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Vinnikov D, Tulekov Z, Blanc PD. Fractional exhaled NO in a metalworking occupational cohort. Int Arch Occup Environ Health 2021; 95:701-708. [PMID: 34626220 DOI: 10.1007/s00420-021-01801-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/22/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Secondary metalworking carries exposure to relatively heavy levels of respirable particulate. We investigated the extent to which metalworking is associated with increased exhaled nitric oxide (FeNO), an established inflammatory biomarker. METHODS We studied 80 metalworking factory employees in Kazakhstan. Informed by industrial hygiene data, we categorized them into three groups: (1) machine operators (41%); (2) welders or assemblers (33%); and (3) all others, including administrative and ancillary staff (26%). Participants completed questionnaires covering occupational history, smoking, home particulate sources, respiratory symptoms, and comorbidities. We measured exhaled carbon monoxide (CO), exhaled fractional nitric oxide (FeNO), and spirometric function. We used mixed-effects modeling to test the associations of occupational group with FeNO, adjusted for covariates. RESULTS The median age was 51.5 (interquartile range 20.5) years; 7% were women. Occupational group (p < 0.01), daily current cigarette smoking intensity (p < 0.05), and age (p < 0.05), each was statistically associated with FeNO. Welders, or assemblers (Group 2), who had intermediate particulate exposure, manifested significantly higher exhaled FeNO compared to machinists (Group 1, with the highest particulate exposure) and all others (Groups 3, the lowest particulate): adjusted Group 2 mean 44.8 ppb (95% confidence interval (CI) 33.8-55.9) vs. Group 1 24.6 ppb (95% 20.5-28.7) and Group 3, 24.3 ppb (95% CI 17.7-30.9). Secondhand smoking and height were not associated with FeNO. CONCLUSION In a metalworking industrial cohort, welders/assemblers manifested significantly higher levels of FeNO. This may reflect respiratory tract inflammation associated with airborne exposures specific to this group.
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Naidoo RN, Blanc PD, Torén K. History of work-related diseases as a tool to protect the health of workers. INDUSTRIAL HEALTH 2021; 59:204-203. [PMID: 34261822 PMCID: PMC8426542 DOI: 10.2486/indhealth.1-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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Chien A, Domeracki S, Guntur S, Taylor K, Lu CM, Lampiris H, Blanc PD. Association between household exposure and cycle threshold in COVID-19 infected health care workers. J Occup Med Toxicol 2021; 16:29. [PMID: 34348733 PMCID: PMC8335465 DOI: 10.1186/s12995-021-00321-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/27/2021] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Household SARS-COV-2 contact constitutes a high-risk exposure for health care workers (HCWs). Cycle threshold (Ct) of reverse transcriptase-polymerase chain reaction testing provides an estimate of COVID-19 viral load, which can inform clinical and workplace management. We assessed whether Ct values differed between HCWs with COVID-19 with and without household exposure. METHODS We analyzed HCW COVID-19 cases whose Ct data could be compared. We defined low Ct at a cut-point approximating a viral load of 4.6 × 106 copies per ml. Logistic regression tested the association of household exposure and symptoms at diagnosis with a low Ct value. RESULTS Of 77 HCWs with COVID-19, 20 were household exposures cases and 34 were symptomatic at testing (7 were both household-exposed and symptomatic at testing). Among household exposures, 9 of 20 (45%) manifested lower Ct values compared to 14 of 57 (25%) for all others. In a bivariate model, household exposure was not statistically associated with lower Ct (Odds Ratio [OR] 1.20; 95% Confidence Interval [CI] 0.97-1.51). In multivariable modelling both household exposure (OR] 1.3; 95% CI 1.03-1.6) and symptoms at diagnosis (OR 1.4; 95% CI 1.15-1.7) were associated with a low Ct value. DISCUSSION Household exposure in HCWs with newly diagnosed COVID-19 was associated with lower Ct values, consistent with a higher viral load, supporting the hypothesis that contracting COVID-19 in that manner leads to a greater viral inoculum.
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Ying D, Schmajuk G, Trupin L, Blanc PD. Inorganic Dust Exposure During Military Service as a Predictor of Rheumatoid Arthritis and Other Autoimmune Conditions. ACR Open Rheumatol 2021; 3:466-474. [PMID: 34085777 PMCID: PMC8281049 DOI: 10.1002/acr2.11273] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE Rheumatoid arthritis (RA) and other autoimmune (AI) conditions are associated with inorganic dust exposure. Many military activities are likely to entail inorganic dust exposures. We wished to identify associations between prior military dust exposure and RA and other AI conditions. METHODS We studied persons from a roster of Army, Navy, Air Force, or Marine Corps personnel who had served in Operation Enduring Freedom and Operations Iraqi Freedom and New Dawn. We linked military occupational codes to a job exposure matrix assigning dust exposure likelihood. We used the Veterans Affairs Health Care System (VAHCS) electronic health care records to identify cases of RA, systemic lupus erythematosus (SLE), systemic sclerosis (SSc), vasculitis, and inflammatory myositis. Generalized estimating equations modeled risk of RA and other AI conditions associated with dust exposure, taking into account military service branch, age at first VAHCS encounter, sex, race/ethnicity, smoking status, and years of military service. RESULTS Of 438 086 veterans (68% ever-smokers), 44% were classified with likely or somewhat likely dust exposure. Cases included 1139 cases with RA, 467 cases with SLE, and 180 cases with other AI diseases (SSc, vasculitis, or inflammatory myositis). Military dust exposure was associated with increased odds of RA (odds ratio [OR] = 1.10; 95% confidence interval [CI] = 1.003-1.20) and increased odds of SSc, vasculitis, or inflammatory myositis (OR = 1.23; 95% CI = 1.14-1.34) but was protective for SLE (OR = 0.81; 95% CI = 0.76-0.88). CONCLUSION Dust exposure during past military service comprises an occupational and environmental risk factor for RA and other AI diseases. This is potentially relevant for prevention activities.
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McNicholas JE, Kosnik R, Blanc PD, Taylor BR, Guntur S. Temporal Trends in COVID-19 Incidence in Two Healthcare Worker Cohorts. J Occup Environ Med 2021; 63:528-531. [PMID: 33950043 PMCID: PMC8168665 DOI: 10.1097/jom.0000000000002208] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Health care workers (HCWs) experience increased occupational risk of contracting COVID-19, with temporal trends that might inform surveillance. METHODS We analyzed data from a Veterans Affairs hospital-based COVID-19 worker telephone hotline collected over 40 weeks (2020). We calculated the proportion of COVID-19+ cases among persons-under-investigation (PUIs) for illness compared to rates from a nearby large university-based health care institution. RESULTS We observed 740 PUIs, 65 (8.8%) COVID-19+. Time trends were similar at the study and comparison hospitals; only for the first of 10 four-week observation periods was the ratio for observed to expected COVID-19+ significant (P < 0.001). DISCUSSION These data suggest that employee health COVID-19+ to PUI ratios could be utilized as a barometer of community trends. Pooling experience among heath care facilities may yield insights into occupational infectious disease outbreaks.
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Gandhi SA, Cohen RA, Blanc PD, Go LHT. Early radiographic pneumoconiosis is associated with impaired exercise gas exchange among coal miners with normal resting spirometry. Am J Ind Med 2021; 64:453-461. [PMID: 33768567 DOI: 10.1002/ajim.23247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/21/2021] [Accepted: 02/22/2021] [Indexed: 11/10/2022]
Abstract
RATIONALE We sought to determine if radiographic pneumoconiosis predicts abnormal gas exchange during exercise in coal mine workers with preserved resting lung function. METHODS We analyzed data from former coal miners seen between 2006 and 2014 in a single clinic specializing in black lung evaluations. We limited the analysis to those with normal resting spirometry and an A-a gradient at peak exercise ≥10 mmHg. We used multivariable logistic regression to estimate predictors of A-a gradient widened to >150% of the reference value. We focused on chest radiographs consistent with pneumoconiosis, taking into account higher silica exposure mining activities and years underground, and adjusting for cigarette smoking, obesity, and coronary artery disease. RESULTS Of 5507 miners, we analyzed data for 742 subjects with normal spirometry and all key clinical variables available, of whom 372 (50.1%) had radiographic evidence of pneumoconiosis. All but 21 had small opacity profusion of less than 2/1. The median A-a gradient at peak exercise was 108% of reference value (interquartile range, 81%-141%). In the multivariable analysis, radiographic pneumoconiosis was associated with increased odds of widened A-a gradient (odds ratio [OR], 2.47; 95% confidence interval [CI], 1.7-3.7). Limited to 660 subjects with normal diffusing capacity for carbon monoxide, the odds were similarly increased (OR, 3.20; 95% CI, 1.5-3.6). DISCUSSION Among coal miners with preserved resting lung function, radiographic evidence of early pneumoconiosis more than doubled the odds of abnormal exercise physiology. Impairment in pneumoconiosis occurs in early disease and may only be evident on exercise testing.
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Garshick E, Blanc PD. Military Deployment and Respiratory Symptoms: Some Answers, Many Questions. Chest 2021; 157:1407-1408. [PMID: 32505302 DOI: 10.1016/j.chest.2020.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 02/13/2020] [Indexed: 11/19/2022] Open
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Melamed J, Gerona R, Blanc PD, Takamoto P, Conner S, Goodnough R. Gamma-Butyrolactone Overdose Potentially Complicated by Co-Ingestion of Industrial Solvent N-Methyl-2-Pyrrolidone. J Anal Toxicol 2021; 45:322-324. [PMID: 32672803 DOI: 10.1093/jat/bkaa076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 04/27/2020] [Accepted: 05/17/2020] [Indexed: 11/14/2022] Open
Abstract
Gamma-hydroxybutyrate (GHB) is misused as an intoxicant, either alone or concurrently with other substances. Because GHB is illegal, the precursor chemicals 1,4-butanediol and gamma-butyrolactone are also misused for the same effect, either through pre-ingestion alteration or endogenous metabolism to GHB. We describe a case of a 50-year-old man with a history of polysubstance misuse who experienced an overdose of GHB from gamma-butyrolactone ingestion. The patient also co-ingested a common industrial solvent, N-methyl-2-pyrrolidone (NMP). This co-ingested substance raised theoretical concern of metabolism to a GHB congener, underscoring that the emergence of new psychoactive substance use patterns requires ongoing vigilance and toxicologic confirmation.
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Andersson M, Blanc PD, Torén K, Järvholm B. Smoking, occupational exposures, and idiopathic pulmonary fibrosis among Swedish construction workers. Am J Ind Med 2021; 64:251-257. [PMID: 33547652 DOI: 10.1002/ajim.23231] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/08/2021] [Accepted: 01/20/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cigarette smoking and occupational exposures each have been reported to increase the risk of idiopathic pulmonary fibrosis (IPF), a disease previously considered of unknown origin. We investigated the risk of IPF mortality associated with combined smoking and occupational exposures. METHODS A registry study of Swedish construction workers (N = 389,132), linked baseline smoking and occupational data with registry data on cause of death and hospital care diagnoses. Occupation was classified by the likelihood of exposure to vapors, gases, dusts, or fumes using a job-exposure matrix. Those likely exposed to asbestos or silica were excluded from the analysis. Age-adjusted relative risks [RRs] were calculated using Poisson regression. Follow-up observation began at age 40 and ended at age 89. RESULTS Heavy smokers at baseline who were exposed to inorganic dusts during their working life had an increased risk of IPF mortality (RR 1.70; 95% confidence interval [CI] 1.11-2.60), while there was no statistically increased risk in the other exposure groups. There were dose-response relationships between smoking at baseline and IPF mortality among both unexposed and dust exposed workers, with similar risk for dust exposed and unexposed, except among baseline heavy smokers, where workers exposed to inorganic dust manifested the highest risk (RR 4.22; 95% CI 2.69-6.60). Excluding workers with chronic obstructive pulmonary disease or emphysema did not affect the results substantively. CONCLUSION A clear dose-response relationship was seen between smoking at baseline and IPF, supporting a causal relationship. Occupational exposure to inorganic dusts, excluding silica and asbestos, was associated with increased risk of IPF in baseline heavy current smokers.
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Kolaitis NA, Gao Y, Soong A, Greenland JR, Hays SR, Golden J, Leard LE, Shah RJ, Kleinhenz ME, Katz PP, Venado A, Kukreja J, Blanc PD, Singer JP. Primary graft dysfunction attenuates improvements in health-related quality of life after lung transplantation, but not disability or depression. Am J Transplant 2021; 21:815-824. [PMID: 32794295 DOI: 10.1111/ajt.16257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/17/2020] [Accepted: 07/31/2020] [Indexed: 01/25/2023]
Abstract
Disability, depressive symptoms, and impaired health-related quality of life (HRQL) are common among patients with life-threatening respiratory compromise. We sought to determine if primary graft dysfunction (PGD), a syndrome of acute lung injury, attenuates improvements in patient-reported outcomes after transplantation. In a single-center prospective cohort, we assessed disability, depressive symptoms, and HRQL before and at 3- to 6-month intervals after lung transplantation. We estimated the magnitude of change in disability, depressive symptoms, and HRQL with hierarchical segmented linear mixed-effects models. Among 251 lung transplant recipients, 50 developed PGD Grade 3. Regardless of PGD severity, participants had improvements in disability and depressive symptoms, as well as generic-physical, generic-mental, respiratory-specific, and health-utility HRQL, exceeding 1- to 4-fold the minimally clinically important difference across all instruments. Participants with PGD Grade 3 had a lower magnitude of improvement in generic-physical HRQL and health-utility than in all other participants. Among participants with PGD Grade 3, prolonged mechanical ventilation was associated with greater attenuation of improvements. PGD remains a threat to the 2 primary aims of lung transplantation, extending survival and improving HRQL. Attenuation of improvement persists long after hospital discharge. Future studies should assess if interventions can mitigate the impact of PGD on patient-reported outcomes.
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Vinnikov D, Tulekov Z, Romanova Z, Krugovykh I, Blanc PD. Smoking practices in relation to exhaled carbon monoxide in an occupational cohort. BMC Public Health 2020; 20:1894. [PMID: 33298031 PMCID: PMC7725030 DOI: 10.1186/s12889-020-09997-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 12/01/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Exposure to carbon monoxide (CO) remains a leading occupational hazard in firefighters, but cigarette and waterpipe smoking likely contributes to the other sources of CO in such workers. The aim of this study was to estimate the contribution of self-reported active cigarette smoking, waterpipe use, and potential job-related sources of CO to the level of exhaled CO in firefighters. METHODS We surveyed the personnel of 18 fire stations (N = 842), median age 28 years, who participated at an annual screening not timed to coincide with recent firefighting. We surveyed smoking and waterpipe history, exposure to secondhand smoke (SHS), use of coal for health and biomass for cooking and time since last exposure to firefighting in the workplace. We measured exhaled CO with an instantaneous reading device (piCO Smokerlyzer). We used multivariable regression models to test the association of time since last smoked cigarette (≤12 h) and waterpipe (≤12 h) and time since last fire (≤6 h) with exhaled CO. RESULTS In analysis limited to men (93.5% of all surveyed), 42% were daily cigarette; 1% were waterpipe smokers; 94% were exposed to SHS, 29% used coal for heating and 4% used biomass for cooking. The median CO was 4 (interquartile range 3;8) ppm. Age (beta 0.74 per 10 years, p < 0.001), use of biomass fuel for cooking (beta 1.38, p = 0.05), cigarette smoked in the last 12 h (beta 8.22, p < 0.001), waterpipe smoked in the last 12 h (beta 23.10, p < 0.001) were statistically associated with CO, but not time since last fire (≤6 h) (beta 4.12, p = 0.12). There was a significant interaction between older age and firefighting for exhaled CO (p = 0.03). CONCLUSIONS Cigarette and recent waterpipe smoking are associated with increased exhaled CO in firefighters. Firefighting itself was a less potent contributor to exhaled CO when measured at an annual screening, but an age interaction was manifested.
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Barnes H, Olin AC, Torén K, McSharry C, Donnelly I, Lärstad M, Iribarren C, Quinlan P, Blanc PD. Occupation versus environmental factors in hypersensitivity pneumonitis: population attributable fraction. ERJ Open Res 2020; 6:00374-2020. [PMID: 33043057 PMCID: PMC7533383 DOI: 10.1183/23120541.00374-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/01/2020] [Indexed: 12/28/2022] Open
Abstract
Background Despite well-documented case series of hypersensitivity pneumonitis (HP), epidemiological data delineating relative contributions of risk factors are sparse. To address this, we estimated HP risk in a case-referent study of occupational and nonoccupational exposures. Methods We recruited cases of HP by ICD-9 codes from an integrated healthcare delivery system (IHCDS) and a tertiary medical care centre. We drew referents, matched for age and sex, from the IHCDS. Participants underwent comprehensive, structured telephone interviews eliciting details of occupational and home environmental exposures. We employed a hierarchical analytic approach for data reduction based on the false discovery rate method within clusters of exposures. We measured lung function and selected biomarkers in a subset of participants. We used multivariate logistic regression to estimate exposure-associated odds ratios (ORs) and population attributable fractions (PAFs) for HP. Results We analysed data for 192 HP cases (148 IHCDS; 44 tertiary care) and 229 referents. Occupational exposures combined more than doubled the odds of developing HP (OR 2.67; 95% CI 1.73–4.14) with a PAF of 34% (95% CI 21–46%); nonoccupational bird exposure also doubled the HP odds (OR 2.02; 95% CI 1.13–3.60), with a PAF of 12% (3–21%). Lung function and selected biomarkers did not substantively modify the risk estimates on the basis of questionnaire data alone. Discussion In a case-referent approach evaluating HP risk, identifiable exposures accounted, on an epidemiological basis, for approximately two in three cases of disease; conversely, for one in three, the risk factors for disease remained elusive. Occupational and environmental factors account for two in three cases of HP. The contributions of risk factors vary markedly depending on case referral source. This could affect clinical ascertainment of cause and the implementation of preventative actions.https://bit.ly/3feAa6P
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Kolaitis NA, Calabrese DR, Ahearn P, Venado A, Florez R, Lei HL, Isaak K, Henricksen E, Martinez E, Chong T, Shah RJ, Leard LE, Kleinhenz ME, Golden J, De Marco T, Greenland JR, Kukreja J, Hays SR, Blanc PD, Singer JP. Tacrolimus trough monitoring guided by mass spectrometry without accounting for assay differences is associated with acute kidney injury in lung transplant recipients. Am J Health Syst Pharm 2020; 76:2019-2027. [PMID: 31696925 DOI: 10.1093/ajhp/zxz243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Tacrolimus is a nephrotoxic immunosuppressant historically monitored via enzyme-based immunoassay (IA). After 2011, the 2 largest laboratory companies in the United States implemented tacrolimus quantification by liquid chromatography-mass spectrometry (LC-MS); this method excludes metabolites, potentially resulting in lower quantified drug concentrations. We sought to determine if tacrolimus therapeutic drug monitoring via LC-MS, as performed using trough targets originally derived from IA values, influences clinical outcomes. METHODS In a single-center retrospective cohort study of lung transplant recipients, risks of acute kidney injury, acute renal failure, and new-onset diabetes after transplantation, as well as chronic lung allograft dysfunction-free survival, were compared in 82 subjects monitored by LC-MS and 102 subjects monitored by IA using Cox proportional hazard models adjusted for age, sex, baseline renal function, and race. RESULTS LC-MS-based monitoring was associated with a greater risk of acute kidney injury (adjusted hazard ratio, 1.65; 95% confidence interval, 1.02-2.67). No statistically significant differences in risks of acute renal failure and new-onset diabetes after transplantation were observed. CONCLUSION Although LC-MS provides a more accurate representation of the blood concentration of the parent compound tacrolimus exclusive of metabolite, established cut points for tacrolimus dosing may need to be adjusted to account for the increased risk of renal injury.
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Venado A, Kolaitis NA, Huang CY, Gao Y, Glidden DV, Soong A, Sutter N, Katz PP, Greenland JR, Calabrese DR, Hays SR, Golden JA, Shah RJ, Leard LE, Kukreja J, Deuse T, Wolters PJ, Covinsky K, Blanc PD, Singer JP. Frailty after lung transplantation is associated with impaired health-related quality of life and mortality. Thorax 2020; 75:669-678. [PMID: 32376733 DOI: 10.1136/thoraxjnl-2019-213988] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 04/01/2020] [Accepted: 04/15/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Lung transplantation and related medications are associated with pathobiological changes that can induce frailty, a state of decreased physiological reserve. Causes of persistent or emergent frailty after lung transplantation, and whether such transplant-related frailty is associated with key outcomes, are unknown. METHODS Frailty and health-related quality of life (HRQL) were prospectively measured repeatedly for up to 3 years after lung transplantation. Frailty, quantified by the Short Physical Performance Battery (SPPB), was tested as a time-dependent binary and continuous predictor. The association of transplant-related frailty with HRQL and mortality was evaluated using mixed effects and Cox regression models, respectively, adjusting for age, sex, ethnicity, diagnosis, and for body mass index and lung function as time-dependent covariates. We tested the association between measures of body composition, malnutrition, renal dysfunction and immunosuppressants on the development of frailty using mixed effects models with time-dependent predictors and lagged frailty outcomes. RESULTS Among 259 adults (56% male; mean age 55.9±12.3 years), transplant-related frailty was associated with lower HRQL. Frailty was also associated with a 2.5-fold higher mortality risk (HR 2.51; 95% CI 1.21 to 5.23). Further, each 1-point worsening in SPPB was associated, on average, with a 13% higher mortality risk (HR 1.13; 95% CI 1.04 to 1.23). Secondarily, we found that sarcopenia, underweight and obesity, malnutrition, and renal dysfunction were associated with the development of frailty after transplant. CONCLUSIONS Transplant-related frailty is associated with lower HRQL and higher mortality in lung recipients. Abnormal body composition, malnutrition and renal dysfunction may contribute to the development of frailty after transplant. Confirming the role of these potential contributors and developing interventions to mitigate frailty may improve lung transplant success.
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Blanc PD, Annesi-Maesano I, Balmes JR, Cummings KJ, Fishwick D, Miedinger D, Murgia N, Naidoo RN, Reynolds CJ, Sigsgaard T, Torén K, Vinnikov D, Redlich CA. The Occupational Burden of Nonmalignant Respiratory Diseases. An Official American Thoracic Society and European Respiratory Society Statement. Am J Respir Crit Care Med 2020; 199:1312-1334. [PMID: 31149852 PMCID: PMC6543721 DOI: 10.1164/rccm.201904-0717st] [Citation(s) in RCA: 232] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Rationale: Workplace inhalational hazards remain common worldwide, even though they are ameliorable. Previous American Thoracic Society documents have assessed the contribution of workplace exposures to asthma and chronic obstructive pulmonary disease on a population level, but not to other chronic respiratory diseases. The goal of this document is to report an in-depth literature review and data synthesis of the occupational contribution to the burden of the major nonmalignant respiratory diseases, including airway diseases; interstitial fibrosis; hypersensitivity pneumonitis; other noninfectious granulomatous lung diseases, including sarcoidosis; and selected respiratory infections. Methods: Relevant literature was identified for each respiratory condition. The occupational population attributable fraction (PAF) was estimated for those conditions for which there were sufficient population-based studies to allow pooled estimates. For the other conditions, the occupational burden of disease was estimated on the basis of attribution in case series, incidence rate ratios, or attributable fraction within an exposed group. Results: Workplace exposures contribute substantially to the burden of multiple chronic respiratory diseases, including asthma (PAF, 16%); chronic obstructive pulmonary disease (PAF, 14%); chronic bronchitis (PAF, 13%); idiopathic pulmonary fibrosis (PAF, 26%); hypersensitivity pneumonitis (occupational burden, 19%); other granulomatous diseases, including sarcoidosis (occupational burden, 30%); pulmonary alveolar proteinosis (occupational burden, 29%); tuberculosis (occupational burden, 2.3% in silica-exposed workers and 1% in healthcare workers); and community-acquired pneumonia in working-age adults (PAF, 10%). Conclusions: Workplace exposures contribute to the burden of disease across a range of nonmalignant lung conditions in adults (in addition to the 100% burden for the classic occupational pneumoconioses). This burden has important clinical, research, and policy implications. There is a pressing need to improve clinical recognition and public health awareness of the contribution of occupational factors across a range of nonmalignant respiratory diseases.
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Mudan A, Copan L, Wang R, Pugh A, Lebin J, Barreau T, Jones RL, Ghosal S, Lee M, Albertson T, Jarrett JM, Lee J, Betting D, Ward CD, De Leon Salazar A, Smollin CG, Blanc PD. Notes from the Field: Methylmercury Toxicity from a Skin Lightening Cream Obtained from Mexico - California, 2019. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2019; 68:1166-1167. [PMID: 31856147 PMCID: PMC6936160 DOI: 10.15585/mmwr.mm6850a4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Torén K, Blanc PD, Naidoo RN, Murgia N, Qvarfordt I, Aspevall O, Dahlman-Hoglund A, Schioler L. Occupational exposure to dust and to fumes, work as a welder and invasive pneumococcal disease risk. Occup Environ Med 2019; 77:57-63. [PMID: 31848233 PMCID: PMC7029234 DOI: 10.1136/oemed-2019-106175] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/31/2019] [Accepted: 11/21/2019] [Indexed: 12/18/2022]
Abstract
Objectives Occupational exposures to metal fumes have been associated with increased pneumonia risk, but the risk of invasive pneumococcal disease (IPD) has not been characterised previously. Methods We studied 4438 cases aged 20–65 from a Swedish registry of invasive infection caused by Streptococcus pneumoniae. The case index date was the date the infection was diagnosed. Six controls for each case, matched for gender, age and region of residency, were selected from the Swedish population registry. Each control was assigned the index date of their corresponding case to define the study observation period. We linked cases and controls to the Swedish registries for socioeconomic status (SES), occupational history and hospital discharge. We applied a job–exposure matrix to characterise occupational exposures. We used conditional logistic analyses, adjusted for comorbidities and SES, to estimate the OR of IPD and the subgroup pneumonia–IPD, associated with selected occupations and exposures in the year preceding the index date. Results Welders manifested increased risk of IPD (OR 2.99, 95% CI 2.09 to 4.30). Occupational exposures to fumes and silica dust were associated with elevated odds of IPD (OR 1.11, 95% CI 1.01 to 1.21 and OR 1.33, 95% CI 1.11 to 1.58, respectively). Risk associated with IPD with pneumonia followed a similar pattern with the highest occupational odds observed among welders and among silica dust exposed. Conclusion Work specifically as a welder, but also occupational exposures more broadly, increase the odds for IPD. Welders, and potentially others with relevant exposures, should be offered pneumococcal vaccination.
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Blanc PD, Redlich CA. Reply to Lee and Strek: Occupational Burden in Chronic Respiratory Disease: Call for Recognition, Training, and Data Capture. Am J Respir Crit Care Med 2019; 200:1559. [PMID: 31343269 PMCID: PMC6909838 DOI: 10.1164/rccm.201907-1379le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Blanc PD. What has been done will be done again. Respirology 2019; 24:1125-1126. [DOI: 10.1111/resp.13724] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 10/16/2019] [Indexed: 11/28/2022]
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Shahbaz M, Blanc PD, Domeracki SJ, Guntur S. Shoulder Injury Related to Vaccine Administration (SIRVA): An Occupational Case Report. Workplace Health Saf 2019; 67:501-505. [PMID: 31540569 DOI: 10.1177/2165079919875161] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transient shoulder pain is a common complaint following intramuscular vaccine administration into the deltoid. More severe vaccination-associated shoulder complications comprising of weakness and decreased range of motion are categorized under the construct "shoulder injury related to vaccine administration" (SIRVA) that subsumes both subjective and objective findings consistent with injury. We describe the presentation and management of a case of SIRVA in a health care worker following seasonal influenza vaccine administration as part of a hospital-based employee health program and review the relevant biomedical literature. We present a case from a single medical center. All data were collected by professionals in occupational health by interviewing, performing physical examinations, and reviewing medical records associated with the injured worker. Severe pain and limited range of shoulder motion developed following an influenza vaccination that was administered using a poorly positioned, larger than recommended needle. Magnetic resonance imaging (MRI) demonstrated moderate glenohumeral joint effusion and synovitis, with fluid accumulating in the subscapularis recess within 1 week of injury. At 8 months after initial injury, MRI showed persistent mild tenosynovitis of the long head of the biceps tendon, interval accumulation of a large glenohumeral joint effusion, and infraspinatus tendinitis with subjacent reactive bone marrow edema. The affected worker experienced work restrictions but had no complete lost workdays to date due to the injury. Occupationally related SIRVA is a preventable adverse event that should be considered in workplace vaccine administration programs, and appropriate education and training provided to vaccine administrators to address this.
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Gajic S, Callahan EC, Brown JK, Elicker B, Ley B, Blanc PD. Pulmonary toxicity associated with pomalidomide. Int J Tuberc Lung Dis 2019; 22:1383-1386. [PMID: 30355421 DOI: 10.5588/ijtld.18.0244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Pomalidomide, previously used to treat multiple myeloma, has been reported to cause acute pulmonary toxicity that improves with drug discontinuation. We present a case of delayed pneumonitis with persistent fibrosis associated with pomalidomide. A 61-year-old male treated with pomalidomide and corticosteroids presented with acute on chronic dyspnea, profound hypoxemia, and ground glass opacities on computerized tomographic imaging. Corticosteroid taper and discontinuation of pomalidomide resulted in clinical improvement, but with substantial residual pulmonary fibrosis. Given the temporal improvement, but not resolution, following discontinuation of an agent with an established propensity for lung injury, we attribute this presentation to pomalidomide toxicity.
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Schmajuk G, Trupin L, Yelin E, Blanc PD. Prevalence of Arthritis and Rheumatoid Arthritis in Coal Mining Counties of the United States. Arthritis Care Res (Hoboken) 2019; 71:1209-1215. [PMID: 30875457 DOI: 10.1002/acr.23874] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 03/05/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Exposure to inhaled mineral dust, in particular silica, is associated with increased odds of rheumatoid arthritis (RA) and other autoimmune diseases. We studied the association of RA with work-related coal and silica exposure in the Appalachian region of the US. METHODS We carried out a random-digit dialed telephone survey in selected counties in Appalachia that had elevated coal workers' pneumoconiosis mortality. Our study cohort included men ages ≥50 with any employment history, and we assessed exposure to coal mining employment, other work-related dust, and ergonomic factors. We ascertained self-reported physician diagnosis of any arthritis and of RA with glucocorticoid treatment. We used multivariable logistic regression analysis to estimate the odds ratios (ORs) and associated population attributable fraction (PAF) estimates. RESULTS Among the 973 men who met study entry criteria (mean ± SD ages 66 ± 10 years; 54% ever smokers), 266 (27%) reported coal mining work and 189 (19%) reported other work-related silica exposure. There were 517 men (53%), who reported any arthritis and 112 (12%) whose disease met the study definition of RA. Adjusting for covariates, coal mining was associated with elevated odds of RA (OR 3.6 [95% confidence interval (95% CI) 2.1-6.2]), which accounted for a PAF of 33% (95% CI 26-40%) of the men studied. For any arthritis, the coal mining-associated OR was 2.3 (95% CI 1.6-3.2), with an associated PAF of 20% (95% CI 14-25%). CONCLUSION In this population of older males living in a coal mining region, we estimated that 20% of arthritis and 33% of RA may be attributable to coal mining work.
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Greenland JR, Wang P, Brotman JJ, Ahuja R, Chong TA, Kleinhenz ME, Leard LE, Golden JA, Hays SR, Kukreja J, Singer JP, Rajalingam R, Jones K, Laszik ZG, Trivedi NN, Greenland NY, Blanc PD. Gene signatures common to allograft rejection are associated with lymphocytic bronchitis. Clin Transplant 2019; 33:e13515. [PMID: 30849195 DOI: 10.1111/ctr.13515] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/04/2019] [Accepted: 02/14/2019] [Indexed: 12/28/2022]
Abstract
Lymphocytic bronchitis (LB) precedes chronic lung allograft dysfunction. The relationships of LB (classified here as Endobronchial or E-grade rejection) to small airway (A- and B-grade) pathologies are unclear. We hypothesized that gene signatures common to allograft rejection would be present in LB. We studied LB in two partially overlapping lung transplant recipient cohorts: Cohort 1 included large airway brushes (6 LB cases and 18 post-transplant referents). Differential expression using DESeq2 was used for pathway analysis and to define an LB-associated metagene. In Cohort 2, eight biopsies for each pathology subtype were matched with pathology-free biopsies from the same subject (totaling 48 samples from 24 subjects). These biopsies were analyzed by multiplexed digital counting of immune transcripts. Metagene score differences were compared by paired t tests. Compared to referents in Cohort 1, LB demonstrated upregulation of allograft rejection pathways, and upregulated genes in these cases characterized an LB-associated metagene. We observed statistically increased expression in Cohort 2 for this LB-associated metagene and four other established allograft rejection metagenes in rejection vs paired non-rejection biopsies for both E-grade and A-grade subtypes, but not B-grade pathology. Gene expression-based categorization of allograft rejection may prove useful in monitoring lung allograft health.
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Lytras T, Kogevinas M, Kromhout H, Carsin AE, Antó JM, Bentouhami H, Weyler J, Heinrich J, Nowak D, Urrutia I, Martínez-Moratalla J, Gullón JA, Vega AP, Raherison Semjen C, Pin I, Demoly P, Leynaert B, Villani S, Gíslason T, Svanes Ø, Holm M, Forsberg B, Norbäck D, Mehta AJ, Probst-Hensch N, Benke G, Jogi R, Torén K, Sigsgaard T, Schlünssen V, Olivieri M, Blanc PD, Watkins J, Bono R, Buist AS, Vermeulen R, Jarvis D, Zock JP. Occupational exposures and incidence of chronic bronchitis and related symptoms over two decades: the European Community Respiratory Health Survey. Occup Environ Med 2019; 76:222-229. [PMID: 30700596 DOI: 10.1136/oemed-2018-105274] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 12/05/2018] [Accepted: 12/21/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Chronic bronchitis (CB) is an important chronic obstructive pulmonary disease (COPD)-related phenotype, with distinct clinical features and prognostic implications. Occupational exposures have been previously associated with increased risk of CB but few studies have examined this association prospectively using objective exposure assessment. We examined the effect of occupational exposures on CB incidence in the European Community Respiratory Health Survey. METHODS Population samples aged 20-44 were randomly selected in 1991-1993, and followed up twice over 20 years. Participants without chronic cough or phlegm at baseline were analysed. Coded job histories during follow-up were linked to the ALOHA Job Exposure Matrix, generating occupational exposure estimates to 12 categories of chemical agents. Their association with CB incidence over both follow-ups was examined with Poisson models using generalised estimating equations. RESULTS 8794 participants fulfilled the inclusion criteria, contributing 13 185 observations. Only participants exposed to metals had a higher incidence of CB (relative risk (RR) 1.70, 95% CI 1.16 to 2.50) compared with non-exposed to metals. Mineral dust exposure increased the incidence of chronic phlegm (RR 1.72, 95% CI 1.43 to 2.06). Incidence of chronic phlegm was increased in men exposed to gases/fumes and to solvents and in women exposed to pesticides. CONCLUSIONS Occupational exposures are associated with chronic phlegm and CB, and the evidence is strongest for metals and mineral dust exposure. The observed differences between men and women warrant further investigation.
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Paulin LM, Smith BM, Koch A, Han M, Hoffman EA, Martinez C, Ejike C, Blanc PD, Rous J, Barr RG, Peters SP, Paine R, Pirozzi C, Cooper CB, Dransfield MT, Comellas AP, Kanner RE, Drummond MB, Putcha N, Hansel NN. Occupational Exposures and Computed Tomographic Imaging Characteristics in the SPIROMICS Cohort. Ann Am Thorac Soc 2018; 15:1411-1419. [PMID: 30339479 PMCID: PMC6322018 DOI: 10.1513/annalsats.201802-150oc] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/23/2018] [Indexed: 12/16/2022] Open
Abstract
RATIONALE Quantitative computed tomographic (CT) imaging can aid in chronic obstructive pulmonary disease (COPD) phenotyping. Few studies have identified whether occupational exposures are associated with distinct CT imaging characteristics. OBJECTIVES To examine the association between occupational exposures and CT-measured patterns of disease in the SPIROMICS (Subpopulations and Intermediate Outcome Measures in COPD Study). METHODS Participants underwent whole-lung multidetector helical CT at full inspiration and expiration. The association between occupational exposures (self-report of exposure to vapors, gas, dust, or fumes [VGDF] at the longest job) and CT metrics of emphysema (percentage of total voxels < -950 Hounsfield units at total lung capacity), large airways (wall area percent [WAP] and square-root wall area of a single hypothetical airway with an internal perimeter of 10 mm [Pi10]), and small airways (percent air trapping [percent total voxels < -856 Hounsfield units at residual volume] and parametric response mapping of functional small-airway abnormality [PRM fSAD]) were explored by multivariate linear regression, and for central airway measures by generalized estimating equations to account for multiple measurements per individual. Models were adjusted for age, sex, race, current smoking status, pack-years of smoking, body mass index, and site. Airway measurements were additionally adjusted for total lung volume. RESULTS A total of 2,736 participants with available occupational exposure data (n = 927 without airflow obstruction and 1,809 with COPD) were included. The mean age was 64 years, 78% were white, and 54% were male. Forty percent reported current smoking, and mean (SD) pack-years was 49.3 (26.9). Mean (SD) post-bronchodilator forced expiratory volume in 1 second (FEV1) was 73 (27) % predicted. Forty-nine percent reported VGDF exposure. VGDF exposure was associated with higher emphysema (β = 1.17; 95% confidence interval [CI], 0.44-1.89), greater large-airway disease as measured by WAP (segmental β = 0.487 [95% CI, 0.320-0.654]; subsegmental β = 0.400 [95% CI, 0.275-0.527]) and Pi10 (β = 0.008; 95% CI, 0.002-0.014), and greater small-airway disease was measured by air trapping (β = 2.60; 95% CI, 1.11-4.09) and was nominally associated with an increase in PRM fSAD (β = 1.45; 95% CI, 0.31-2.60). These findings correspond to higher odds of percent emphysema, WAP, and air trapping above the 95th percentile of measurements in nonsmoking control subjects in individuals reporting VGDF exposure. CONCLUSIONS In an analysis of SPIROMICS participants, we found that VGDF exposure in the longest job was associated with an increase in emphysema, and in large- and small-airway disease, as measured by quantitative CT imaging.
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