experiment. Clin Toxicol (Phila) 2010; 48:757-61. [PMID: 20849332 DOI: 10.3109/15563651003749290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Bronze drinking vessels famous for their intricate carvings and used by the aristocracy in the Chinese Shang dynasty (1555-1145 BCE) are known to have been fabricated with alloys containing soft metallic lead. The contribution of lead leaching from such vessels into the fermented grain wines drunk by the Chinese nobility in ancient times has not been previously estimated. METHODS Three bronze vessels containing 8% lead by weight were fabricated to resemble the late Shang bronze goblets. Shaoxing drinking rice wine was purchased locally and placed in the vessels, using a white grape wine and water as comparisons. Sampling was performed at baseline, 2 min, and then at days 1, 2, 4, and 7. Lead concentrations in the liquid matrix were measured using atomic absorption spectroscopy. RESULTS Significant amounts of lead leached into the liquid within one day: 13,900 μg/L in water, 45,900 μg/L in rice wine, and 116,000 μg/L in white wine. Lead continued to leach into both the grape and rice wines with the passage of time. DISCUSSION Significant lead contamination of Shaoxing rice wine was detected when it was left in bronze goblets fabricated to resemble the Shang dynasty vessels. If a liter of contaminated wine was drunk daily, the daily intake of lead could have been as high as 85 mg. Such a high degree of contamination could cause chronic lead poisoning, affecting the health of the Shang nobility who used bronze beverage containers, before lead was excluded from the manufacture of bronze.
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Affiliation(s)
- Alan D Woolf
- Department of Medicine, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA.
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Abstract
Acute encephalopathy from childhood lead poisoning is fortunately rare. However, in pediatric patients with developmental disabilities and pica, there is a risk of lead exposure at a dose commensurate with encephalopathy, coupled with a risk of delayed diagnosis because of difficulty in distinguishing between baseline and altered behavior. We report here a 4-year old autistic boy who presented to the pediatrician's office with gastrointestinal symptoms and behavioral changes and was at first thought to have a viral syndrome. He returned 2 days later with a worsening illness; increasing pallor, vomiting, abdominal colic, and changes in consciousness were recognized in the emergency department as lead-induced anemia and encephalopathy, associated with a positive abdominal film for paint chips and a blood lead level equal to 216 microg/dL (10.43 micromol/L) (reference, <10 microg/dL or 0.483 micromol/L). As this case illustrates, prompt recognition is dependent on the skills and suspicions of an astute clinician, especially in the busy emergency department.
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Affiliation(s)
- Mathew George
- Harvard Medical Toxicology Program, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115, USA.
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Scharman EJ, Erdman AR, Cobaugh DJ, Olson KR, Woolf AD, Caravati EM, Chyka PA, Booze LL, Manoguerra AS, Nelson LS, Christianson G, Troutman WG. Methylphenidate poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila) 2010; 45:737-52. [DOI: 10.1080/15563650701665175] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Michel BA, Tschumi U, Woolf AD, Zeidler H, Beglinger C, Dalvit G, Felder M, Graf A, Steurer J. [Chronic musculo-skeletal pain in Switzerland: patient care from the view of physicians and patients]. Praxis (Bern 1994) 2009; 98:933-940. [PMID: 19711286 DOI: 10.1024/1661-8157.98.17.933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
A considerable percentage of the population suffers from chronic musculoskeletal pain (CMP) and patient management does not appear to be optimal. The aim of the present investigations was to assess and evaluate epidemiologic data and discover eventual deficits in patient management. This investigation included several sequential steps: First a European study including Switzerland evaluated the prevalence and characteristics of patients with CMP as well as of the treating physicians. The results were discussed and elaborated in two workshops, where general practitioners and patients were included. In a further step the results of these workshops were evaluated again in a telephone survey addressing patients and physicians both in the French and German speaking parts of Switzerland. Considerable deficits were discovered in the management of patients with CMP: In 35% no firm diagnosis was established, the life quality was considerably reduced in about 13 of the patients, the patients' information on their disorders were found to be rather limited, furthermore, there were misconceptions about medical treatment. The two workshops confirmed the results of the first study. The causes of pain often remained unclear, there were considerable communication problems between patient and physician, medical treatment appeared to be inappropriate, and there were deficits in the time management during consultations. The telephone survey confirmed these deficits. In conclusion management of patients with CMP is characterized by considerable deficits such as missing or unclear diagnosis, misconceptions in medical contexts and treatment. Many of the deficits may be improved and call for measures for optimizing the management of patients with CMP.
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Affiliation(s)
- B A Michel
- Rheumaklinik und Institut für Physikalische Medizin, Universitätsspital Zürich, Zurich.
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Olson KR, Erdman AR, Woolf AD, Scharman EJ, Christianson G, Caravati EM, Wax PM, Booze LL, Manoguerra AS, Keyes DC, Chyka PA, Troutman WG. Calcium Channel Blocker Ingestion: An Evidence-Based Consensus Guideline for Out-of-Hospital Management. Clin Toxicol (Phila) 2009; 43:797-822. [PMID: 16440509 DOI: 10.1080/15563650500357404] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In 2003, U.S. poison control centers were consulted after 9650 ingestions of calcium channel blockers (CCBs), including 57 deaths. This represents more than one-third of the deaths reported to the American Association of Poison Control Centers' Toxic Exposure Surveillance System database that were associated with cardiovascular drugs and emphasizes the importance of developing a guideline for the out-of-hospital management of calcium channel blocker poisoning. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial management of patients with suspected ingestions of calcium channel blockers. An evidence-based expert consensus process was used to create this guideline. This guideline applies to ingestion of calcium channel blockers alone and is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. The panel's recommendations follow. The grade of recommendation is in parentheses. 1) All patients with stated or suspected self-harm or the recipient of a potentially malicious administration of a CCB should be referred to an emergency department immediately regardless of the amount ingested (Grade D). 2) Asymptomatic patients are unlikely to develop symptoms if the interval between the ingestion and the call is greater than 6 hours for immediate-release products, 18 hours for modified-release products other than verapamil, and 24 hours for modified-release verapamil. These patients do not need referral or prolonged observation (Grade D). 3) Patients without evidence of self-harm should have further evaluation, including determination of the precise dose ingested, history of other medical conditions, and the presence of co-ingestants. Ingestion of either an amount that exceeds the usual maximum single therapeutic dose or an amount equal to or greater than the lowest reported toxic dose, whichever is lower (see Table 5), would warrant consideration of referral to an emergency department (Grade D). 4) Do not induce emesis (Grade D). 5) Consider the administration of activated charcoal orally if available and no contraindications are present. However, do not delay transportation in order to administer charcoal (Grade D). 6) For patients who merit evaluation in an emergency department, ambulance transportation is recommended because of the potential for life-threatening complications. Provide usual supportive care en route to the hospital, including intravenous fluids for hypotension. Consider use of intravenous calcium, glucagon, and epinephrine for severe hypotension during transport, if available (Grade D). 7) Depending on the specific circumstances, follow-up calls should be made to determine outcome at appropriate intervals based on the clinical judgment of the poison center staff (Grade D).
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Affiliation(s)
- Kent R Olson
- American Association of Poison Control Centers, 3201 New Mexico Ave., NW, Suite 330, Washington, DC 20016, USA
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Abstract
BACKGROUND Brimonidine tartrate, a centrally acting selective alpha-2 adrenergic agonist with a toxicity that is often compared with that of clonidine, is used as eye drops to lower intraocular pressure in glaucoma. We investigated characteristics of childhood exposures to brimonidine-containing products. METHODS All brimonidine exposures in children 0 to 5 years of age between 1997 and 2005 were retrieved from the American Association of Poison Control Centers' Toxic Exposure Surveillance System database and the US Food and Drug Administration's Medwatch Adverse Events Reporting System. The design of the study was retrospective, and the main outcome measures were frequency of exposures over time, reason, symptoms/signs of toxicity, dose, management site, treatment, and outcome. RESULTS There were 413 brimonidine reports in the Toxic Exposure Surveillance System and 340 in the Adverse Events Reporting System during the 9 years under study, of which 185 Toxic Exposure Surveillance System reports involved children < or =5 years of age versus 15 cases in the Adverse Events Reporting System. There were no deaths. The peak age of poisoning in the Toxic Exposure Surveillance System pediatric cases was 2 years of age, and circumstances were unintentional poisoning in 176 cases, usually by ingestion (84.3%). Common symptoms in 176 children included drowsiness (40.9%), ataxia (4.5%), pallor (4.5%), irritability (4.0%), hypotension (4.0%), bradycardia (4.0%), miosis (3.4%), and respiratory depression (3.4%). Of the 176 unintentional pediatric poisonings, 73 children were observed at home and 103 were seen at a health care facility; 28 were hospitalized and 11 received naloxone. Of the 15 pediatric cases in the Adverse Events Reporting System data set, all were hospitalized, and 13 had ocular exposures only. CONCLUSIONS All children < or =5 years of age with confirmed brimonidine ingestions should be medically evaluated and monitored for an extended period. Indications for the use of naloxone in brimonidine poisoning remain uncertain.
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Affiliation(s)
- Melisa Lai Becker
- Division of Emergency Medicine, Cambridge Hospital, Cambridge, Massachusetts, USA
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Manoguerra AS, Erdman AR, Woolf AD, Chyka PA, Martin Caravati E, Scharman EJ, Booze LL, Christianson G, Nelson LS, Cobaugh DJ, Troutman WG. Valproic acid poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila) 2009; 46:661-76. [DOI: 10.1080/15563650802178136] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Woolf AD, Hussain J, McCullough L, Petranovic M, Chomchai C. Infantile lead poisoning from an Asian tongue powder: A case report & subsequent public health inquiry. Clin Toxicol (Phila) 2008; 46:841-4. [DOI: 10.1080/15563650801898536] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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50
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Woolf AD, Erdman AR, Nelson LS, Caravati EM, Cobaugh DJ, Booze LL, Wax PM, Manoguerra AS, Scharman EJ, Olson KR, Chyka PA, Christianson G, Troutman WG. Tricyclic antidepressant poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila) 2008; 45:203-33. [PMID: 17453872 DOI: 10.1080/15563650701226192] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
A review of U.S. poison center data for 2004 showed over 12,000 exposures to tricyclic antidepressants (TCAs). A guideline that determines the conditions for emergency department referral and prehospital care could potentially optimize patient outcome, avoid unnecessary emergency department visits, reduce healthcare costs, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the lead author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate prehospital triage and management of patients with suspected ingestions of TCAs by 1) describing the manner in which an ingestion of a TCA might be managed, 2) identifying the key decision elements in managing cases of TCA ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of TCAs alone. Co-ingestion of additional substances could require different referral and management recommendations depending on their combined toxicities. This guideline is based on the assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all the circumstances involved. This guideline does not substitute for clinical judgment. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) Patients with suspected self-harm or who are the victims of malicious administration of a TCA should be referred to an emergency department immediately (Grade D). 2) Patients with acute TCA ingestions who are less than 6 years of age and other patients without evidence of self-harm should have further evaluation including standard history taking and determination of the presence of co-ingestants (especially other psychopharmaceutical agents) and underlying exacerbating conditions, such as convulsions or cardiac arrhythmias. Ingestion of a TCA in combination with other drugs might warrant referral to an emergency department. The ingestion of a TCA by a patient with significant underlying cardiovascular or neurological disease should cause referral to an emergency department at a lower dose than for other individuals. Because of the potential severity of TCA poisoning, transportation by EMS, with close monitoring of clinical status and vital signs en route, should be considered (Grade D). 3) Patients who are symptomatic (e.g., weak, drowsy, dizzy, tremulous, palpitations) after a TCA ingestion should be referred to an emergency department (Grade B). 4) Ingestion of either of the following amounts (whichever is lower) would warrant consideration of referral to an emergency department: an amount that exceeds the usual maximum single therapeutic dose or an amount equal to or greater than the lowest reported toxic dose. For all TCAs except desipramine, nortriptyline, trimipramine, and protriptyline, this dose is >5 mg/kg. For despiramine it is >2.5 mg/kg; for nortriptyline it is >2.5 mg/kg; for trimipramine it is >2.5 mg/kg; and for protriptyline it is >1 mg/kg. This recommendation applies to both patients who are naïve to the specific TCA and to patients currently taking cyclic antidepressants who take extra doses, in which case the extra doses should be added to the daily dose taken and then compared to the threshold dose for referral to an emergency department (Grades B/C). 5) Do not induce emesis (Grade D). 6) The risk-to-benefit ratio of prehospital activated charcoal for gastrointestinal decontamination in TCA poisoning is unknown. Prehospital activated charcoal administration, if available, should only be carried out by health professionals and only if no contraindications are present. Do not delay transportation in order to administer activated charcoal (Grades B/D). 7) For unintentional poisonings, asymptomatic patients are unlikely to develop symptoms if the interval between the ingestion and the initial call to a poison center is greater than 6 hours. These patients do not need referral to an emergency department facility (Grade C). 8) Follow-up calls to determine the outcome for a TCA ingestions ideally should be made within 4 hours of the initial call to a poison center and then at appropriate intervals thereafter based on the clinical judgment of the poison center staff (Grade D). 9) An ECG or rhythm strip, if available, should be checked during the prehospital assessment of a TCA overdose patient. A wide-complex arrhythmia with a QRS duration longer than 100 msec is an indicator that the patient should be immediately stabilized, given sodium bicarbonate if there is a protocol for its use, and transported to an emergency department (Grade B). 10) Symptomatic patients with TCA poisoning might require prehospital interventions, such as intravenous fluids, cardiovascular agents, and respiratory support, in accordance with standard ACLS guidelines (Grade D). 11) Administration of sodium bicarbonate might be beneficial for patients with severe or life-threatening TCA toxicity if there is a prehospital protocol for its use (Grades B/D). 12) For TCA-associated convulsions, benzodiazepines are recommended (Grade D). 13) Flumazenil is not recommended for patients with TCA poisoning (Grade D).
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Affiliation(s)
- Alan D Woolf
- American Association of Poison Control Centers, Washington, District of Columbia, USA
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