Monitoring and reducing exposure of infants to pollutants in house dust

The health risks to babies from pollutants in house dust may be 100 times greater than for adults. The young ingest more dust and are up to ten times more vulnerable to such exposures. House dust is the main exposure source for infants to allergens, lead, and PBDEs, as well as a major source of exposure to pesticides, PAHs, Gram-negative bacteria, arsenic, cadmium, chromium, phthalates, phenols, and other EDCs, mutagens, and carcinogens. Median or upper percentile concentrations in house dust of lead and several pesticides and PAHs may exceed health-based standards in North America. Early contact with pollutants among the very young is associated with higher rates of chronic illness such as asthma, loss of intelligence, ADHD, and cancer in children and adults. The potential of infants, who live in areas with soil contaminated by automotive and industrial emissions, can be given more protection by improved home cleaning and hand washing. Babies who live in houses built before 1978 have a prospective need for protection against lead exposures; homes built before 1940 have even higher lead exposure risks. The concentration of pollutants in house dust may be 2-32 times higher than that found in the soil near a house. Reducing infant exposures, at this critical time in their development, may reduce lifetime health costs, improve early learning, and increase adult productivity. Some interventions show a very rapid payback. Two large studies provide evidence that home visits to reduce the exposure of children with poorly controlled asthma triggers may return more than 100% on investment in 1 yr in reduced health costs. The tools provided to families during home visits, designed to reduce dust exposures, included vacuum cleaners with dirt finders and HEPA filtration, allergy control bedding covers, high-quality door mats, and HEPA air filters. Infants receive their highest exposure to pollutants in dust at home, where they spend the most time, and where the family has the most mitigation control. Normal vacuum cleaning allows deep dust to build up in carpets where it can be brought to the surface and become airborne as a result of activity on the carpet. Vacuums with dirt finders allow families to use the three-spot test to monitor deep dust, which can reinforce good cleaning habits. Motivated families that receive home visits from trained outreach workers can monitor and reduce dust exposures by 90% or more in 1 wk. The cost of such visits is low considering the reduction of risks achieved. Improved home cleaning is one of the first results observed among families who receive home visits from MHEs and CHWs. We believe that proven intervention methods can reduce the exposure of infants to pollutants in house dust, while recognizing that much remains to be learned about improving the effectiveness of such methods.

Misdiagnosis of symptomatic cerebral aneurysm. Prevalence and correlation with outcome at four institutions

BACKGROUND AND PURPOSE

It is not known what fraction of patients with symptomatic cerebral aneurysms are misdiagnosed at initial medical presentation. It is also not clear whether misdiagnosed patients more frequently deteriorate before definitive aneurysm diagnosis and therapy or achieve a poorer outcome than correctly diagnosed patients.

METHODS

We reviewed records of consecutive patients with symptomatic cerebral aneurysms managed by four tertiary-care neurosurgical services during a recent 19-month period. Clinical course and outcome were analyzed according to misdiagnosis or correct diagnosis at initial medical evaluation.

RESULTS

Fifty-four of 217 patients (25%) were misdiagnosed at initial medical evaluation, including 46 of 121 patients (38%) initially in good clinical condition (clinical grade 1 or 2). Forty-six of 54 patients (85%) in the misdiagnosis group were initially grade 1 or 2 compared with 75 of 163 patients (46%) with correct initial diagnosis (P < .01). Twenty-six of 54 misdiagnosed patients (48%) deteriorated or rebled before definitive aneurysm treatment compared with 4 of 165 correctly diagnosed patients (2%) (P < .001). Among patients initially presenting as clinical grade 1 or 2, overall good or excellent outcome was achieved in 91% of those with correct initial diagnosis and 53% of patients with initial misdiagnosis (P < .001). Deterioration before correct diagnosis accounted for 16 of 67 patients (24%) with poor or worse final outcome in this series.

CONCLUSIONS

Patients in good clinical condition with symptomatic cerebral aneurysms were commonly misdiagnosed. Misdiagnosed patients were more likely than correctly diagnosed patients to deteriorate clinically and had a worse overall outcome. Misdiagnosed cases accounted for a significant fraction of overall poor outcomes among consecutive cases of symptomatic aneurysms.

Exposure of children to pollutants in house dust and indoor air

This review summarizes occurrence and exposure studies for pollutants in house dust and related indoor air exposures. A standard sampling method and control methods to reduce these exposures are discussed, including recommendations for future research. Infants and toddlers receive a broad and significant range of exposures to lead, pesticides, PAHs, allergens, and VOCs in house dust and indoor air. Carpet dust in eight Columbus and nine Seattle homes contained concentrations of potentially carcinogenic PAHs ranging from 3 to 290 micrograms/g, of lead from 250 to 2250 micrograms/g, and of PCBs from 210 to 1900 ng/g. Dust collected from ten used sofas in Seattle averaged 16.3, 37.2, and 229 micrograms/g for dust mite allergen, cat allergen, and lead, respectively; dust samples showed mutagenic activity. Biological and chemical pollutants in indoor dust and air have been associated with lead poisoning, cancer, allergy, asthma, damage to the nervous system, and sick building symptoms. The 11% of toddlers who have pica tend to have the highest exposures and risks. Further, the exposure of toddlers to lead via the dust pathway can be greater than by other routes. Standard method ASTM 5438.94 for sampling house dust has been used to characterize current and chronic exposure of toddlers in epidemiological studies. The accumulation of dust, dust mites, and tracked-in soil in old carpets, sofas, and mattresses appears to be a major source of exposure to lead, pesticides, allergens, PAHs, and VOCs. Remodeling and energy conservation can reduce ventilation and increase relative humidity, dust, dust mites, molds, VOCs, and other indoor air pollutants. The U.S. faces large and increasing costs from asthma and allergy. Asthma incidence in the U.S. has increased from 0.5% in 1930 to 8%-12% in 1991. Asthma hospitalization rates for children are increasing at the rate of 4%/yr in the U.S. and 14%/yr in Seattle. Such hospital visits would be rare with effective diagnosis, patient education, and control of home exposures. Asthma was estimated to cost $6.2 billion in 1990; hospital visits of children in Seattle cost $2,526,000 in 1993. Forty percent of the U.S. population has been sensitized to allergens; one in three homes has high relative humidity, which favors dust mites, molds, allergies, asthma, and other respiratory diseases. Reducing indoor allergens can reduce costs, severity, and the risk of being sensitized and developing allergic disease. Use of volunteer Master Home Environmentalists to do free in-home surveys and education in Seattle may reduce immediate health costs from allergens as well as long-term risks from lead, carcinogens, and home chemicals.(ABSTRACT TRUNCATED AT 400 WORDS)

Intracranial aneurysms: size, risk of rupture, and prophylactic surgical treatment

Intracranial saccular aneurysms frequently cause devastating neurologic injury when they rupture. With recent improvements in diagnostic imaging, however, an increasing number of aneurysms are now diagnosed in the unruptured state. Controversy exists regarding the appropriate management of these lesions. We have retrospectively examined a group of 86 patients from Connecticut with 104 intracranial aneurysms to determine whether small (less than 10 mm in greatest diameter) aneurysms have potential for rupture, and whether there is a role for prophylactic surgical therapy for these unruptured aneurysms. The majority of ruptured and unruptured aneurysms in the series measured less than 10 mm in greatest diameter. Out of a total of 82 patients who underwent surgical therapy, 44 had surgery for unruptured aneurysms. The major surgical morbidity in this group was 2%. We conclude that surgical therapy for small unruptured intracranial aneurysms may be beneficial since these lesions likely have substantial potential for rupture and because surgical treatment carries an acceptable risk.

Comparison of a modified (two-item) Frisby with the standard Frisby and Random-Dot E stereotests when used with preschool children

The purpose of this study was to assess the clinical value of the standard Frisby stereotest with young children, and the effects of modifying the standard Frisby to a two-item, forced-choice format. A description of the modified test is presented along with data that indicate the standard Frisby and Random-Dot E (RDE) stereotests are appropriate for children as young as age 30 months; both instruments yield similar results; and the modified two-item Frisby extends the applicability of the test to even younger and/or less communicative children.