105 EVALUATION OF A NEW PHYSIOTHERAPY-LED VESTIBULAR SERVICE EMBEDDED IN THE FALLS AND SYNCOPE UNIT

Background

Clinical presentations in the falls and syncope unit (FASU) are diverse and require a range of skillsets. Vestibular disorders amount to a significant proportion of presentations. In our FASU, we embedded a 0.5 FTE specialist physiotherapist with expertise in vestibular disorders to work alongside medical and nursing staff. We conducted a service evaluation of the activity of this new service.

Methods

Retrospective Service Evaluation Approval was granted by our Research & Innovation Office. Pseudonymised data was collected corresponding to all new FASU physiotherapy service attendances between August 2021 and May 2022. Descriptive statistics were complemented by a binary logistic regression model to establish independent predictors of more than one physiotherapy session being required over the period.

Results

There were 104 episodes recorded by the new service, corresponding to 101 unique patients. Mean age was 67.7 (SD 19.0, range 17-93), and 73.1% were women. 67% were treated and discharged in 1 session. On average, patients had had a mean of 2 falls prior to the consultation (range 0-25). 28.8% were using a walking aid, and 54.8% self-reported fear of falling. 25% of the referrals to the service were due to suspected vestibular disorders, 62% of which were directly treated by the physiotherapy service. The logistic regression model adjusting by age, sex, use of walking aid, number of falls, and fear of falling showed that only referral for vestibular disorder was an independent predictor of patients needing more than 1 physiotherapy treatment (OR 3.91, 95% CI 1.32-11.58, P=0.014).

Conclusion

Vestibular disorders are common in FASU, and a majority can be treated by a specialist physiotherapy service. Repeated vestibular maneuvers are often needed in such patients. A responsive, embedded physiotherapy service in FASU can directly address this need and further evaluation will focus on the impact of this service on avoidance of ED attendances.

110 DEVELOPMENT AND DELIVERY OF A MULTI-DISCIPLINARY HYBRID EDUCATION PROGRAM IN SYNCOPE AND RELATED DISORDERS DURING THE COVID-19 PANDEMIC

Background

Syncope and related disorders is an important area for training of all health professionals. During the COVID-19 pandemic, we adapted the delivery of our annual face-to-face certified program to a 9-month hybrid program. Here, we describe the development, delivery, and evaluation of such new program.

Methods

A pre-existing curriculum was modified to incorporate online content, online lecture delivery and interactive group learning, in addition to individual practical placements in a syncope management unit, in line with government and hospital infection control guidance at the time. Monthly content included video consultant case presentations, ECG analysis and interpretation, and instructional videos of diagnostic testing and relevant technologies. A comprehensive online week-long lecture program was developed.

Results

The lecture week included 30 clinical lectures, 10 clinical case presentations and 10 ‘how to’ practical videos for testing/monitoring procedures. Further learning over zoom incorporated learner case presentations in a small group format. At the completion of the course the leaners attended a final online half day of lectures and completed the multi choice question examination.

Conclusion

“Thank you so much for putting together such a fantastic week of training.” “The quality and expertise of the speakers was outstanding.” “I have taken a huge amount away to incorporate into my practice and local unit.”

The above learner feedback is consistent with our aim to deliver a high-quality specialist program for those interested in advancing the management of syncope and related disorders. Over time, this specialist training will aid the development of regional syncope management units across Ireland. The benefits of a hybrid learning model include multiple options to cater for all categories of learners, thus suggesting it is the cornerstone of future learning modalities.

281 PREVALENCE OF STOPPFALL FALLS-RISK-INCREASING DRUGS (FRIDS) IN PATIENTS PRESENTING TO HOSPITAL WITH A FALL

Background

Falls cause presentation and admission to hospital. Falls-Risk-Increasing-Drugs (FRIDs) are a modifiable risk factor. STOPPFalls criteria was developed, using an expert Delphi panel, to achieve consensus on a comprehensive list of FRIDs. The aim of this study was to identify the prevalence of STOPPFall PRIDs in patients presenting to hospital with falls and identify whether review by a specialist Falls and Syncope Service (FASS) reduces FRIDs.

Methods

This was a retrospective observational study. Patients ≥65 years reviewed by the hospital FASS in the emergency department (over 6-months) and in house (over 2-months), were included. Medication appropriateness at admission and discharge were assessed using STOPPFall criteria. Ethical approval was received from the local research and innovation office (ref7013).

Results

Of 156 patients, 87(55.8%) were ≥65 years; 46% female, mean age 78.1(SD7.5) years. The mean number of conditions was 4(SD4.4); the mean number of regular medications was 6.9(SD4.5). Reasons for referral to FASS included falls (34.5%), dizziness/near fall (35.6%), and transient loss of consciousness (29.9%). For 21.8% there was an associated injury; 11.5% a fracture. Thirty-seven (42.5%) had experienced at least one fall in the previous 12-months.

Sixty-four (73.6%) were on ≥1 STOPPFall FRID. The most common STOPPFall FRID prescribed to older adults were diuretics (24.1%), anti-depressants (20.7%) and benzodiazepines/benzodiazepine-related drugs (13.8%). At least 1 STOPPFall FRID was stopped in 31.3%. The most commonly deprescribed STOPPFall FRIDs were diuretics (20%), alpha blockers (6%) and benzodiazepines/benzodiazepine-related drugs (4.7%). Adults <65years (n=69) were more likely to be prescribed a STOPPFall FRID at admission than older adults (≥65years); 88.4% vs 73.6%, p=0.021.

Conclusion

STOPPFall FRIDs are prevalent in fallers of all ages. Even one review by a specialist FASS leads to medication optimization. The effectiveness of STOPPFalls criteria in the prevention of falls should be evaluated further in intervention studies.

HLA-DPB1 E69 genotype and exposure in beryllium sensitisation and disease

OBJECTIVES

Human leukocyte antigen-DP beta 1 (HLA-DPB1) with a glutamic acid at the 69th position of the ß chain (E69) genotype and inhalational beryllium exposure individually contribute to risk of chronic beryllium disease (CBD) and beryllium sensitisation (BeS) in exposed individuals. This retrospective nested case-control study assessed the contribution of genetics and exposure in the development of BeS and CBD.

METHODS

Workers with BeS (n=444), CBD (n=449) and beryllium-exposed controls (n=890) were enrolled from studies conducted at nuclear weapons and primary beryllium manufacturing facilities. Lifetime-average beryllium exposure estimates were based on workers' job questionnaires and historical and industrial hygienist exposure estimates, blinded to genotype and case status. Genotyping was performed using sequence-specific primer-PCR. Logistic regression models were developed allowing for over-dispersion, adjusting for workforce, race, sex and ethnicity.

RESULTS

Having no E69 alleles was associated with lower odds of both CBD and BeS; every additional E69 allele increased odds for CBD and BeS. Increasing exposure was associated with lower odds of BeS. CBD was not associated with exposure as compared to controls, yet the per cent of individuals with CBD versus BeS increased with increasing exposure. No evidence of a gene-by-exposure interaction was found for CBD or BeS.

CONCLUSIONS

Risk of CBD increases with E69 allele frequency and increasing exposure, although no gene by environment interaction was found. A decreased risk of BeS with increasing exposure and lack of exposure response in CBD cases may be due to the limitations of reconstructed exposure estimates. Although reducing exposure may not prevent BeS, it may reduce CBD and the associated health effects, especially in those carrying E69 alleles.

204 FRAILTY BUT NOT AGE IS ASSOCIATED WITH IMPAIRED ORTHOSTATIC CEREBRAL OXYGENATION

Background

The effects of age and frailty on cerebrovascular function are poorly understood. Here we investigate the hypotheses that aging, and frailty are accompanied by impaired regulation of cerebral oxygenation during standing in a patient population of older adults.

Methods

We recruited patients from a national Falls and Syncope service. All patients underwent an active stand test (5–10 min lying, 3 min standing) with continuous monitoring of blood pressure (BP) and heart rate. Tissue saturation index (TSI) was concurrently measured using near-infrared spectroscopy and its recovery measured at 30s after standing. Frailty was assessed as a comorbidity count using a 27-item questionnaire. Robust linear regression was used to investigate the association between TSI, age and frailty in a multivariate model with covariate adjustment, including the concurrent BP values. A p-value <0.05 was considered significant.

Results

304 patients (median(IQR): 71(14) years, 57% females) were recruited. Age was not associated with cerebral oxygenation after standing (β: −0.001 (−0.017 0.015), p = 0.899), even after stratification by sex (males: β: −0.010 (−0.045 0.024), p = 0.558, females: β: 0.000 (−0.017 0.018), p = 0.967). Frailty, was associated with a lower TSI at 30s after standing (β: −0.153 (−0.248–0.058), p = 0.002). After sex stratification, no associations with frailty were observed in males (β: −0.052 (−0.226 0.123), p = 0.557), while frailer females demonstrated a lower TSI at 30 seconds after standing (β: −0.179 (−0.294–0.063), p = 0.003) despite BP correction.

Conclusion

Our results suggest alternative mechanisms of cerebral oxygenation regulation independent of blood pressure (and presumably cerebral autoregulation) are involved in frailty related impairments of brain haemodynamics which are also independent of ageing. Such impairments represent novel biomarkers of frailty and represent potentially novel modifiable risk factors (independent of BP management) of hypoperfusion related disorders in clinical ageing.

Recent CO2 levels promote increased production of the toxin parthenin in an invasive Parthenium hysterophorus biotype

Recent carbon dioxide (CO₂) concentrations promoted higher parthenin concentrations in an invasive Parthenium hysterophorus biotype. Mean concentrations of parthenin, an allelopathic and defensive sesquiterpene lactone, were 49% higher at recent (~400 ppm) than at mid-twentieth-century (~300 ppm) CO₂ concentrations, but did not vary in a non-invasive biotype, suggesting that recent increases in atmospheric CO₂ may have already altered the chemistry of this destructive weed, potentially contributing to its invasive success.

Cerebral perfusion responses to active standing are attenuated in patients with vasovagal syncope

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Irish Research Council (IRC): Government of Ireland Postgraduate Scholarship Programme 2018, Dublin, Ireland Fundació Universitària Agustí Pedro i Pons, Universitat de Barcelona, Barcelona, Spain

Background

Syncope is a transient loss of consciousness due to cerebral hypoperfusion. While traditionally peripheral haemodynamics are monitored during clinical assessment of syncope, relatively little is known about cerebrovascular haemodynamics during orthostasis in patients with syncope.

Purpose

Here we investigated whether young patients with syncope present an altered cerebral perfusion when compared to healthy controls. Given potential hyper-reactivity of the autonomic nervous system previously reported in these patients, we hypothesise that an overly active cerebral autoregulation will be present in patients with syncope.

Methods

Consecutive patients were prospectively recruited from a National Falls and Syncope Unit, and a convenience sample of young healthy community dwelling adults was recruited from a local university (16-30 years). Participants performed a 3 minute active stand test with continuous measurement of beat-to-beat peripheral haemodynamics (blood pressure (BP), heart rate (HR)) and changes in concentration of oxygenated Δ[O2Hb] and deoxygenated Δ[HHb] haemoglobin were derived from a near-infrared spectroscopy (NIRS) monitor. Baseline, steady state and other time domain features were derived for Δ[O2Hb] (nadir, overshoot, overshoot-to-nadir, overshoot-to-nadir recovery rate) and Δ[HHb] (peak, trough, peak-to-trough, peak-to-trough recovery rate) and multiple linear regression was used to compare differences between the two groups correcting for covariates (p < 0.05 significant).

Results

Patients (n = 40) were younger (20(5.5) vs 23(1) years, p = 0.003) than controls (n = 17) and were well matched in gender, weight, height, BMI and resting haemodynamics. Patients had a smaller Δ[O2Hb] overshoot-to-nadir difference (β: -0.749, CI:(-1.593 0.094), p = 0.08), a slower Δ[O2Hb] recovery rate (β: -0.186, CI:(-0.388 0.016), p = 0.071), and smaller Δ[HHb] peak-to-trough difference (β: -0.530, CI:( -0.921 0.138), p = 0.018) and slower Δ[HHb] recovery rate (β: -0.151, CI: (0.244 0.057), p = 0.008).

Conclusion

Patients with syncope had signs of an attenuated cerebral oxygenation response to an AS when compared to controls. We hypothesise that this is due to hyper-reactive cerebral autoregulation mechanism, which might be related to a hyper-sensitive autonomic system. Furthering our understanding of vasovagal syncope physiology can help inform future interventions and treatments. This study shows the clinical value of measuring cerebral perfusion using NIRS, an easy to use and readily applicable tool, in the assessment of syncope. Abstract Figure. Cerebral oxygenation upon standing

Do patients with syncope have a hyper-reactive autonomic nervous system?

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Irish Research Council (IRC): Government of Ireland Postgraduate Scholarship Programme 2018, Dublin, Ireland Fundació Universitària Agustí Pedro i Pons, Universitat de Barcelona, Barcelona, Spain.

Background

The origin of syncope, a transient loss of consciousness due to cerebral hypoperfusion, remains unclear. Recent studies suggest that a hypersensitive autonomic nervous system might be involved in the pathophysiology of vasovagal syncope (VVS).

Purpose

Here we test the hypothesis that patients with VVS have a hyper-reactive autonomic nervous system by investigating the peripheral haemodynamic responses during a standing (AS) test in a group of young VVS patients vs a control group.

Methods

A prospective sample of consecutive patients from a National Falls and Syncope Unit was recruited, and a convenience sample of young healthy community dwelling adults was recruited from a local university (16-30 years). Participants performed a 3 minute AS with continuous measurement of beat-to-beat blood pressure (BP), heart rate (HR), and cerebral oxygenation measured with near infrared spectroscopy. Baseline, steady-state and other time domain features were obtained for systolic BP (SBP) (i.e. nadir, overshoot, overshoot-to-nadir, overshoot-to-nadir recovery rate) and for HR (i.e. peak, trough, peak-to-trough, peak-to-trough recovery rate). Multiple linear regression was used to compare these features between patients and controls while correcting for covariates (p < 0.05 significant).

Results

Forty patients and 17 controls were included, the former group being younger ((20(5.5) vs 23(1) years, p = 0.003). During steady-state standing SBP was higher as compared to controls (β: 6.853, CI: (0.713 12.993), p = 0.029). Patient data trended toward lower steady-state HR (β: -5.262, CI:(-11.201 0.677), p = 0.081), together with a larger peak-to-trough difference (β: 7.212, CI:(1.329 -15.754), p = 0.096).

Conclusion

These results tend to support the hypothesis and previous literature suggesting the presence of autonomic hyper-reactivity in patients with syncope, presenting as an exaggerated peripheral circulatory response to standing. Understanding the pathophysiology of VVS can help us improve its assessment and develop better treatment pathways for these patients. Abstract Figure.

Ongoing risk of bladder cancer among former workers at the last benzidine manufacturing facility in the USA

OBJECTIVE

To determine whether there is an ongoing risk of developing bladder cancer in a previously studied cohort of workers exposed to both benzidine and dichlorobenzidine or dichlorobenzidine only in the last benzidine manufacturing plant in the USA.

METHODS

Workers (n=488) were identified from the quarterly 941 forms the employer was required to submit to the Social Security Administration from 1960 to 1977. Exposures were assigned based on dates worked and known benzidine/dichlorobenzidine production schedules. Incidence, vital status and cause of death were determined through 2014. Analyses were restricted to white men.

RESULTS

Bladder cancer incidence and mortality were significantly increased (25 incident cases, standardised incidence ratio (SIR) 2.19, 95% CI 1.42 to 3.23, and 5 deaths, standardised mortality ratio (SMR) 3.79, 95% CI 1.23 to 8.84). There were significant increases in incidence and mortality in those exposed to both benzidine and dichlorobenzidine (SIR 3.11, 95% CI 1.97 to 4.67, SMR 4.10, 95% CI 1.12 to 10.50), but not among workers exposed to dichlorobenzidine only (two incident cases, SIR 0.89, 95% CI 0.11 to 3.23 and one death, SMR 2.90, 95% CI 0.07 to 16.15). Bladder cancer incidence and mortality were increased in individuals with >20 years since last exposure with >5 years worked (six observed, SIR 5.94, 95% CI 2.18 to 12.92 and two deaths, SMR 7.93, 95% CI 0.96 to 28.65).

CONCLUSIONS

Incidence and mortality due to bladder cancer increased among workers exposed to benzidine but not among workers exposed only to dichlorobenzidine. The risk of incidence and death from bladder cancer remain elevated more than 20 years after last exposure to benzidine in those who worked >5 years.

Impact of a specialist service in the Emergency Department on admission, length of stay and readmission of patients presenting with falls, syncope and dizziness

BACKGROUND

Up to half of patients presenting with falls, syncope or dizziness are admitted to hospital. Many are discharged without a clear diagnosis for their index episode, however, and therefore a relatively high risk of readmission.

AIM

To examine the impact of ED-FASS (Emergency Department Falls and Syncope Service) a dedicated specialist service embedded within an ED, seeing patients of all ages with falls, syncope and dizziness.

DESIGN

Pre- and post-cohort study.

METHODS

Admission rates, length of stay (LOS) and readmission at 3 months were examined for all patients presenting with a fall, syncope or dizziness from April to July 2018 (pre-ED-FASS) inclusive and compared to April to July 2019 inclusive (post-ED-FASS).

RESULTS

There was a significantly lower admission rate for patients presenting in 2019 compared to 2018 [27% (453/1676) vs. 34% (548/1620); X2 = 18.0; P < 0.001], with a 20% reduction in admissions. The mean LOS for patients admitted in 2018 was 20.7 [95% confidence interval (CI) 17.4-24.0] days compared to 18.2 (95% CI 14.6-21.9) days in 2019 (t = 0.98; P = 0.3294). This accounts for 11 344 bed days in the 2018 study period, and 8299 bed days used after ED-FASS. There was also a significant reduction in readmission rates within 3 months of index presentation, from 21% (109/1620) to 16% (68/1676) (X2 = 4.68; P = 0.030).

CONCLUSION

This study highlights the significant potential benefits of embedding dedicated multidisciplinary services at the hospital front door in terms of early specialist assessment and directing appropriate patients to effective ambulatory care pathways.

Mesothelioma risk among those exposed to chrysotile asbestos only and mixtures that include amphibole: a case-control study in the USA, 1975-1980

OBJECTIVES

Occupational asbestos exposure is causally linked to mesothelioma. However, whether exposure to only chrysotile asbestos is associated with mesothelioma risk, and the heterogeneity in risk by different fibre types/lengths remains unclear. We investigated whether mesothelioma risk differs among workers exposed to only chrysotile asbestos compared with chrysotile and ≥1 amphibole (ie, amosite, tremolite, anthophyllite and crocidolite) over the working lifetime.

METHODS

We analysed next-of-kin interview data including occupational histories for 580 white men (176 cases and 404 controls) from a case-control study of mesothelioma conducted in the USA in 1975-1980. Asbestos exposure was determined by an occupational hygienist using a job-exposure matrix and exposure categories included chrysotile only and nine chrysotile-amphibole mixtures. Logistic regression models were used to estimate the ORs and 95% CIs of mesothelioma, comparing each asbestos category to the unexposed group, adjusted for age at death and data source. Analysis of contrasts was used to assess overall heterogeneity and pair-wise differences in risk.

RESULTS

Exposure to long and short chrysotile only was associated with increased mesothelioma risk compared with the unexposed (OR=3.8 (95% CI 1.3 to 11.2)). The complex mixture of extra-long amosite, short and long chrysotile, tremolite and anthophyllite was associated with the highest risk (OR=12.8 (95% CI 4.1 to 40.2)). There was evidence for overall heterogeneity among the asbestos exposure categories (p heterogeneity=0.02). However, the lower risk observed for exposure to chrysotile only compared with the complex mixture was not significant (p difference=0.10).

CONCLUSIONS

Our findings suggest that policies aimed at regulating asbestos should target both pure chrysotile and mixtures that include amphibole.

1064 Sleep Patterns Among Urban Haitian Earthquake Survivors Who Experienced the Trauma of Nonpartner Sexual Violence: A Latent Class Analysis Approach

Introduction

Sleep health is crucial to recovery from trauma. Haiti’s Cité Soleil residents (approximately 350,000) live in extreme poverty and regularly experience or witness life-threatening events, including gang and non-partner sexual violence (NPSV). Differences in levels of sleep disturbance among men and women in resource-limited settings who survive disasters as well as NPSV are understudied. In a larger study in which we investigated trauma symptoms among 2010 Haiti earthquake survivors via the Trauma-symptom checklist -40 (N=526; 290 males, 236 females), we also assessed self-reported frequency of sleep disturbance symptoms using the measure’s sleep disturbance subscale, comparing the latter by NPSV victim status and by gender.

Methods

SAS enabled 3-Class Latent Class Analysis (LCA): Class 1 (“No symptoms”), Class 2 (“Some symptoms”), Class 3 (“All Symptoms)”.

Results

Distribution of class membership differed by gender (χ2 = 23.9, df = 2, p &lt; .0001). Proportions of respondents assigned to the three classes differed between genders (Females: Class 1, 29.2%; Class 2, 35.5%; Class 3, 35.3%); Males: Class 1, 25.7%; Class 2, 54.4%; Class 3, 19.9%). NPSV status influenced levels of sleep disturbance symptoms, and membership distribution differed across classes by gender (χ2 = 23.9, df = 2, p &lt; .0001). Class 2 membership was greater for men (65.9%), but class 3 membership was greater for women (59.3%). Women who experienced NPSV were statistically more likely members of sleep disturbance symptom classes (Class 2 or Class 3) than Class 1 (χ2= 14.9, df = 2, p = 0.0006). No difference was found in Class membership for men reporting NPSV (χ2= 1.6, df = 2, p = 0.45).

Conclusion

Investigating the sleep health of Cité Soleil residents adds to the body of literature on sleep health, sleep equity and gendered vulnerability. Findings suggest women in post-disaster settings, especially in LMICs, are at even greater risk for a variety of adverse health outcomes and for suboptimal sleep, even when local men have similar traumatogenic experiences, such as NPSV. Girls and women in post-disaster LMIC settings need trauma-informed sleep health promotion and NPSV-prevention.

Support

N/A

Perception of Impact of Frequent Short Training as an Enhancement of Annual Refresher Training

Introduction of facilitated hands-on drills as often as monthly and the use of online modules prior to annual refresher training for emergency response teams were investigated through surveys and group discussions. This research explores how these drills are perceived by emergency response team members, emergency response team coordinators, instructors, and management at the company. Using these tools throughout the year, members of emergency response teams from automobile manufacturing facilities reported an increased ability to maintain their skill sets, build teamwork, and continually refresh and strengthen their ability to protect their fellow workers as well as plant operations and equipment. The results also document examples of how this innovative program that incorporates frequent training has led to workplace improvements.

Assessing the impact of health and safety training: Increased behavioral change and organizational performance

BACKGROUND

Annual health and safety refresher training is mandated for workers in a number of employment sectors and also is used to maintain and enhance skills when not legally required.

METHODS

One year following training, hazardous waste worker training participants were asked if the training had been applied at their work or in the community, corresponding to Kirkpatrick levels of training evaluation. Likely response themes were drafted by the authors using qualitative data coding.

RESULTS

Of the 1,726 refresher participants, 1,094 (63%) provided an entry. Eight theme categories were adapted from the originals, spanning the activities trainees reported as applications of their training: events, actions, awareness, emergency response, equipment, planning and standard operating procedures, training, and use of written resources.

CONCLUSIONS

Asking participants to reflect on how training has been applied provides an opportunity to describe workplace changes made during the past year. Participants documented that training resulted in actions to protect them from hazardous exposures. Specific events where training was used and where actions were taken to improve health and safety represent Kirkpatrick Levels III and IV applications of training. Collecting similar data may be useful to others wishing to identify impacts of training and can be integrated into routine program assessment.

How Hydration Habits Influence Morning Balance and Blood Pressure (BP) of Institutionalized Older Adults (IOA)

Date Presented 04/05/19

Institutionalized older adults (IOA) have an elevated risk for dehydration, falling, and poor blood pressure (BP) regulation due to aging, comorbidities, medications, and a person’s beverage habits. Poor fluid habits can negatively affect health, participation, and performance. This study examines the PEO fit of beverage habits of IOA to identify influencers (plus or minus) of morning balance and BP and subsequently possible falls. The research findings provide evidence for use in a hydration program.

Primary Author and Speaker: Carol Rice

Contributing Authors: Noralyn Pickens

Hydration Habits and Daily Fluid Intake of Institutionalized Older Adults

Date Presented 04/06/19

Institutionalized older adults have an elevated risk for dehydration due to aging body systems, medication effects, urinary incontinence, impaired mobility and cognition, and the individual’s beverage habits. Being dehydrated has negative consequences on health, participation, and performance. This study examines the PEO fit of beverage habits for institutionalized older adults to identify associations (+ or -) with overall fluid intake, thereby providing evidence for a hydration program.

Primary Author and Speaker: Carol Rice

Contributing Authors: Noralyn Pickens

Increasing Breast and Cervical Cancer Screening in Rural and Border Texas with Friend to Friend Plus Patient Navigation

The Friend to Friend plus Patient Navigation Program (FTF+PN) aims to build an effective, sustainable infrastructure to increase breast and cervical screening rates for underserved women in rural Texas. The objective of this paper is to identify factors that (1) distinguish participants who chose patient navigation (PN) services from those who did not (non-PN) and (2) were associated with receiving a mammogram or Papanicolaou (Pap) test. This prospective study analyzed data collected from 2689 FTF+PN participants aged 18-99 years from March 1, 2012 to February 28, 2015 who self-identified as African American (AA), Latina, and non-Hispanic white (NHW). Women who were younger, AA or Latina, had less than some college education, attended a FTF+PN event because of the cost of screening or were told they needed a screening, and who reported a barrier to screening had higher odds of being a PN participant. Women who were PN participants and had more contacts with program staff had greater odds of receiving a mammogram and a Pap compared with their reference groups. Latina English-speaking women had lower odds of receiving a mammogram and a Pap compared with NHW women and Latina Spanish-speaking women had higher odds of receiving a Pap test compared with NHW women. Women with greater need chose PN services, and PN participants had higher odds of getting a screening compared with women who did not choose PN services. These results demonstrate the success of PN in screening women in rural Texas but also that racial/ethnic disparities in screening remain.

Managers' perceptions of the value and impact of HAZWOPER worker health and safety training

BACKGROUND

Worker training is a core component of the OSHA Hazardous Waste Operations and Emergency Response (HAZWOPER) standard, but few studies have considered what motivates managers to provide HAZWOPER training to employees or what they value in that training.

METHODS

In 2012, four university-based programs conducted an exploratory survey of managers who sent employees to HAZWOPER courses. Results from 109 respondents were analyzed.

RESULTS

Forty-two percent of respondents cited regulations as the most important reason to provide HAZWOPER training; many indicated they would provide less training if there were no standard in place. Three-quarters (74%) reported training had improved workplace conditions. Fewer than half said they were likely to involve trained employees in aspects of the organization's H&S program.

DISCUSSION

Compliance with regulatory requirements is an important factor shaping managers' training delivery decisions. Managers recognize positive impacts of training. These impacts could be enhanced by further leveraging employee H&S knowledge and skills.

IARC monographs: 40 years of evaluating carcinogenic hazards to humans

BACKGROUND

Recently, the International Agency for Research on Cancer (IARC) Programme for the Evaluation of Carcinogenic Risks to Humans has been criticized for several of its evaluations, and also for the approach used to perform these evaluations. Some critics have claimed that failures of IARC Working Groups to recognize study weaknesses and biases of Working Group members have led to inappropriate classification of a number of agents as carcinogenic to humans.

OBJECTIVES

The authors of this Commentary are scientists from various disciplines relevant to the identification and hazard evaluation of human carcinogens. We examined criticisms of the IARC classification process to determine the validity of these concerns. Here, we present the results of that examination, review the history of IARC evaluations, and describe how the IARC evaluations are performed.

DISCUSSION

We concluded that these recent criticisms are unconvincing. The procedures employed by IARC to assemble Working Groups of scientists from the various disciplines and the techniques followed to review the literature and perform hazard assessment of various agents provide a balanced evaluation and an appropriate indication of the weight of the evidence. Some disagreement by individual scientists to some evaluations is not evidence of process failure. The review process has been modified over time and will undoubtedly be altered in the future to improve the process. Any process can in theory be improved, and we would support continued review and improvement of the IARC processes. This does not mean, however, that the current procedures are flawed.

CONCLUSIONS

The IARC Monographs have made, and continue to make, major contributions to the scientific underpinning for societal actions to improve the public's health.

Childhood exposure to Libby amphibole during outdoor activities

Residents of Libby, MT were exposed to amphibole asbestos through multiple environmental pathways. Previous exposure characterization has primarily relied on qualitative report of these exposure activities. The objectives of this study were to describe available data from the US EPA preremediation actions for Libby amphibole (LA) exposure in Libby, MT and develop an approach to characterize outdoor residential exposure to LA among children. Homes in Libby, MT included in the US EPA preremediation Contaminant Screening Survey (CSS) were categorized by the presence of interior and/or exterior visible vermiculite and concentrations of LA were measured in samples of dust and soil. Airborne exposure to LA while digging/gardening, raking, and mowing were estimated using US EPA activity-based sampling (ABS) results. Residential histories and frequency/duration of childhood activities were combined with ABS to demonstrate the approach for estimating potential exposure. A total of 3154 residential properties participated in the CSS and 44% of these had visible exterior vermiculite. Airborne concentrations of LA where there was visible vermiculite outdoors were 3-15 times higher during digging/gardening, raking, and mowing activities compared with homes without visible outdoor vermiculite. Digging and gardening activities represented the greatest contribution to estimated exposures and 73% of the participants reported this activity before the age of 6 years. This methodology demonstrated the use of historical preremediation data to estimate residential exposures of children for specific activities. Children younger than age 6 years may have been exposed to LA while digging/gardening, especially at homes where there is visible outdoor vermiculite. This approach may be extended to other activities and applied to the entire cohort to examine health outcomes.

Reduced axonal motor protein expression in non-lesional grey matter in multiple sclerosis

Background:

Multiple sclerosis (MS) is a neurological disease characterised by central nervous system inflammation, demyelination, axonal degeneration and neuronal injury. Preventing neuronal and axon damage is of paramount importance in attempts to prevent disease progression. Intact axonal transport mechanisms are crucial to axonal integrity and evidence suggests these mechanisms are disrupted in MS. Anterograde axonal transport is mediated to a large extent through the kinesin superfamily proteins. Recently, certain kinesin superfamily proteins (KIF5A, KIF1B and KIF21B) were implicated in MS pathology.

Objectives:

To investigate the expression of KIF5A, KIF21B and KIF1B in MS and control post-mortem grey matter.

Methods:

Using both quantitative real-time polymerase chain reaction (PCR) and Immunodot-blots assays, we analysed the expression of kinesin superfamily proteins in 27 MS cases and 13 control cases not linked to neurological disease.

Results:

We have shown significant reductions in KIF5A, KIF21B and KIF1B messenger ribonucleic acid (mRNA) expression and also KIF5A protein expression in MS grey matter, as compared to control grey matter.

Conclusion:

We have shown significant reductions in mRNA and protein levels of axonal motor proteins in the grey matter of MS cases, which may have important implications for the pathogenesis of neuronal/axonal injury in the disease.

Factors that influence awareness and treatment of atrial fibrillation in older adults

AIM

The aims of this study were to investigate the prevalence of atrial fibrillation (AF), treatment rates of AF and the factors underlying awareness and treatment, in a large nationally representative study.

METHODS

A population sample of people aged 50+, living in the Republic of Ireland, were recruited as part of The Irish longitudinal study on ageing. Ten-minute electrocardiogram recordings were obtained (n = 4890), and analysed to detect AF. Self-reported arrhythmias, subjective and objective health measures (cardiovascular diseases, CHA2DS2-VASc variables and blood pressure) and medications were also recorded. Logistic regressions were used to determine associations with outcomes of presence of AF, lack of awareness and untreated AF.

RESULTS

Overall prevalence of AF was 3% (95% CI: 2.4-3.7%), with a marked age gradient and sex difference [4.8% (men) vs. 1.4% (women); P < 0.0001]. In total, 67.8% were at high risk of stroke (CHA2DS2-VASc ≥ 2), of whom 59.3% were inadequately treated. A high proportion of 38.1% were unaware of having AF. CHA2DS2-VASc nor HAS-BLED score influenced awareness or treatment. Lack of awareness was associated with lower education (P = 0.01), lower cognition (P = 0.04), rural location (OR = 3.67; P = 0.02) and number of general practitioner visits (P = 0.01), whereas untreated AF was influenced by frailty status (P = 0.04).

CONCLUSION

With projected doubling of numbers of persons over 80 in the next 30 years in the British Isles, detection and management of AF is pressing. Two-thirds of adults at high risk of stroke were inadequately treated. More regular screening for AF, application of criteria for stroke and bleeding risk and awareness of factors influencing diagnosis and treatment is recommended.

Soil Nutrients, Bacteria Populations, and Veterinary Pharmaceuticals across a Backgrounding Beef Feedlot

Beef cattle backgrounding operations that grow out weaned calves for feedlot finishing contain several environmentally significant constituents. A better understanding of these constituents and their environmental distribution will aid in the development of effective management guidelines for sustainable beef production. This research investigated soil nutrients, bacterial, and veterinary pharmaceutical concentrations across a small backgrounding beef feedlot on a karst landscape. Results indicated that all contaminants were highly concentrated in the feeder area (FD) and were lower in the other feedlot areas. The FD soils had a pH of 8.2, 59 mg kg soil organic matter (SOM), 2002 mg kg soil test phosphorus (STP), 99.7 mg kg NH-N, and 18.3 mg kg NO-N. The other locations were acidic (5.9-6.9 pH) and contained 39 mg kg SOM, 273 mg kg STP, 21.5 mg kg NH-N, and 2.0 NO-N mg kg. Bacteria populations in the FD averaged 2.7 × 10 total cells, 3.9 × 10 spp., 2.9 × 10 spp, and 4.5 × 10 cells per gram of soil. spp. and spp. concentrations were 1 to 4 orders of magnitude lower at the other locations. showed lower dynamic range and was generally uniformly distributed across the landscape. Antibiotic and parasiticide concentrations in the FD were 86.9 ng g monensin, 25.0 ng g lasalocid, and 10.3 ng g doramectin. Their concentrations were 6- to 27-fold lower in the other feedlot locations. Contaminant management plans for this small feedlot will therefore focus on the feeder and nearby grazing areas where soil nutrients, bacteria populations, and veterinary pharmaceuticals were most concentrated.

Evaluation of residual uranium contamination in the dirt floor of an abandoned metal rolling mill

A single, large, bulk sample of uranium-contaminated material from the dirt floor of an abandoned metal rolling mill was separated into different types and sizes of aliquots to simulate samples that would be collected during site remediation. The facility rolled approximately 11,000 tons of hot-forged ingots of uranium metal approximately 60 y ago, and it has not been used since that time. Thirty small mass (≈ 0.7 g) and 15 large mass (≈ 70 g) samples were prepared from the heterogeneously contaminated bulk material to determine how measurements of the uranium contamination vary with sample size. Aliquots of bulk material were also resuspended in an exposure chamber to produce six samples of respirable particles that were obtained using a cascade impactor. Samples of removable surface contamination were collected by wiping 100 cm of the interior surfaces of the exposure chamber with 47-mm-diameter fiber filters. Uranium contamination in each of the samples was measured directly using high-resolution gamma ray spectrometry. As expected, results for isotopic uranium (i.e., U and U) measured with the large-mass and small-mass samples are significantly different (p < 0.001), and the coefficient of variation (COV) for the small-mass samples was greater than for the large-mass samples. The uranium isotopic concentrations measured in the air and on the wipe samples were not significantly different and were also not significantly different (p > 0.05) from results for the large- or small-mass samples. Large-mass samples are more reliable for characterizing heterogeneously distributed radiological contamination than small-mass samples since they exhibit the least variation compared to the mean. Thus, samples should be sufficiently large in mass to insure that the results are truly representative of the heterogeneously distributed uranium contamination present at the facility. Monitoring exposure of workers and the public as a result of uranium contamination resuspended during site remediation should be evaluated using samples of sufficient size and type to accommodate the heterogeneous distribution of uranium in the bulk material.

Impact of an oncology pharmacist attendance at a multidisciplinary lung clinic

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Background: Medication misadventure contributes to unplanned hospital admissions in patients with cancer. Often, numerous medications are added to existing ones and general practitioners (GP) may lack experience in managing problems involving cancer related medication. A survey exploring the unmet needs of our lung cancer outpatients highlighted the need for more medication information. Inpatient clinical pharmacy services are known to impact on patient care and morbidity. This project aimed to evaluate the effects of extending this service to outpatients. Methods: An oncology pharmacist joined the lung cancer clinic team for 6 months. Consented patients completed assessments of medication adherence (using Morisky tool) and satisfaction with medicines information at baseline and within 30 days of review. Post pharmacist review, a medication list and plan (detailing recommendations/interventions) were provided to patients and community and hospital healthcare providers. Uptake of recommendations was evaluated 7 days after review. Assessment results (pre and post review) were analyzed using the matched pairs Wilcoxon test. Interventions were categorized and graded according to risk avoided. Unplanned admissions and clinic attendance rates were compared to the previous year and analyzed using the Rate Ratio Test assuming Poisson counts.GPs opinion of the service was evaluated via survey. Ethics approval was obtained from HREC. The project was supported by an educational grant from Roche Pharmaceuticals. Results: 48 patients were recruited. Medication adherence (p=0.007) and patient satisfaction (p<0.001) were significantly improved. 154 pharmacist interventions were made: 4.5% extreme risk and 43.5% high risk. Ratios of unplanned admissions and clinic attendances decreased; 0.3 to 0.26 (p= 0.265) and 3.32 to 2.98 (p=0.004) respectively. 31 of 48 general practitioners (GPs) completed the survey, 74% found the service useful. Conclusions: Adding a pharmacist to the outpatient lung team led to significant improvements in patient medication adherence. Both patients and GPs were highly satisfied with the service. Medication misadventure, unplanned admissions and clinic attendances were reduced.

Checklist model to improve work practices in small-scale demolition operations with silica dust exposures

A systematic approach was developed to review, revise and adapt existing exposure control guidance used in developed countries for use in developing countries. One-page employee and multiple-page supervisor guidance sheets were adapted from existing documents using a logic framework and workers were trained to use the information to improve work practices. Interactive, hands-on training was delivered to 26 workers at five small-scale demolition projects in Maputo City, Mozambique, and evaluated. A pre-and-post walkthrough survey used by trained observers documented work practice changes. Worker feedback indicated that the training was effective and useful. Workers acquired knowledge (84% increase, p < 0.01) and applied the work practice guidance. The difference of proportions between use of work practice components before and after the intervention was statistically significant (p < 0.05). Changes in work practices following training included preplanning, use of wet methods and natural ventilation and end-of-task review. Respirable dust measurements indicated a reduction in exposure following training. Consistency in observer ratings and observations support the reliability and validity of the instruments. This approach demonstrated the short-term benefit of training in changing work practices; follow-up is required to determine the long-term impact on changes in work practices, and to evaluate the need for refresher training.

Cadmium and lung cancer mortality accounting for simultaneous arsenic exposure

OBJECTIVES

Prior investigations identified an association between airborne cadmium and lung cancer but questions remain regarding confounding by arsenic, a well-established lung carcinogen.

METHODS

A cadmium smelter population exhibiting excess lung cancer was re-analysed using a retrospective exposure assessment for arsenic (As), updated mortality (1940-2002), a revised cadmium (Cd) exposure matrix and improved work history information.

RESULTS

Cumulative exposure metrics for both cadmium and arsenic were strongly associated making estimation of their independent effects difficult. Standardised mortality ratios (SMRs) were modelled with Poisson regression with the contribution of arsenic to lung cancer risk constrained by exposure-response estimates previously reported. The results demonstrate (1) a statistically significant effect of Cd independent of As (SMR=3.2 for 10 mg-year/m(3) Cd, p=0.012), (2) a substantial healthy worker effect for lung cancer (for unexposed workers, SMR=0.69) and (3) a large deficit in lung cancer mortality among Hispanic workers (SMR=0.27, p=0.009), known to have low lung cancer rates. A supralinear dose-rate effect was observed (contribution to risk with increasing exposure intensity has declining positive slope). Lung cancer mortality was somewhat better predicted using a cadmium burden metric with a half-life of about 20-25 years.

CONCLUSIONS

These findings support an independent effect for cadmium in risk of lung cancer mortality. 1/1000 excess lifetime risk of lung cancer death is predicted from an airborne exposure of about 2.4 μg/m(3) Cd.

The exposure metric: does including time since exposure in the calculation of working lifetime exposure provide a better understanding of disease risk than the cumulative exposure?

BACKGROUND

When exposure measurements are available for occupational epidemiology studies, the cumulative exposure (the sum of the products of duration and exposure intensity at all jobs) is generally selected as the summary metric for chronic diseases. For silica exposures, a metric that weights each exposure by the number of years since it occurred has been suggested as more biologically relevant. Comparative reports of analyses using both metrics have not been found in the literature, however.

METHODS

We calculated both metrics for silica exposure, and evaluated exposure-response relations for lung cancer and silicosis in two separate case-control studies.

RESULTS

Generally the results were consistent, due to the high correlation between the two metrics and the fact that the rate of time away from work during the employment years was low.

CONCLUSION

The significant relation between exposure and silicosis using the weighted metric provides additional point estimates of risk, adding to the understanding of exposure-response.

Occupational exposure to trichloroethylene and cancer risk for workers at the Paducah Gaseous Diffusion Plant

OBJECTIVE

The Paducah Gaseous Diffusion Plant (PGDP) became operational in 1952; it is located in the western part of Kentucky. We conducted a mortality study for adverse health effects that workers may have suffered while working at the plant, including exposures to chemicals.

MATERIALS AND METHODS

We studied a cohort of 6820 workers at the PGDP for the period 1953 to 2003; there were a total of 1672 deaths to cohort members. Trichloroethylene (TCE) is a specific concern for this workforce; exposure to TCE occurred primarily in departments that clean the process equipment. The Life Table Analysis System (LTAS) program developed by NIOSH was used to calculate the standardized mortality ratios for the worker cohort and standardized rate ratio relative to exposure to TCE (the U.S. population is the referent for ageadjustment). LTAS calculated a significantly low overall SMR for these workers of 0.76 (95% CI: 0.72-0.79). A further review of three major cancers of interest to Kentucky produced significantly low SMR for trachea, bronchus, lung cancer (0.75, 95% CI: 0.72-0.79) and high SMR for Non-Hodgkin's lymphoma (NHL) (1.49, 95% CI: 1.02-2.10).

RESULTS

No significant SMR was observed for leukemia and no significant SRRs were observed for any disease. Both the leukemia and lung cancer results were examined and determined to reflect regional mortality patterns. However, the Non-Hodgkin's Lymphoma finding suggests a curious amplification when living cases are included with the mortality experience.

CONCLUSIONS

Further examination is recommended of this recurrent finding from all three U.S. Gaseous Diffusion plants.