Perfluoroalkyl Substance Serum Concentrations and Cholesterol Absorption-Inhibiting Medication Ezetimibe

BACKGROUND

Per- and polyfluoroalkyl substances (PFAS) are human-made compounds with a widespread presence in human blood and other organs. PFAS have been associated with multiple health effects, including higher serum cholesterol and LDL cholesterol.

OBJECTIVE

Potential population differences in serum PFAS attributable to ezetimibe, a medication that inhibits cholesterol absorption, are of interest for several reasons. The "C8" Health Project survey data from six contaminated water districts in the mid-Ohio Valley of the United States provide a wide enough range of serum PFAS and a sufficient number of ezetimibe takers to explore this topic.

METHODS

A total of 44,126 adult participants of the C8 Health Survey were included in the community-based study. The status of taking (1075) or non-taking of ezetimibe, alone or in combination with another lipid-lowering agent, was acquired. The geometric mean serum concentrations of the four most commonly detected serum PFAS were compared based on the status of ezetimibe use.

RESULTS

There is no significant difference in serum concentrations of perfluorohexanesulfonic acid (PFHxS), perfluorooctanoic acid (PFOA), perfluorooctanesulfonic acid (PFOS), and perfluorononanoic acid (PFNA) between ezetimibe users and non-users after adjustment for age, sex, body mass index, estimated glomerular filtration rate (eGFR), cigarette smoking, education, and average household income.

CONCLUSION

The sterol absorption-inhibiting medication ezetimibe does not appear to affect serum PFAS concentrations. We sought but did not find direct evidence that ezetimibe could inhibit PFAS uptake nor inferential evidence that inter-individual differences in sterol absorption could provide a confounding factor explanation for the association of serum total- and LDL-cholesterol with serum PFAS.

Associations of serum perfluoroalkyl substances with concentrations of blood manganese and selenium

The aim of this study was to estimate the associations of blood manganese and selenium with serum concentrations of selected perfluoroalkyl substances (PFAS). The presence or absence of this association is important because PFAS have documented pro-oxidant properties, whereas manganese and selenium are critical to antioxidant responses. For this purpose, the data from NHANES for US adults aged ≥ 20 years (N = 3982), adolescents aged 12-19 years (N = 1524), and children aged 3-11 years (N = 639) were analyzed. Among adults, concentrations of blood manganese were found to be inversely associated with serum concentrations of perfluorooctanoic acid or PFOA (β =  - 0.04204, p < 0.01), perfluorononanoic acid or PFNA (β =  - 0.02700, p < 0.01), perfluorohexane sulfonate or PFHxS (β =  - 0.04306, p < 0.01), and perfluorooctane sulfonate or PFOS (β =  - 0.04494, p < 0.01). Blood concentrations of selenium were found to be positively associated with PFHxS only among adults (β = 0.000678, p = 0.047) and adolescents (β = 0.01377, p = 0.02). The Mn results but not the less consistent Se associations were robust to adjustments for serum albumin. Possible reasons for the inverse association of PFOA, PFHxS, PFNA, and PFOS with Mn among US adults are discussed. The finding raises concerns about manganese's diminished ability to mount antioxidant responses to PFAS exposure.

Associations between the concentrations of α-klotho and selected perfluoroalkyl substances in the presence of eGFR based kidney function and albuminuria: Data for US adults aged 40-79 years

Exposures to per- and polyfluoroalkyl substances (PFAS) cause oxidative stress, a risk factor for tissue damage leading to kidney and cardiovascular diseases. The antiaging protein klotho is known to act as an anti-oxidative agent, and how klotho homeostasis interacts with PFAS has not been reported. This study among 3981 US adults aged 40-79 years old evaluated relationships of internal PFAS contamination to α-klotho across stages of estimated glomerular filtration rate or eGFR-based kidney function and albuminuria defined as urinary albumin creatinine ratio of >30 mg/g creatinine. In the absence of albuminuria and when eGFR based kidney function was in stage GF-1 (eGFR ≥ 90 mL/min/1.73 m²), statistically significant inverse associations between α-klotho and PFNA (β = -0.04930, p < 0.01), PFDA (β = -0.03307, p = 0.02), and PFUnDA (β = -0.03451, p = 0.01), PFHxS (β = -0.03011, p = 0.04) and PFOS (β = -0.03126, p = 0.03) were noted. No associations between α-klotho and PFAS were observed when kidney function was in stages GF-2 (60 ≤ eGFR < 90 mL/min/1.73 m²) or GF-3A (45 ≤ eGFR < 60 mL/min/1.73 m²) in the presence or absence of albuminuria. Unexpectedly, however, in the absence of albuminuria, with kidney function in stage GF-3B/4 (15 ≤ eGFR < 45 mL/min/1.73 m²), associations were positive between α-klotho and PFOA (β = 0.20989, p < 0.01), PFNA (β = 0.18373, p < 0.1), PFDA (β = 0.20413, p < 0.01), PFUnDA (β = 0.17660, p < 0.01), and PFOS (β = 0.14267, p < 0.01). The inverse relationship of PFAS to the antioxidant protein α-klotho in those with healthy kidney function has not been previously reported and should be evaluated in other populations.

Do hospital workers experience a higher risk of respiratory symptoms and loss of lung function?

Background

Hospital work environment contains various biological and chemical exposures that can affect indoor air quality and have impact on respiratory health of the staff. The objective of this study was to investigate potential effects of occupational exposures on the risk of respiratory symptoms and lung function in hospital work, and to evaluate potential interaction between smoking and occupational exposures.

Methods

We conducted a cross-sectional study of 228 staff members in a hospital and 228 employees of an office building as the reference group in Shiraz, Iran. All subjects completed a standardized ATS respiratory questionnaire and performed a spirometry test.

Results

In Poisson regression, the adjusted prevalence ratios (aPR) among the hospital staff were elevated for cough (aPR 1.90, 95% CI 1.15, 3.16), phlegm production (aPR 3.21, 95% CI 1.63, 6.32), productive cough (aPR 2.83, 95% CI 1.48, 5.43), wheezing (aPR 3.18, 95% CI 1.04, 9.66), shortness of breath (aPR 1.40, 95% CI 0.93, 2.12), and chest tightness (aPR 1.73, 95% CI 0.73, 4.12). Particularly laboratory personnel experienced increased risks of most symptoms. In linear regression adjusting for confounding, there were no significant differences in lung function between the hospital and office workers. There was an indication of synergism between hospital exposures and current smoking on FEV1/FVC% (interaction term β = − 5.37, 95% CI − 10.27, − 0.47).

Conclusions

We present significant relations between hospital work, especially in laboratories, and increased risks of respiratory symptoms. Smoking appears to enhance these effects considerably. Our findings suggest that policymakers should implement evidence-based measures to prevent these occupational exposures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02098-5.

Official health communications are failing PFAS-contaminated communities

BACKGROUND

Environmental health agencies are critical sources of information for communities affected by chemical contamination. Impacted residents and their healthcare providers often turn to federal and state agency webpages, fact sheets, and other documents to weigh exposure risks and interventions.

MAIN BODY

This commentary briefly reviews scientific evidence concerning per- and polyfluoroalkyl substances (PFAS) for health outcomes that concern members of affected communities and that have compelling or substantial yet differing degree of scientific evidence. It then features official documents in their own language to illustrate communication gaps, as well as divergence from scientific evidence and from best health communication practice. We found official health communications mostly do not distinguish between the needs of heavily contaminated communities characterized by high body burdens and the larger population with ubiquitous but substantially smaller exposures. Most health communications do not distinguish levels of evidence for health outcomes and overemphasize uncertainty, dismissing legitimate reasons for concern in affected communities. Critically, few emphasize helpful approaches to interventions. We also provide examples that can be templates for improvement.

CONCLUSIONS

Immediate action should be undertaken to review and improve official health communications intended to inform the public and health providers about the risks of PFAS exposure and guide community and medical decisions.

Perfluoroalkyl Substances and Abdominal Aortic Calcification

OBJECTIVE

To evaluate if serum perfluoroalkylated substances (PFAS) were associated with abdominal aortic calcification (AAC).

METHODS

We used weighted logistic regression to investigate the gender-specific association between PFAS serum levels and AAC more than or equal to 6 from dual-energy X-ray absorptiometry (DXA) scans of the thoraco-lumbar spine from National Health and Nutrition Examination Survey 2013-2014 survey participants aged more than or equal to 40 years.

RESULTS

After adjusting for confounding, none of log-transformed perfluorooctanoic acid (PFOA), perfluorooctane sulfonate (PFOS), perfluorohexane sulfonic acid (PFHxS), or perfluorononanoic acid (PFNA) were significantly associated with AAC for either men or women (adjusted odds ratios [ORs] ranged from 0.80 to 1.33, P  > 0.05 each). For PFOA and PFOS, the association was positive only in women (although the difference was not statistically significant in either case).

CONCLUSION

These findings do not provide general support for a relationship of PFAS exposure to AAC, although the results show a need for gender-specific consideration in a larger dataset.

Per- and Polyfluoroalkyl Substance and Cardio Metabolic Markers in Firefighters

OBJECTIVE

To evaluate if serum polyfluoroalkyl substances (PFAS) were associated with cardiometabolic markers.

METHODS

Serum PFAS were evaluated in 38 Arizona firefighters and 49 participants from the 2009 to 2010 National Health and Nutrition Examination Survey (NHANES). Cardiometabolic markers including carotid intima-medial thickness (CIMT) were measured in the firefighters.

RESULTS

Firefighters had elevated perfluorohexane sulfonic acid (PFHxS) and lower perfluorononanoic acid (PFNA) and perfluoroundecanoic acid (PFUA) compared to NHANES participants; for nine of the other 12 PFAS the values were not significantly different. There were significant negative associations among firefighters between perfluorodecanoic acid (PFDeA) and total cholesterol and PFUA and interleukin-6. PFAS concentrations were not associated with CIMT.

CONCLUSION

PFHxS levels were elevated in firefighters compared to NHANES subjects. Serum PFAS concentrations were not associated with increased cardiometabolic risk measures in this population of firefighters.

Perfluoroalkyl substance excretion: Effects of organic anion-inhibiting and resin-binding drugs in a community setting

BACKGROUND

Longer serum half-lives of perfluoroalkyl substances (PFAS) in humans compared to other species has been attributed to differences in the activity of organic anion transporters (OAT).

METHODS

Among 56,175 adult participants in the community-based C8 Health Project, 23 subjects were taking the uricosuric OAT-inhibitor probenecid, and 36 subjects were taking the bile acid sequestrant cholestyramine. In regression models of log transformed serum PFAS, medication effects were estimated in terms of mean ratios, adjusting for age, gender, BMI, estimated glomerular filtration rate (eGFR) and water-district of residence.

RESULTS

Probenecid was associated with modest, but not statistically significant increases in serum PFAS concentrations. In contrast, cholestyramine significantly lowered serum PFAS concentrations, notably for perfluorooctane sulfonic acid (PFOS).

CONCLUSIONS

The effectiveness of cholestyramine in a community setting supports the importance of gastrointestinal physiology for PFAS excretion kinetics, especially for PFOS. We did not find clear evidence that probenecid, an inhibitor of OAT, affects PFAS clearance.

Per- and Polyfluoroalkyl Substance Toxicity and Human Health Review: Current State of Knowledge and Strategies for Informing Future Research

Reports of environmental and human health impacts of per- and polyfluoroalkyl substances (PFAS) have greatly increased in the peer-reviewed literature. The goals of the present review are to assess the state of the science regarding toxicological effects of PFAS and to develop strategies for advancing knowledge on the health effects of this large family of chemicals. Currently, much of the toxicity data available for PFAS are for a handful of chemicals, primarily legacy PFAS such as perfluorooctanoic acid and perfluorooctane sulfonate. Epidemiological studies have revealed associations between exposure to specific PFAS and a variety of health effects, including altered immune and thyroid function, liver disease, lipid and insulin dysregulation, kidney disease, adverse reproductive and developmental outcomes, and cancer. Concordance with experimental animal data exists for many of these effects. However, information on modes of action and adverse outcome pathways must be expanded, and profound differences in PFAS toxicokinetic properties must be considered in understanding differences in responses between the sexes and among species and life stages. With many health effects noted for a relatively few example compounds and hundreds of other PFAS in commerce lacking toxicity data, more contemporary and high-throughput approaches such as read-across, molecular dynamics, and protein modeling are proposed to accelerate the development of toxicity information on emerging and legacy PFAS, individually and as mixtures. In addition, an appropriate degree of precaution, given what is already known from the PFAS examples noted, may be needed to protect human health. Environ Toxicol Chem 2021;40:606-630. © 2020 SETAC.

Weather Conditions and COVID-19 Incidence in a Cold Climate: A Time-Series Study in Finland

Background: The current coronavirus disease 2019 (COVID-19) is spreading globally at an accelerated rate. There is some previous evidence that weather may influence the incidence of COVID-19 infection. We assessed the role of meteorological factors including temperature (T) and relative humidity (RH) considering the concentrations of two air pollutants, inhalable coarse particles (PM₁₀) and nitrogen dioxide (NO₂) in the incidence of COVID-19 infections in Finland, located in arctic-subarctic climatic zone.

Methods: We retrieved daily counts of COVID-19 in Finland from Jan 1 to May 31, 2020, nationwide and separately for all 21 hospital districts across the country. The meteorological and air quality data were from the monitoring stations nearest to the central district hospital. A quasi-Poisson generalized additional model (GAM) was fitted to estimate the associations between district-specific meteorological factors and the daily counts of COVID-19 during the study period. Sensitivity analyses were conducted to test the robustness of the results.

Results: The incidence rate of COVID-19 gradually increased until a peak around April 6 and then decreased. There were no associations between daily temperature and incidence rate of COVID-19. Daily average RH was negatively associated with daily incidence rate of COVID-19 in two hospital districts located inland. No such association was found nationwide.

Conclusions: Weather conditions, such as air temperature and relative humidity, were not related to the COVID-19 incidence during the first wave in the arctic and subarctic winter and spring. The inference is based on a relatively small number of cases and a restricted time period.

Occupational exposures and respiratory symptoms and lung function among hairdressers in Iran: a cross-sectional study

Objective

Exposures at hairdressers’ work have been reported to lead to an increased risk of several health outcomes. The present study aimed to investigate the relations between occupational exposures and respiratory symptoms and lung function among hairdressers in Iran.

Methods

We conducted a cross-sectional study to compare potential respiratory effects among 140 women working as hairdressers to such effects among 140 women working as office workers (administrative personnel). Both groups worked in Shiraz, Iran. Respiratory symptoms were assessed by a standard respiratory questionnaire. The questionnaire also inquired about substances used and workspace conditions, including ventilation type. Lung function levels were measured by spirometry.

Results

Respiratory symptoms, including cough, wheezing, shortness of breath, and chest tightness were significantly more frequent in hairdressers compared to the reference group (p < 0.05). After controlling for potential confounders, hairdressers had a prevalence ratio (PR) of 2.18 (95% CI 1.26–3.77) for cough, 9.59 (95% CI 1.004–91.73) for wheezing, 2.06 (95% CI 1.25–3.39) for shortness of breath, and 3.31 (95% CI 1.84–5.97) for chest tightness compared to the reference group. Lung function parameters (including VC, FVC, and FEV1) were significantly reduced in hairdressers (p < 0.001). Absence of air conditioning predicted greater reduction in lung function (p < 0.05) in the exposed. Decrease in FVC with normal FEV1/FVC in the exposed group suggested existence of restrictive lung function.

Conclusions

This study provides evidence of increased prevalence of respiratory symptoms and restrictive lung function impairment among hairdressers in Iran.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00420-020-01645-z.

Occurrence of respiratory symptoms and lung function deficits among fruit and vegetable market workers

OBJECTIVE

The objective of this study was to investigate the potential effects of occupational exposures among fruit and vegetable market workers on the occurrence of respiratory symptoms and on the level of lung function parameters.

METHODS

We conducted a cross-sectional study of 140 men working as fruit and vegetable market workers (response rate 100%) and a reference group of 77 male office workers as the reference group (response rate 55%) from Shiraz, Iran. The outcomes of interest included occurrence of respiratory symptoms assessed by a standard respiratory questionnaire and lung function assessed by spirometry.

RESULTS

In Poisson regression analyses, the exposed group showed increased prevalence ratio (PR) of wheezing (adjusted PR 5.32, 95% CI 1.40 to 20.26), after controlling for confounding. Cough (PR 3.30, 95% CI 1.16 to 9.40) and wheezing (PR 9.40, 95% CI 2.28 to 38.64) showed increased PRs among vegetable distributors. Forced expiratory volume in 1 s (FEV₁) and FEV₁/forced vital capacity were significantly decreased among exposed workers after controlling for confounders. The absolute value of FEV₁ level was reduced significantly among fruit and vegetable carters (-0.99, 95% CI -1.68 to -0.32) and vegetable (-0.51, 95% CI -0.93 to -0.10) and fruit (-0.51, 95% CI -0.86 to -0.15) distributors in comparison with the reference group in the adjusted full model.

CONCLUSIONS

This study provides evidence that fruit and vegetable market workers are at an increased risk of respiratory symptoms and reduced lung function. Workplace conditions and safety training clearly need improvement, and there is a likely role for proper use of personal protective equipment.

Associations between apolipoprotein B and selected perfluoroalkyl substances among diabetics and nondiabetics

Previous population investigation of perfluoroalkyl substances (PFAS) features associations with lipids in a number of populations; these investigations have seldom included consideration of apolipoproteins. Apolipoprotein B (Apo B) fractions were considered in this descriptive analysis because they are essential to the assembly, transport, and cellular uptake of lipid classes associated with poorer health outcomes, and they are associated with incident and prevalent disease. Regression models stratified by diabetes and lipid lowering medication (LLM) status for data from National Health and Nutrition Examination Survey for 2007-2014 were fitted to interrogate associations between selected PFAS and Apo B for US adults aged ≥ 20 years. Adjusted concentrations of Apo B were positively associated with perfluorooctanoic acid (PFOA β = 0.03878, p < 0.01), perfluorooctane sulfonic acid (PFOS β = .02029, p = 0.02), and perfluorononanoic acid (PFNA β = .01968, p = .03) for nondiabetics who were not taking lipid lowering medications. These associations were not seen among diabetic participants, except for perfluorodecanoic acid (PFDA) in those taking LLMs (β = 0.03831, p = 0.02). We also note that LLMs have an inferred greater impact on Apo B in the diabetics compared to the nondiabetic populations. We have considered several sources of confounding and think the data are most consistent with a weak causal association that PFAS exposure increases Apo B. The rodent toxicology literature also contains evidence that PFAS disrupt fatty acid trafficking including Apo B, although how the specific findings may relate to circulating human Apo B concentrations is unclear. We therefore advocate for attempts to replicate the findings in other populations and to consider additional types of mechanistic studies.

The Value Proposition for Pathologists: A Population Health Approach

The transition to a value-based payment system offers pathologists the opportunity to play an increased role in population health by improving outcomes and safety as well as reducing costs. Although laboratory testing itself accounts for a small portion of health-care spending, laboratory data have significant downstream effects in patient management as well as diagnosis. Pathologists currently are heavily engaged in precision medicine, use of laboratory and pathology test results (including autopsy data) to reduce diagnostic errors, and play leading roles in diagnostic management teams. Additionally, pathologists can use aggregate laboratory data to monitor the health of populations and improve health-care outcomes for both individual patients and populations. For the profession to thrive, pathologists will need to focus on extending their roles outside the laboratory beyond the traditional role in the analytic phase of testing. This should include leadership in ensuring correct ordering and interpretation of laboratory testing and leadership in population health programs. Pathologists in training will need to learn key concepts in informatics and data analytics, health-care economics, public health, implementation science, and health systems science. While these changes may reduce reimbursement for the traditional activities of pathologists, new opportunities arise for value creation and new compensation models. This report reviews these opportunities for pathologist leadership in utilization management, precision medicine, reducing diagnostic errors, and improving health-care outcomes.

Perfluoroalkyl acids and thyroid hormones across stages of kidney function

Data for US adults aged ≥20 years for 2007-2012 (N = 7020) were used to study concentrations of thyroid stimulating hormone (TSH), free (FT3) and total triiodothyronine (TT3), free (FT4) total thyroxine (TT4), and thyroglobulin (TGN) across stages of glomerular function (GF). Data for 2007-2008 and 2011-2012 (N = 2549) were used to study associations between thyroid hormone biomarkers and five serum perfluoroalkyl acids (PFAAs). We report how thyroid hormone biomarkers vary in human serum across stages of GF. Stages considered were: GF-1 (normal, eGFR >90 mL/min/1.73 m²), GF-2 (60 ≤ eGFR≤90 mL/min/1.73 m²), GF-3A (45 ≤eGFR<60 mL/min/1.73 m²), and GF-3B/4 (15 ≤ eGFR<45 mL/min/1.73 m²). Regression models stratified by GF stages were fitted to evaluate associations between the concentrations of selected PFAAs and thyroid hormones and to evaluate the variability in concentrations of thyroid hormones across the stages of GF. Adjusted geometric means (AGM) for TSH sharply increased from GF-1 (1.34 μIU/mL) to GF-2 (1.58 μIU/mL) and then remained relatively stable. AGMs of FT3 and TT3 decreased consistently from GF-1 to GF-3B/4; from 3.24 to 2.79 pg/mL for FT3 and from 115.7 to 96.4 ng/dL for TT3. AGMs for FT4 increased from GF-2 onward. TGN increased as glomerular filtration worsened from GF-1 through GF-3B/4. In contrast to strong relationships of thyroid hormone markers to stages of renal function, only scattered, inconsistent findings characterized relationship of PFAAs to thyroid markers across stages of kidney disease. For example, TSH was positively associated with PFOA at GF-2 (β = 0.08522, p < 0.01) but negatively associated at GF-3A (β = - 0.22926, p = 0.04). Thus, associations between kidney disease and thyroid hormone are clear, but the relationships between PFAAs and thyroid hormones vary inconsistently from stage to stage and reveal no trend. For thyroid hormone investigations, we conclude stratification by glomerular function stage is likely not needed.

Participant Reactions to Medical Screening: A Survey of Satisfaction With the C8 (PFOA) Health Project

We report participant perceptions of the 2005–2006 C8 Health Project, a massive medical monitoring effort in response to perfluorooctanoic acid (C8) in West Virginia and Ohio. The C8 Health Project consisted of a health survey ( n = 69,030), blood testing for ten per- and polyfluoroalkyl substances, and 50+ laboratory tests ( n = 66,899). A randomly selected subgroup was surveyed in 2007 on (1) demographics (2) satisfaction with the project, and (3) perceptions of outcomes such as contribution to personal/family, community health, and links to health outcomes. The response rate was 573/1500 (38.2 percent). Most (92.7 percent) characterized their participation experience as “excellent” or “good,” and most (96.2 percent) considered the project very “important,” “important,” or “moderately important.” No demographic variable predicted important changes in satisfaction or perception of project importance. We conclude that responses to the survey indicate strong positive assessments of project benefits.

Perfluoroalkyl acids serum concentrations and their relationship to biomarkers of renal failure: Serum and urine albumin, creatinine, and albumin creatinine ratios across the spectrum of glomerular function among US adults

Associations between selected perfluoroalkyl acids (PFAAs) and biomarkers of renal function were evaluated for US adult aged ≥ 20 years (N = 8220) in the National Health and Nutrition Examination Survey for 2005-2014. Glomerular filtration (GF) stage-stratified regression models were classified by estimated glomerular filtration rate (eGFR) with GF-1 (eGFR > 90 mL/min/1.73 m²), GF-2 (eGFR 60-89 mL/min/1.73 m²), GF-3A (45-59 mL/min/1.73 m²), and GF-3B/4 (15-44 mL/min/1.73 m²). For GF-1, PFOA, PFOS, and PFHxS were positively and significantly associated with serum creatinine. Serum albumin levels were positively associated with the PFAA considered at all stages and most associations were significant. Further, PFAS serum concentration associations to serum albumin were about 2-3 times stronger at GF-3B/4 than at GF-1. In contrast, urine albumin was negatively and significantly associated with PFOA and PFHxS serum concentrations at all stages of renal function, while, PFOS and PFNA were negatively and significantly associated to urine albumin at GF-3A and GF-3B/4. Urine albumin/creatinine ratios were negatively and significantly associated with PFOA, PFOS, and, and PFHxS serum concentrations at all stages of renal function, as well as with PFNA and PFDA at GF-3A and GF-3B/4. Recent work revealed that serum PFAAs have an inverted U-shaped association to the calculated stages of renal failure based on eGFR; this work adds that albuminuria makes additional negative contributions to already existing negative associations of PFAA to eGFR in advancing stages of renal failure. We hypothesize that both progressive renal failure per se and especially renal failure with albuminuria cause the kidneys to reabsorb less and to excrete more of the PFAAs studied. We suspect this finding may generalize to some other perfluoroalkyl substances (PFAS). The findings also imply study design considerations for evaluating associations to diseases and biomarkers associated with renal failure, such as diabetes.

Dynamics of associations between perfluoroalkyl substances and uric acid across the various stages of glomerular function

National Health and Nutrition Examination Survey 2007-2014 data (N = 6844) for adults aged ≥ 20 years were analyzed to estimate associations of perfluoroalkyl substances (PFAS), namely, PFOA, PFOS, PFDA, PFHxS, and PFNA with uric acid across stages of declining glomerular function. The population was stratified by the estimated glomerular filtration rates (eGFR) stages accompanying kidney disease: GF-1 with eGFR > 90 mL/min/1.73 m²; GF-2 with eGFR 60-89 mL/min/1.73 m²; GF-3A with eGFR 45-59 mL/min/1.73 m²; and GF-3B/4 with eGFR 15-44 mL/min/1.73 m². Adjusted and unadjusted geometric means of uric acid increased from GF-1 to GF-3B/4 for males and females. Adjusted geometric means for uric acid were higher for males by 1.38, 1.03, and 0.62 mg/dL for GF-1, GF2, and GF-3 respectively but for GF-3B/4, females had higher adjusted geometric means than males by 0.16 mg/dL, revealing narrowing of sex differences in uric acid as glomerular function declines. The direction of association between PFAS and uric acid was positive for GF-1 and GF-2 for males and for every PFAS except PFDA for females. For males for GF-3B/4, association between every PFAS except PFHxS and uric acid was found to be negative (p < 0.01). For females, only PFHxS actually reverses its relationship with increasing stages of renal disease. Uric acid associations with PFAS reverse in males with advanced renal failure. An implication is that previously reported association of PFAS exposure with uric acid is not due to renal failure. Understanding of other biomarkers associated with both PFAS exposure and renal failure may benefit from similar evaluation.

Environmental perfluoroalkyl acid exposures are associated with liver disease characterized by apoptosis and altered serum adipocytokines

Exposures to perfluoroalkyl substances (PFAS) including perfluoroalkyl acids (PFAAs) are associated with increased liver enzymes in cohort studies including the C8 Health Study. In animal models, PFAAs disrupt hepatic lipid metabolism and induce apoptosis to cause nonalcoholic fatty liver disease (NAFLD). PFAAs are immunotoxic and inhibit pro-inflammatory cytokine release from stimulated leukocytes in vitro. This cross-sectional study tests the hypothesis that environmental PFAAs are associated with increased hepatocyte apoptosis and decreased pro-inflammatory cytokines in serum. Biomarkers previously associated with PFAS exposures and/or NAFLD were evaluated as secondary endpoints. Two hundred adult C8 Health Study participants were included. Measured serum biomarkers included: perfluorohexane sulfonate (PFHxS); perfluorooctanoic acid (PFOA); perfluorooctane sulfonate (PFOS); perfluorononanoic acid (PFNA); cytokeratin 18 M30 (CK18 M30, hepatocyte apoptosis); adipocytokines; insulin; and cleaved complement 3 (C3a). Confounder-adjusted linear regression models determined associations between PFAS and disease biomarkers with cut-offs determined by classification and regression tree analysis. CK18 M30 was positively associated with PFHxS (β = 0.889, p = 0.042); PFOA (β = 2.1, p = 0.005); and PFNA (β = 0.567, p = 0.03). Tumor necrosis factor α (TNFα) was inversely associated with PFHxS (β = -0.799, p = 0.001); PFOA (β = - 1.242, p = 0.001); and PFOS (β = -0.704, p < 0.001). Interleukin 8 was inversely associated with PFOS and PFNA. PFAAs were also associated with sexually dimorphic adipocytokine and C3a responses. Overall, PFAA exposures were associated with the novel combination of increased biomarkers of hepatocyte apoptosis and decreased serum TNFα. These data support previous findings from cohorts and experimental systems that PFAAs may cause liver injury while downregulated some aspects of the immune response. Further studies of PFAAs in NAFLD are warranted and should evaluate sex differences.

Roles of gender and obesity in defining correlations between perfluoroalkyl substances and lipid/lipoproteins

Data from National Health and Nutrition Examination Survey (NHANES) for 2005-2014 for those aged ≥20 years fasting for ≥8 h (N = 3629) were analyzed to evaluate the role that gender and obesity play in defining correlations between selected perfluoroalkyl substances (PFAS) and total cholesterol (TC), low density lipoprotein cholesterol (LDL), high density lipoprotein cholesterol (HDL), and triglycerides. PFAS considered for analyses were: perfluorooctanoic acid (PFOA), perfluorooctane sulfonate (PFOS), perfluorodecanoic acid (PFDA), perfluorononanoic acid (PFNA), perfluorohexane sulfonate (PFHxS), perfluoroundecanoic acid (PFUnDA), and 2-(N-methyl-perfluorooctane sulfonamido) acetic acid (Me-FOSAA). Gender and obesity stratified regression models were fitted to estimate associations between PFAS and lipid/lipoproteins with adjustments made for confounders. For obese males, but not for nonobese males, positive associations were found between TC and LDL with PFOA (β = 0.0519, p = 0.01 for TC and β = 0.0822, p = 0.03 for LDL), and PFNA (β = 0.0328, p = 0.03 for TC and β = 0.0679, p = 0.04 for LDL). For obese females, adjusted concentrations of TC increased with increase in the concentrations of PFDA (β = 0.0247, p = 0.048), PFNA (β = 0.0286, p = 0.04), and Me-PFOSAA (β = 0.0274, p = 0.02), and there was a positive association of LDL with PFOS (β = 0.0375, p = 0.04), PFDA (β = 0.0397, p = 0.047), and PFNA (β = 0.0593, p = 0.02). The findings, concerning the relationship of longer chain PFAS to serum lipids, suggest greater susceptibility to elevated TC and LDL cholesterol in the obese participants, with some differences between men and women. The key contributing modifiable risk for nonalcoholic steatosis is obesity, and, the development of nonalcoholic steatosis is recognized to be sexually dimorphic. The epidemiologic observation of a susceptible obese subgroup in our data is consistent with toxicology literature findings of disrupted cholesterol metabolism via induced steatosis following PFAS exposure. Gender differences affect serum concentration of PFAS during the reproductive years, and our data add a secondary question concerning whether they also affect the interaction between PFAS exposure and lipid handling in males and females.

Associations between lipid/lipoprotein levels and perfluoroalkyl substances among US children aged 6-11 years

Observed levels of lipid/lipoproteins are known to be associated with exposure to perfluoroalkyl substances (PFAS). In order to evaluate and update these associations among US children aged 6-11 years, data (N = 458) from National Health and Nutrition Examination Survey for 2013-2014 were used. The associations between the observed levels of total cholesterol, high density lipoprotein (HDL) cholesterol, and non-HDL cholesterol and selected PFAS were studied. PFAS data were available for perfluorononanoic acid (PFNA), perfluorohexane sulfonate (PFHxS), linear isomer of perfluorooctanoic acid (PFOA), linear isomer of perfluorooctane sulfonate (PFOS), monomethyl branch isomer of PFOS, and sum of PFAS. Regression models were fitted to evaluate these associations. A statistically significant (p = 0.03) positive association between the levels of linear isomer of PFOS and total cholesterol was observed. A 10% increase in the levels of linear isomer of PFOS measured in ng/L was found to be accompanied by a 0.03-0.42% increase in the levels of total cholesterol measured in mg/dL. For PFNA, girls in the first quartile of PFNA were found to have lower adjusted levels for total cholesterol than the girls in the fourth quartile of PFNA (152.6 vs. 164.7 mg/dL, p < 0.01). Also, non-Hispanic blacks in the first quartile of PFNA were found to have lower adjusted levels for total cholesterol than the non-Hispanic blacks in the fourth quartile of PFNA (143.4 vs. 160.5 mg/dL, p = 0.04). A negative association between branch isomer of PFOS and non-HDL cholesterol was also observed (β = -0.0066, p = 0.04). The adjusted levels of non-HDL cholesterol were higher in the second quartile of ∑PFAS than in the fourth quartile of ∑PFAS (103.0 vs. 97.5 mg/dL, p < 0.01). Linear PFOS and possibly PFNA are associated with total cholesterol in the most recent NHANES childhood sample. Concentrations of PFAS and associations with cholesterol have both decreased compared to previous literature.

Increased risk of respiratory diseases in adults with Type 1 and Type 2 diabetes

AIMS

Diabetes is linked with decreases in lung elasticity and in capacity to transfer carbon monoxide. Systemic inflammation, a common concern with diabetes, may contribute to airflow obstruction. We examined the association of self-reported diabetes with self-reported respiratory diseases (RDs) among 53,146 adults from the C8 Health Project.

METHODS

Participants were categorized into three groups: Type 1 (T1D, n = 781), Type 2 (T2D, n = 4277), or no diabetes (n = 48,088). ORs (95% CIs) for the association of diabetes with four RDs were computed: emphysema, chronic obstructive pulmonary disease (COPD), chronic bronchitis (CB), and asthma. Covariates controlled for were age, sex, estimated glomerular filtration rate, C-reactive protein, smoking history, BMI, and perfluorooctonaoic acid (C8).

RESULTS

RDs were present in 26%, 21% and 13% of persons with T1D, T2D, and no diabetes, respectively. In multivariable analyses, persons with T1D were 62% more likely to have any RD (OR: 1.62, CI: (1.36-1.93)), while those with T2D were 1.3 times as likely (OR: 1.26, CI: 1.15-1.37)). Compared to those without diabetes, in those with T1D and T2D diabetes respectively, ORs (CIs) for COPD were 1.89 (1.38-2.57), 1.45 (1.23-1.71), asthma: 1.51 (1.21-1.87), 1.38 (1.24-1.53), CB: 1.96 (1.57-2.45), 1.35 (1.20-1.52) and emphysema: 1.25 (0.85-1.82), 1.31 (1.10-1.56). Population attributable risks for any RDs associated with a history of smoking were 19%, 30%, and 26% for those with Type 1, Type 2, and no diabetes respectively.

CONCLUSIONS

Diabetes, more so in T1D, appears to increase RD risk. Smoking is an important risk factor, but not as informative in Type 1 diabetes.

Associations between smoking and lipid/lipoprotein concentrations among US adults aged ≥20 years

Cross-sectional data from National Health and Nutrition Examination Survey for the years 1999-2012 for those aged ≥20 years, fasting for at least 8 h, and classified as smokers and nonsmokers on the basis of observed serum cotinine levels were used to evaluate the impact of smoking on the adjusted and unadjusted concentrations of low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, total cholesterol (TC), and triglycerides (TG). Adjustments were made for the effects of gender; race/ethnicity; survey year; dietary intake of alcohol; caffeine; cholesterol; saturated, unsaturated, and total fatty acids; fasting time; body mass index; and poverty income ratio. Adjusted levels of LDL and TC did not vary among smokers and nonsmokers. Smokers had lower adjusted levels of HDL than nonsmokers (48.8 vs. 51.4 mg/dL, p < 0.01) and higher adjusted levels of TG (124.4 vs. 111.9 mg/dL, p < 0.01) than nonsmokers. Adjusted odds of smokers having abnormal levels were 1.6 (95% confidence interval (CI) 1.4-1.8) for HDL, 1.2 (95% CI 1.1-1.4) for TC, and 1.3 (95% CI 1.2-1.5) for TG. Males had lower adjusted levels than females for HDL (45.2 vs. 55.4 mg/dL, p < 0.01) and TC (191.3 vs. 196.6 mg/dL, p < 0.01) but higher adjusted levels than females for TG (126.3 vs. 110.1 mg/dL, p < 0.01) and LDL (114.4 vs. 112.6 mg/dL, p = 0.02). A unit increase in body mass index was associated with 1.4% decrease in the adjusted levels of HDL, 0.18% increase in the adjusted levels of LDL, and a 2.3% increase in the adjusted levels of TG.

BTEX exposure assessment and quantitative risk assessment among petroleum product distributors

The aim of this study was to evaluate benzene, toluene, ethylbenzene, and xylene (BTEX) exposure among workers at four stations of a major oil distribution company. Personal BTEX exposure samples were collected over working shift (8h) for 50 workers at four stations of a major oil distribution company in Iran. Measured mean values for workers across four sites were benzene (2437, 992, 584, and 2788μg/m³ respectively), toluene (4415, 2830, 1289, and 9407μg/m³), ethylbenzene (781, 522, 187, and 533μg/m³), and xylene (1134, 678, 322, and 525μg/m³). The maximum mean concentration measured across sites for benzene was 2788μg/m³ (Station 4), toluene was 9407μg/m³ (Station 4), ethylbenzene was 781μg/m³ (Station 1) and xylene was 1134μg/m³ (Station 1). The 8h averaged personal exposure benzene concentration exceeded the recommended value of 1600μg/m³ established by the Iranian Committee for Review and Collection of Occupational Exposure Limit and American Conference of Governmental Industrial Hygienists. Mean values for excess lifetime cancer risk for exposure to benzene were then calculated across workers at each site. Estimates of excess risk ranged from 1.74 ± 4.05 (Station 4) to 8.31 ± 25.81 (Station 3). Risk was assessed by calculation of hazard quotients and hazard indexes, which indicated that xylene and particularly benzene were the strongest contributors. Tanker loading was the highest risk occupation at these facilties. Risk management approaches to reducing exposures to BTEX compounds, especially benzene, will be important to the health of workers in Iran.

Quality Improvement Intervention for Reduction of Redundant Testing

Laboratory data are critical to analyzing and improving clinical quality. In the setting of residual use of creatine kinase M and B isoenzyme testing for myocardial infarction, we assessed disease outcomes of discordant creatine kinase M and B isoenzyme +/troponin I (-) test pairs in order to address anticipated clinician concerns about potential loss of case-finding sensitivity following proposed discontinuation of routine creatine kinase and creatine kinase M and B isoenzyme testing. Time-sequenced interventions were introduced. The main outcome was the percentage of cardiac marker studies performed within guidelines. Nonguideline orders dominated at baseline. Creatine kinase M and B isoenzyme testing in 7496 order sets failed to detect additional myocardial infarctions but was associated with 42 potentially preventable admissions/quarter. Interruptive computerized soft stops improved guideline compliance from 32.3% to 58% (P < .001) in services not receiving peer leader intervention and to >80% (P < .001) with peer leadership that featured dashboard feedback about test order performance. This successful experience was recapitulated in interrupted time series within 2 additional services within facility 1 and then in 2 external hospitals (including a critical access facility). Improvements have been sustained postintervention. Laboratory cost savings at the academic facility were estimated to be ≥US$635 000 per year. National collaborative data indicated that facility 1 improved its order patterns from fourth to first quartile compared to peer norms and imply that nonguideline orders persist elsewhere. This example illustrates how pathologists can provide leadership in assisting clinicians in changing laboratory ordering practices. We found that clinicians respond to local laboratory data about their own test performance and that evidence suggesting harm is more compelling to clinicians than evidence of cost savings. Our experience indicates that interventions done at an academic facility can be readily instituted by private practitioners at external facilities. The intervention data also supplement existing literature that electronic order interruptions are more successful when combined with modalities that rely on peer education combined with dashboard feedback about laboratory order performance. The findings may have implications for the role of the pathology laboratory in the ongoing pivot from quantity-based to value-based health care.

Use of Pathology Data to Improve High-Value Treatment of Cervical Neoplasia

We investigated the influence of pathology data to improve patient outcomes in the treatment of high-grade cervical neoplasia in a joint pathology and gynecology collaboration. Two of us (B.S.D. and M.D.) reviewed all cytology, colposcopy and surgical pathology results, patient history, and pregnancy outcomes from all patients with loop electrosurgical excision procedure specimens for a 33-month period (January 2011-September 2013). We used this to determine compliance to 2006 consensus guidelines for the performance of loop electrosurgical excision procedure and shared this information in 2 interprofessional and interdisciplinary educational interventions with Obstetrics/Gynecology and Pathology faculty at the end of September 2013. We simultaneously emphasized the new 2013 guidelines. During the postintervention period, we continued to provide follow-up using the parameters previously collected. Our postintervention data include 90 cases from a 27-month period (October 2013-December 2015). Our preintervention data include 331 cases in 33 months (average 10.0 per month) with 76% adherence to guidelines. Postintervention, there were 90 cases in 27 months (average 3.4 per month) and 96% adherence to the 2013 (more conservative) guidelines (P < .0001, χ² test). Preintervention, the rate of high-grade squamous intraepithelial lesion in loop electrosurgical excision procedures was 44%, whereas postintervention, there was a 60% high-grade squamous intraepithelial lesion rate on loop electrosurgical excision procedure (P < .0087 by 2-tailed Fisher exact test). The duration between diagnosis of low-grade squamous intraepithelial lesion and loop electrosurgical excision procedure also increased significantly from a median 25.5 months preintervention to 54 months postintervention (P < .0073; Wilcoxon Kruskal-Wallis test). Postintervention, there was a marked decrease of loop electrosurgical excision procedure cases as well as better patient outcomes. We infer improved patient safety, and higher value can be achieved by providing performance-based pathologic data.

Tetryl exposure: forgotten hazards of antique munitions

Background

Older yet still abundant munitions such as tetryl present easily forgotten health hazards and associated needs for worker protection.

Case presentation

Symptoms and findings from 22 workers who were exposed to tetryl are summarized.

Conclusions

This study highlights the health hazards from exposure to tetryl. Occupational health professionals need to maintain vigilance to protect workers from the risks of handling older munitions.

Prostate-specific antigen and perfluoroalkyl acids in the C8 health study population

Purpose:

To inform questions raised by inconsistent findings regarding an association between perfluoroalkyl acids (PFAAs) and prostate cancer by assessing the relationship of PFAAs in human serum to prostate-specific antigen (PSA).

Materials and Methods:

Using 2005 to 2006 survey data from a large survey population, we compared serum PFAA concentrations in adult males with PSA concentrations adjusted for risk factors including age, body mass index, smoking status, and socioeconomic status.

Results:

Perfluoroalkyl acids are not consistently associated with PSA concentration in general, or with PSA more than 4.0.

Discussion:

These findings do not provide evidence that PFAA exposure is associated with PSA.

Urinary polycyclic aromatic hydrocarbon biomarkers and diabetes mellitus

OBJECTIVE

The aim of the current study is to investigate the association of polycyclic aromatic hydrocarbons (PAHs), a group of environmental pollutants, with diabetes mellitus. Animal studies link PAHs to inflammation and subsequent development of diabetes mellitus. In addition, occupational studies suggest that exposure to other aromatic hydrocarbons such as dioxins may be associated with diabetes risk in humans.

DESIGN

We examined participants from the merged National Health and Nutrition Examination Survey 2001-2002, 2003-2004 and 2005-2006. Exposures of interest were eight urinary monohydroxy-PAHs. Our outcome was diabetes mellitus defined as a glycohemoglobin level (HbA1c) ≥6.5%, a self-reported physician diagnosis of diabetes or use of oral hypoglycaemic medication or insulin. Analyses were adjusted for age, sex, body mass index, race, alcohol consumption, poverty-income ratio, total cholesterol and serum cotinine.

RESULTS

We observed a positive association between urinary biomarkers of 1 and 2-hydroxynapthol, 2-hydroxyphenanthrene and summed low molecular weight (LMW) PAH biomarkers, and diabetes mellitus. Compared with participants with summed LMW PAH biomarkers in the lowest quartile, the multivariable-adjusted OR of diabetes mellitus among those in the highest quartile was 3.1 (95% CI 1.6 to 5.8).

CONCLUSIONS

Urinary biomarkers of 1 and 2-hydroxynapthol, 2-hydroxyphenanthrene and summed LMW PAH biomarkers are associated with diabetes mellitus in US adults 20-65 years of age. The association of a one-time biomarker of PAH exposure has limitations commonly associated with cross-sectional studies, yet is consistent with experimental animal data and is worthy of additional consideration.

Inverse association of colorectal cancer prevalence to serum levels of perfluorooctane sulfonate (PFOS) and perfluorooctanoate (PFOA) in a large Appalachian population

Background

Perfluorooctanoate (PFOA) and perfluorooctane sulfonate (PFOS) are persistent environmental contaminants that affect metabolic regulation, inflammation, and other factors implicated in the development and progression of colorectal cancer (CRC). However, the link between these compounds and CRC remains unknown. In this cross-sectional study, we investigated the association of CRC diagnosis to PFOA and PFOS blood levels in a large Appalachian population.

Methods

Participants were 47,359 adults ≥ 21 years of age and residing in six PFOA-contaminated water districts in the mid-Ohio Valley (N = 47,151 cancer-free adults, 208 cases of primary CRC). All participants completed a comprehensive health survey between 2005 and 2006; serum levels of PFOA, PFOS, and a range of other blood markers were also measured. Medical history was assessed via self report and cancer diagnosis confirmed via chart review.

Results

CRC showed a strong inverse, dose–response association with PFOS serum levels (odds ratio (OR) adjusted for potential confounders = 0.2, 95% confidence interval (CI) 0.2,0.3) for highest vs. lowest quartile of PFOS, P-trend < 0.00001) and a significant, but more modest inverse association with PFOA (adjusted OR = 0.6 (CI 0.4, 0.9) for highest vs. lowest quartile, P-trend = 0.001). These inverse associations were stronger in those diagnosed within the previous 6 years and resident in the same water district for a minimum of 10–15 years preceding assessment. The relationship between PFOA and CRC was also more pronounced in men and leaner adults, and showed a stronger linear trend at lower exposure levels.

Conclusions

In this large cross-sectional study, we found a strong, inverse association between PFOS and likelihood of CRC diagnosis and a significant, although more modest inverse association between PFOA and CRC. If confirmed in prospective investigations, these findings may aid in identifying new strategies for CRC prevention and treatment and inform future studies regarding mechanisms underlying CRC pathogenesis.

Polycyclic aromatic hydrocarbon biomarkers and serum markers of inflammation. A positive association that is more evident in men

BACKGROUND

Polycyclic aromatic hydrocarbons (PAHs) are potent atmospheric pollutants, occurring from anthropogenic and natural sources. Several animal studies have reported a positive association of PAHs with inflammation. However, it is not clear if lower background exposure to PAHs is associated with inflammation in humans, independent of smoking, a major source of PAHs.

METHODS

We examined participants from the National Health and Nutrition Examination Survey 2001-2002, 2003-2004, and 2005-2006. Our exposures of interest were eight urinary monohydroxy polycyclic aromatic hydrocarbon biomarkers. Our outcomes were serum markers of inflammation; C-reactive protein (CRP) (≤10 mg/L) and total white blood cell (WBC) count (4000-12,000 cells/μL).

RESULTS

Compared to participants with summed biomarkers of low-molecular weight (LMW) PAHs in the lowest quartile, the multivariable odds ratios (95% confidence interval) of high serum CRP (≥3 mg/L) and high total WBC count (defined as at or above the 95 percentile of total WBC distribution) among participants in the highest exposure quartile were 1.77 (1.13, 2.76) and 1.34 (1.12, 1.60) respectively. Urinary 1-hydroxypyrene, the biomarker of the higher molecular weight pyrene, was positively associated with total WBC count, and to lesser extent with serum CRP. In subsequent analyses, the positive association between LMW PAHs and serum CRP and total WBC count was found to be present within the stratified subgroups, independent of smoking and other potential confounders. The positive association was more evident among adult males when compared to females.

CONCLUSIONS

Urinary PAH biomarkers were found to be positively associated with serum CRP and total WBC count independent of smoking and other potential confounders. The association was more evident in men.

Predictors of survival in patients with non-small cell lung cancer

PURPOSE/OBJECTIVES

To examine how routine laboratory biomarkers and clinical parameters available within medical records related to overall survival in patients with non-small cell lung cancer (NSCLC).

DESIGN

Retrospective chart review.

SETTING

University-based cancer center in rural West Virginia.

SAMPLE

110 patients from the U.S. Appalachian region with a primary diagnosis of NSCLC at initial hospitalization.

METHODS

Electronic medical records were reviewed for one year after discharge or until death. The Kaplan-Meier method was used to compare survival curves for each prognostic factor. Cox proportional hazards model was used for multivariate analyses.

MAIN RESEARCH VARIABLES

Total white blood cell, neutrophil, lymphocyte, and platelet counts; hemoglobin level; body mass index (BMI); performance status; and cancer stage.

FINDINGS

Low BMI (lower than 18.5 lb/in2), advanced cancer stage (IIIB or IV), and elevated neutrophil (higher than 8 x 103/mcl) and platelet (300-826 x 1012/L) counts were significant, independent prognostic factors for shorter survival time in NSCLC. BMI (hazard ratio [HR] = 2.15, 95% confidence interval [CI] [0.94, 4.9]) and neutrophil (HR = 2.93, 95% CI [1.53, 5.59]) and platelet (HR = 2.65, 95% CI [1.25, 5.62]) counts were overall prognostic predictors for patients with advanced NSCLC and remained in the multivariate survival model.

CONCLUSIONS

This study detected two known clinical parameters, cancer stage and nutritional status (i.e., BMI and neutrophil and platelet counts), as having independent prognostic significance for shorter survival in NSCLC. Research on survival in patients with NSCLC should include those identified laboratory biomarkers and clinical parameters for screening patients at risk for shorter survival time following hospitalization. Investigation of whether treatments tailored to address neutrophil and platelet counts and BMI can improve survival outcomes also is warranted.

IMPLICATIONS FOR NURSING

Attention to common biomarkers recorded in patient charts (e.g., neutrophil and platelet counts) as well as BMI could allow nurses to identify patients at risk for low survival. Interventions should be identified and initiated. Longitudinal studies in clinical settings that follow the survival of patients with NSCLC are essential.

Perfluorooctanoic acid and cardiovascular disease in US adults

BACKGROUND

Cardiovascular disease (CVD) is a major public health problem. Identifying novel risk factors for CVD, including widely prevalent environmental exposures, is therefore important. Perfluorooctanoic acid (PFOA) is a manmade chemical used in the manufacture of common household consumer products. Biomonitoring surveys have shown that PFOA is detectable in the blood of more than 98% of the US population. Experimental animal studies suggest that an association between PFOA and CVD is plausible. However, this association in humans has not been previously examined. We therefore examined the independent relationship between serum PFOA levels and CVD outcomes in a representative sample of Americans.

METHODS

We examined 1216 subjects (51.2% women) from the 1999-2003 National Health and Nutritional Examination Survey. Serum PFOA levels were examined in quartiles. The main outcomes of interest were self-reported CVD, including coronary heart disease and stroke, and objectively measured peripheral arterial disease (PAD), defined as an ankle-brachial blood pressure index of less than 0.9.

RESULTS

We found that increasing serum PFOA levels are positively associated with CVD and PAD, independent of confounders such as age, sex, race/ethnicity, smoking status, body mass index, diabetes mellitus, hypertension, and serum cholesterol level. Compared with quartile 1 (reference) of PFOA level, the multivariable odds ratio (95% CI) among subjects in quartile 4 was 2.01 (1.12-3.60; P = .01 for trend) for CVD and 1.78 (1.03-3.08; P = .04 for trend) for PAD.

CONCLUSION

Exposure to PFOA is associated with CVD and PAD, independent of traditional cardiovascular risk factors.

Circulating maternal perfluoroalkyl substances during pregnancy in the C8 Health Study

Perfluoroalkyl substances are manmade chemicals used in many consumer products and have become ubiquitous in the environment. Animal studies and a limited number of human studies have demonstrated developmental effects in offspring exposed to perfluoroalkyl substances in utero, but the implications of timing of in utero exposure have not been systematically investigated. The present study investigated variation in perfluorocarbon levels of 9952 women of childbearing age who had been exposed to perfluorooctanoic acid (PFOA) in drinking water contaminated by industrial waste. An analysis of variance with contrast was performed to compare the levels of PFOA and perfluorooctanesulfonic acid (PFOS) in pregnant and nonpregnant women overall and during each trimester of pregnancy. We found that pregnant women had lower circulating PFOA and PFOS concentrations in peripheral blood than nonpregnant women and that PFOA levels were consistently lower throughout all trimesters for pregnancy, suggesting transfer to the fetus at an early stage of gestation. These results are discussed in the context of the endocrine-disrupting properties of perfluoroalkyl substances that have been characterized in animal and human studies. Our conclusion is that further, systematic study of the potential implications of intrauterine perfluorocarbon exposure during critical periods of fetal development is urgently needed.

Left atrial volume by echocardiography in patients with false positive myocardial perfusion scans

A stress-induced myocardial perfusion abnormality (MPS), in the absence of angiographically significant epicardial coronary artery disease, is considered a "false-positive" test result. We hypothesized that echocardiography would provide complementary prognostic and pathophysiologic data relevant to the management of patients with MPS and normal coronary angiograms. Accordingly, left atrial volume index (LAVi) was assessed by echocardiography in 38 patients with false positive MPS as defined by normal coronary angiograms and 26 patients with true negative MPS from a total of 1,356 patients stressed from July 2006-May 2008. Pathologically abnormal elevation of LAVi (≥ 32 mL/m(2)) was observed in 16 of 19 women (84%) and 11 of 19 men (58%) in the false positive MPS (FPMPS) group while none of the patients in the true negative MPS (TNMPS) group had elevated LAVi. In the FPMPS group mean LAVi was significantly higher in women than men (40.64 ± 11.4 mL/m(2) versus 32.6 ± 10.5 mL/m(2), P = 0.01). The mean LAVi in the FPMPS group was significantly different from the TNMPS group (36.6 ± 11.6 versus 21 ± 7 mL/m(2), P = 0.000). A stepwise logistic regression determined BSA, LAV and LAVi as useful in predicting false positive and true negative MPS. All three were significant predictors (P < 0.01) and the area under the ROC curve was 0.91. Our findings in this relatively small cohort suggest that patients with false positive MPS have a greater increased LAVi.

Serum perfluorooctanoate (PFOA) and perfluorooctane sulfonate (PFOS) concentrations and liver function biomarkers in a population with elevated PFOA exposure

Background: Perfluorooctanoate (PFOA) and perfluorooctane sulfonate (PFOS) persist in the environment and are found in relatively high concentrations in animal livers. Studies in humans have reported inconsistent associations between PFOA and liver enzymes.

Objectives: We examined the cross-sectional association between serum PFOA and PFOS concentrations with markers of liver function in adults.

Methods: The C8 Health Project collected data on 69,030 persons; of these, a total of 47,092 adults were included in the present analysis. Linear regression models were fitted for natural log (ln)-transformed values of alanine transaminase (ALT), γ-glutamyltransferase (GGT), and direct bilirubin on PFOA, PFOS, and potential confounders. Logistic regression models were fitted comparing deciles of PFOA or PFOS in relation to high biomarker levels. A multilevel analysis comparing the evidence for association of PFOA with liver function at the individual level within water districts to that at the population level between water districts was also performed.

Results: ln-PFOA and ln-PFOS were associated with ln-ALT in linear regression models [PFOA: coefficient, 0.022; 95% confidence interval (CI): 0.018, 0.025; PFOS: coefficient, 0.020; 95% CI: 0.014, 0.026] and with raised ALT in logistic regression models [with a steady increase in the odds ratio (OR) estimates across deciles of PFOA and PFOS; PFOA: OR = 1.10; 95% CI: 1.07, 1.13; PFOS: OR = 1.13; 95% CI: 1.07, 1.18]. There was less consistent evidence of an association of PFOA and GGT or bilirubin. The relationship with bilirubin appears to rise at low levels of PFOA and to fall again at higher levels.

Conclusions: These results show a positive association between PFOA and PFOS concentrations and serum ALT level, a marker of hepatocellular damage.

Perfluorocarbon exposure, gender and thyroid function in the C8 Health Project

Perfluorocarbons from common household products such as food containers, stain- resistant protection for clothing, furniture and carpets, paints, and fire-fighting foams are found in soil, water, plants, animal and human serum worldwide. Previous research has shown a significant association between these chemicals and thyroid disease in women. The present data from the C8 Health Project assessed thyroid function in a cross-sectional analysis of 52,296 adults with a year or more of exposure to perfluorooctanoate (PFOA) from drinking water. Outcomes were: thyroxine, T3 uptake, and thyroid stimulating hormone (TSH). Analyses were stratified by gender and age group (< 20 - < 50 years and > 50). Both PFOA and perfluorooctane sulfonate (PFOS) were associated with significant elevations in serum thyroxine and a significant reduction in T3 uptake in all participants. There were also significant gender/PFOS interactions for T3( )uptake and thyroxine, as well as gender/PFOA interactions for T3 uptake. Results provide evidence for disruption of thyroid function related to these common chemicals and possible mechanisms are discussed.