Risk of ischemic heart disease following occupational exposure to welding fumes: a systematic review with meta-analysis

Proposal of a workplace classification model for heart attack accidents from the field of occupational safety and health engineering

Research on occupational accidents is a key factor in improving working conditions and sustainability. Fatal accidents incur significant human and economic costs. Therefore, it is essential to examine fatal accidents to identify the factors that contribute to their occurrence. This study presents an overview of fatal heart attack accidents at work in Spain over the period 2009-2021. Descriptive analysis was conducted considering 13 variables classified into five groups. These variables were selected as predictors to determine the occurrence of this type of accident using a machine learning technique. Thirteen Naïve Bayes prediction models were developed using an unbalanced dataset of 15,616 valid samples from the Spanish Delta@database, employing a two-stage algorithm. The final model was retained using a General Performance Score index. The model selected for this study used a 70:30 distribution for the training and test datasets. A sample was classified as a fatal heart attack if its posterior probability exceeded 0.25. This model is assumed to be a compromise between the confusion matrix values of each model. Sectors with the highest number of heart attacks are 'Health and social work', 'Transport and storage', 'Manufacturing', and 'Construction'. The incidence of heart attacks and fatal heart attack accidents is higher in men than in women and higher in private sector employees. The findings and model development may assist in the formulation of surveillance strategies and preventive measures to reduce the incidence of heart attacks in the workplace.

Occupational particle exposure and chronic kidney disease: a cohort study in Swedish construction workers

OBJECTIVES

Increasing epidemiological and experimental evidence suggests that particle exposure is an environmental risk factor for chronic kidney disease (CKD). However, only a few case-control studies have investigated this association in an occupational setting. Hence, our objective was to investigate associations between particle exposure and CKD in a large cohort of Swedish construction workers.

METHODS

We performed a retrospective cohort study in the Swedish Construction Workers' Cohort, recruited 1971-1993 (n=286 089). A job-exposure matrix was used to identify workers exposed to nine different particulate exposures, which were combined into three main categories (inorganic dust and fumes, wood dust and fibres). Incident CKD and start of renal replacement therapy (RRT) were obtained from validated national registries until 2021 and analysed using adjusted Cox proportional hazards models.

RESULTS

Exposure to inorganic dust and fumes was associated with an increased risk of CKD and RRT during working age (adjusted HR for CKD at age <65 years 1.15, 95% CI 1.05 to 1.26). The elevated risk did not persist after retirement age. Exposure to cement dust, concrete dust and diesel exhaust was associated with CKD. Elevated HRs were also found for quartz dust and welding fumes.

CONCLUSIONS

Workers exposed to inorganic particles seem to be at elevated risk of CKD and RRT. Our results are in line with previous evidence of renal effects of ambient air pollution and warrant further efforts to reduce occupational and ambient particle exposure.

Carcinogenic and non-carcinogenic risk of exposure to metal fume in different types of welding processes

The international agency for cancer research (IARC) has classified welding fumes as definitive carcinogens. The aim of the present study was to assess health risk due to exposure to welding fumes in different welding types. In this study, exposure to fumes of iron (Fe), chromium (Cr), and nickel (Ni) in the breathing zone air of 31 welder engaged in arc, argon and CO2 welding was assessed. Carcinogenic and non-carcinogenic risk assessments due to exposure to fumes were performed using the method proposed by the Environmental Protection Agency (EPA) by Monte Carlo simulation. The results showed that in the CO2 welding, concentration of Ni, Cr, and Fe was lower than the 8-h Time-Weighted Average Threshold Limit Value (TWA-TLV), recommended by the American Conference of Governmental Industrial Hygienists (ACGIH). In argon welding, Cr and Fe concentrations were higher than the TWA-TLV. In arc welding, concentrations of Ni and Fe were more than the TWA-TLV. In addition, the risk of non-carcinogenicity due to exposure to Ni and Fe in all three types of welding was more than standard level (HQ>1). The results indicated that the welders are at health risk due to exposure to metal fumes. Preventive exposure control measures such as local ventilation need to be implemented in welding workplaces.

Characterization of welding fume and airborne heavy metals in electronic manufacturing workshops in Hangzhou, China: implication for occupational population exposure

Occupational exposure to contaminants created by electronic manufacturing process is not well characterized. The aim of this study was to carry out risk assessments of exposure to welding fume and airborne heavy metals (HMs) in electronic manufacturing workshops. Seventy-six air samples were collected from five sites in Hangzhou, China. In welding workshops, the most abundant contaminant found was welding fume, followed by Fe, Mn, Zn, Cu, Pb, Cd, and Cr. The concentration of Mn was positively correlated with Fe (r = 0.906). When compared with non-welding workshops, the Fe content in the air of welding workshops increased significantly (P < 0.05), while the Cu content decreased significantly (P < 0.05). Singapore semi-quantitative health risk assessment model and the United States Environmental Protection Agency (US EPA) inhalation risk assessment model were applied to assess the occupational exposure. In welding workshops, the levels of 8-h time weighted average (8 h-TWA) calculated for welding fume (range 0.288 ~ 6.281 mg/m³), Mn (range Nd ~ 0.829 mg/m³), and Fe (range 0.027 ~ 2.234 mg/m³) partly exceeded the permissible limits. While, in non-welding workshops, the average of 8 h-TWA for Cu (0.411 mg/m³) was higher than the limit. The risk rates (RR) assessed for Pb (2.4 vs 1.7), Mn (2.0 vs 1.4), and Fe (1.4 vs 1.0) were higher in welding workshops than that in non-welding workshops, but Cu (1.0 vs 2.2) were lower. The mean excess lifetime cancer risks (ELCR) in welding (5.59E - 06 per 1000 people) and non-welding (1.88E - 06 per 1000 people) workshops were acceptable. The mean non-cancer risk (HQ) estimated for Mn was greater than 10 in both welding (HQ = 164) and non-welding (HQ = 11.1) workshops. These results indicate that there was a risk of occupational exposure implication in the electronic manufacturing workshops. Reducing contaminant exposure through engineering controls and management strategies, such as efficient ventilation and reducing exposure hours, is thus suggested.

Air Pollution and the Heart: Updated Evidence from Meta-analysis Studies

PURPOSE OF REVIEW

Although environmental exposure such as air pollution is detrimental to cardiovascular disease (CVD), the effects of different air pollutants on different CVD endpoints produced variable findings. We provide updated evidence between air pollutants and CVD outcomes including mitigation strategies with meta-analytic evidence.

RECENT FINDINGS

An increased exposure to any class of air pollutants including particulate matter (PM), gas, toxic metals, and disruptive chemicals has been associated with CVD events. Exposure to PM < 2.5 μm has been consistently associated with most heart diseases and stroke as well as CVDs among at-risk individuals. Despite this, there is no clinical approach available for systemic evaluation of air pollution exposure and management. A large number of epidemiological evidence clearly suggests the importance of air pollution prevention and control for reducing the risk of CVDs and mortality. Cost-effective and feasible strategies for air pollution monitoring, screening, and necessary interventions are urgently required among at-risk populations and those living or working, or frequently commuting in polluted areas.

Environmental Stressors and the PINE Network: Can Physical Environmental Stressors Drive Long-Term Physical and Mental Health Risks?

Both psychosocial and physical environmental stressors have been linked to chronic mental health and chronic medical conditions. The psycho-immune-neuroendocrine (PINE) network details metabolomic pathways which are responsive to varied stressors and link chronic medical conditions with mental disorders, such as major depressive disorder via a network of pathophysiological pathways. The primary objective of this review is to explore evidence of relationships between airborne particulate matter (PM, as a concrete example of a physical environmental stressor), the PINE network and chronic non-communicable diseases (NCDs), including mental health sequelae, with a view to supporting the assertion that physical environmental stressors (not only psychosocial stressors) disrupt the PINE network, leading to NCDs. Biological links have been established between PM exposure, key sub-networks of the PINE model and mental health sequelae, suggesting that in theory, long-term mental health impacts of PM exposure may exist, driven by the disruption of these biological networks. This disruption could trans-generationally influence health; however, long-term studies and information on chronic outcomes following acute exposure event are still lacking, limiting what is currently known beyond the acute exposure and all-cause mortality. More empirical evidence is needed, especially to link long-term mental health sequelae to PM exposure, arising from PINE pathophysiology. Relationships between physical and psychosocial stressors, and especially the concept of such stressors acting together to impact on PINE network function, leading to linked NCDs, evokes the concept of syndemics, and these are discussed in the context of the PINE network.

Effect of occupational exposure to welding fumes and noise on heart rate variability: An exposed-unexposed study on welders and airport workers' population

Introduction

Welding fumes (WF) are a complex mixture of gas and particles. Action of occupational exposure to WF on cardiovascular system has been recently studied as for noise.

Research question

The main objectives of our study are therefore to evaluate the impact of exposure to WF, noise, and combined WF and noise on autonomic nervous system as assessed by heart rate variability (HRV).

Methods

The study groups were 16 welders and eight airport workers (as a control group). All the participants underwent ambulatory electrocardiogram, personal WF, and noise exposure monitoring, respectively, with dust track and calibrated noise dosimeter during workday. Atmospheric environmental assessments at workplaces have been also performed. HRV parameters were summarized for all the workday and hourly. Correlation tests were used to examine relation between HRV parameters and levels of noise exposure in the two population. Analysis of covariance (ANCOVA) was used for mean of each HRV parameters.

Results

For HRV parameters, we found significant higher levels for mean range of high frequency (HF), standard deviation of normal-to-normal R-R interval (SDNN), and root mean square of successive heartbeat interval difference (RMSSD) in welders which suggested an imbalance between sympathetic and parasympathetic nervous system in this population. For relation between noise and HRV parameters, we noted that levels of low frequency (LF), HF, and SDNN were significantly correlated with mean noise levels for welders (respectively, r = 0.62, r = 0.357, r = 0.48), not in control group. Using ANCOVA, we found that working as a welder significantly increases mean of HF (p = 0.01) and RMSSD (p = 0.02) and decreases in LF/HF (p = 0.008). Indeed, the interaction between exposure to WF and mean noise levels for HF (p = 0.005), LF/HF (p = 0.01), and RMSSD (p = 0.007) was significant.

Conclusion

This study shows an impact of WF and noise on ANS balance. One hypothesis is WF exposure could increase sensibility to noise exposure on autonomic nervous system or there is a synergic effect.

Occupational exposure to particles and biomarkers of cardiovascular disease-during work and after vacation

Objective

Ambient particle matter is a risk factor for cardiovascular disease (CVD). However, little is known about associations between particles in occupational settings and risk of CVD. We investigated associations between occupational dust exposure and biomarkers of CVD, and potential recovery effects after vacation.

Methods

Personal dust exposure measurements (respirable silica, respirable dust < 4 µm, and particles of 0.1–10 µm (PM 0.1–10) were conducted once, and biological sampling were performed twice on non-smoking, male construction workers in Stockholm county, Sweden; during work and immediately after summer vacation. Linear regressions with adjustments for confounders and covariates were performed evaluating associations between occupational dust exposure and biomarkers. Paired t tests were performed evaluating changes before and after vacation.

Results

Sixty-five workers participated. Homocysteine concentrations were significantly higher with increasing concentrations (mg/m³) of respirable silica, respirable dust, and PM 0.1–10, and pulse rate with higher levels of respirable dust and dust of PM 0.1–10. Homocysteine levels were also positively correlated to number of years of dust exposure, as were low-density lipoprotein (LDL) levels. A clear recovery effect was present for LDL after vacation, but not for homocysteine.

Conclusions

Occupational dust exposure was associated with some CVD risk markers, even at mean exposure concentrations below the Swedish occupational exposure limits for respirable silica and respirable dust, respectively. Vacation resulted in recovery for some risk markers. However, the change of the homocysteine and LDL levels suggest a long-term effect. Reduction of occupational exposure to dust may decrease the risk of CVD among exposed workers.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00420-022-01900-5.

Welding fume nanoparticles from solid and flux-cored wires: Solubility, toxicity, and role of fluorides

Welding fume particles are hazardous. Their toxicity likely depends on their composition and reactivity. This study aimed at exploring the role of sodium or other fluorides (NaF), which are intentionally added to flux-cored wire electrodes for stainless steel welding, on the solubility (in phosphate buffered saline) and toxicity of the generated welding fume particles. A multi-analytical particle characterization approach along with in-vitro cell assays was undertaken. The release of Cr(VI) and Mn from the particles was tested as a function of fluoride solution concentration. The welding fume particles containing NaF released significantly higher amounts of Cr(VI) compared with solid wire reference fumes, which was associated with increased cytotoxicity and genotoxicity in-vitro. No crystalline Na or potassium (K) containing chromates were observed. Cr(VI) was incorporated in an amorphous mixed oxide. Solution-added fluorides did not increase the solubility of Cr(VI), but contributed to a reduced Mn release from both solid and flux-cored wire fume particles and the reduction of Cr(VI) release from solid wire fume particles. Chemical speciation modeling suggested that metal fluoride complexes were not formed. The presence of NaF in the welding electrodes did not have any direct, but possibly an indirect, role in the Cr(VI) solubility of welding fumes.

Effects of mild steel welding fume particles on pulmonary epithelial inflammation and endothelial activation

Welders have an increased risk for cardiovascular disease (CVD) following exposure to welding fumes. The underlying mechanisms are largely unknown; however, oxidative stress, systemic inflammation, and endothelial dysfunction have been suggested as contributing factors to particle-induced CVD. We investigated effects of mild steel welding fume (MSWF) on three target cell types: macrophages, pulmonary epithelial, and vascular endothelial cells. Cells were exposed to MSWF at nontoxic doses for 6 h/day, for five consecutive days. The expression of 40 genes involved in inflammation, fibrosis, and endothelial activation was analyzed. Moreover, changes in the reactive oxygen species production and migration capacity of cells were assessed. The expression of matrix metallopeptidase 1 (MMP1) was induced in both epithelial and endothelial cells following repeated exposure to MSWF. Although MMP1 is important in inflammatory responses in vivo, this effect was not concurrent with changes in the inflammatory status, cell proliferation, and migration capacities, nor did it induce oxidative stress in the cells. Thus, repeated exposure with low doses of MSWF was sufficient neither for inducing inflammatory stress in epithelial cells and macrophages nor for endothelial activation, and higher concentrations of MSWF or the nonparticle fraction of MSWF may be critical in causing the increased risk of CVD observed among welders.

Welding Fumes, a Risk Factor for Lung Diseases

(1) Background: Welding fumes (WFs) are composed of fine and ultrafine particles, which may reach the distal airways and represent a risk factor for respiratory diseases. (2) Methods: In vitro and in vivo studies to understand WFs pathogenesis were selected. Epidemiological studies, original articles, review, and meta-analysis to examine solely respiratory disease in welders were included. A systematic literature search, using PubMed, National Institute for Occupational Safety and Health Technical Information Center (NIOSHTIC), and Web of Science databases, was performed. (3) Results: Dose, time of exposure, and composition of WFs affect lung injury. Inflammation, lung defense suppression, oxidative stress, DNA damage, and genotoxic effects were observed after exposure both to mild and stainless steel WFs. (4) Conclusions: The detection of lung diseases associated with specific occupational exposure is crucial as complete avoidance or reduction of the exposure is difficult to achieve. Further studies in the area of particle research may aid the understanding of mechanisms involved in welding-related lung disease and to expand knowledge in welding-related cardiovascular diseases.

Home-based and informal work exposes the families to high levels of potentially toxic elements

The city of Limeira presents a relevant productive chain of jewelry and fashion jewelry, including a scenario of outsourcing informal home practices. It is highly complex to understand the potentially toxic elements (PTE: Cr, Mn, Ni, Cu, Zn, As, Cd, Sn, Sb, Hg, and Pb) exposures of the workers because this productive chain encompasses households. This study aimed to investigate the associations between blood PTE levels and informal work in the home environment. Fifty-two families divided into Exposed group (n = 112) and Control group (n = 53) were included. Families' blood (n = 165) and welder's breathing zone air samples (n = 9) were collected and PTEs concentrations were determined by ICP-MS. Questionnaires were applied to collect sociodemographic information and workplace details. Principal component analysis, Mann-Whitney test, cluster and a logistic regression analysis based on environment-wide association studies (EWAS) were carried out. Ni, Cu, Zn, Cd and Pb concentrations in the air samples were higher than occupational guidelines. Eighty percent of the workers were female, and 43.5% of those females then worked as welder. A significant difference was found for Pb concentration between the exposed and control group (p < 0.0001) and between sexes (p = 0.0046). For Cu (p < 0.0001) and Sb (p = 0.0434), differences were found between the sexes. The receiver operating characteristic of the EWAS was 0.80, providing evidence of a potential model to associate exposure levels and occupational factors. PTEs concentrations in the air samples raised concerns, particularly for children, who were in the same exposure scenario. Inadequate work conditions were observed in the houses, revealing the need of public actions to protect these families.

Effects of copper and zinc on ischemic heart disease and myocardial infarction: a Mendelian randomization study

Background

Despite great progress in prevention and control, ischemic heart disease (IHD) remains a leading cause of global morbidity and mortality. Diet plays a key role in IHD, but a comprehensive delineation of the role of dietary factors in IHD is not yet quite complete.

Objective

The aim of this study was to test the long-standing hypothesis that copper is protective and zinc harmful in IHD.

Design

We used separate-sample instrumental variable analysis with genetic instruments (Mendelian randomization). We obtained single nucleotide polymorphisms (SNPs) from a genome wide association study, strongly (P value < 5 × 10-8) and independently associated with erythrocyte copper and zinc. We applied these genetic predictors of copper and zinc to the largest, most extensively genotyped IHD case (n ≤ 76014)-control (n ≤ 264785) study, based largely on CARDIoGRAMplusC4D 1000 Genomes and the UK Biobank SOFT CAD, to obtain SNP-specific Wald estimates for the effects of copper and zinc on IHD, which were combined through the use of inverse variance weighting. Sensitivity analysis included use of the MR-Egger method, and reanalysis including SNPs independently associated with erythrocyte copper and zinc at P value < 5 × 10-6.

Results

Genetically instrumented copper was negatively associated with IHD (OR: 0.94; 95% CI: 0.90, 0.98). Genetically instrumented zinc was positively associated with IHD (OR: 1.06; 95% CI: 1.02, 1.11). Sensitivity analysis via MR-Egger gave no indication of unknown pleiotropy; less strongly associated SNPs gave similar results for copper.

Conclusion

Genetic validation of a long-standing hypothesis suggests that further investigation of the effects, particularly of copper, on IHD may provide a practical means of reducing the leading cause of mortality and morbidity.

Biological monitoring of welders' exposure to chromium, molybdenum, tungsten and vanadium

BACKGROUND

Welders are exposed to a number of metallic elements during work. Bioaccessability, that is important for element uptake, has been little studied. This study addresses bioaccessability and uptake of chromium (Cr), molybdenum (Mo), tungsten (W) and vanadium (V) among welders.

METHODS

Bioaccessability of Cr, Mo, V and W was studied in airborne particulate matter collected by personal sampling of the workroom air among shipyard welders by using the lung lining fluid simulant Hatch solution. Associations between concentrations of Hatch soluble and non-soluble elements (Hatch_sol and Hatch_non-sol) and concentrations of the four elements in whole blood, serum, blood cells and urine were studied.

RESULTS

Air concentrations of the four elements were low. Only a small fraction of Cr, V and W was Hatch_sol, while similar amounts of Mo were Hatch_sol and Hatch_non-sol. Welders (N=70) had statistically significantly higher concentrations of all four elements in urine and serum when compared to referents (N=74). Highly statistically significant associations were observed between urinary W and Hatch_sol W (p<0.001) and serum V and Hatch_sol V (p<0.001), in particular when air samples collected the day before collection of biological samples were considered.

CONCLUSIONS

Associations between Hatch_sol elements in air and their biological concentrations were higher than when Hatch_non-sol concentrations were considered. Associations were generally higher when air samples collected the day before biological sampling were considered as compared to air samples collected two days before.

Occupational exposure to particles and mitochondrial DNA - relevance for blood pressure

BACKGROUND

Particle exposure is a risk factor for cardiovascular diseases. Mitochondrial DNA (mtDNA) is a primary target for oxidative stress generated by particle exposure. We aimed to elucidate the effects of occupational exposure to particle-containing welding fumes on different biomarkers of mtDNA function, and in turn, explore if they modify the association between particle exposure and cardiovascular response, measured as blood pressure.

METHODS

We investigated 101 welders and 127 controls (all non-smoking males) from southern Sweden. Personal sampling of the welders' exposure to respirable dust was performed during work hours (average sampling time: 6.8 h; range: 2.4-8.6 h) and blood pressure was measured once for each subject. We measured relative mtDNA copy number by quantitative PCR and methylation of the mitochondrial regulatory region D-loop and the tRNA encoding gene MT-TF by bisulfite-pyrosequencing. We calculated the relative number of unmethylated D-loop and MT-TF as markers of mtDNA function to explore the modification of mtDNA on the association between particle exposure and blood pressure. General linear models were used for statistical analyses.

RESULTS

Welders had higher mtDNA copy number (β = 0.11, p = 0.003) and lower DNA methylation of D-loop (β = -1.4, p = 0.002) and MT-TF (β = -1.5, p = 0.004) than controls. Higher mtDNA copy number was weakly associated with higher personal respirable dust exposure among welders with exposure level above 0.7 mg/m3 (β = 0.037, p = 0.054). MtDNA function modified the effect of welding fumes on blood pressure: welders with low mtDNA function had higher blood pressure than controls, while no such difference was found in the group with high mtDNA function.

CONCLUSION

Increased mtDNA copy number and decreased D-loop and MT-TF methylation were associated with particle-containing welding fumes exposure, indicating exposure-related oxidative stress. The modification of mtDNA function on exposure-associated increase in blood pressure may represent a mitochondria-environment interaction.

Stretching the stress boundary: Linking air pollution health effects to a neurohormonal stress response

Inhaled pollutants produce effects in virtually all organ systems in our body and have been linked to chronic diseases including hypertension, atherosclerosis, Alzheimer's and diabetes. A neurohormonal stress response (referred to here as a systemic response produced by activation of the sympathetic nervous system and hypothalamus-pituitary-adrenal (HPA)-axis) has been implicated in a variety of psychological and physical stresses, which involves immune and metabolic homeostatic mechanisms affecting all organs in the body. In this review, we provide new evidence for the involvement of this well-characterized neurohormonal stress response in mediating systemic and pulmonary effects of a prototypic air pollutant - ozone. A plethora of systemic metabolic and immune effects are induced in animals exposed to inhaled pollutants, which could result from increased circulating stress hormones. The release of adrenal-derived stress hormones in response to ozone exposure not only mediates systemic immune and metabolic responses, but by doing so, also modulates pulmonary injury and inflammation. With recurring pollutant exposures, these effects can contribute to multi-organ chronic conditions associated with air pollution. This review will cover, 1) the potential mechanisms by which air pollutants can initiate the relay of signals from respiratory tract to brain through trigeminal and vagus nerves, and activate stress responsive regions including hypothalamus; and 2) the contribution of sympathetic and HPA-axis activation in mediating systemic homeostatic metabolic and immune effects of ozone in various organs. The potential contribution of chronic environmental stress in cardiovascular, neurological, reproductive and metabolic diseases, and the knowledge gaps are also discussed. This article is part of a Special Issue entitled Air Pollution, edited by Wenjun Ding, Andrew J. Ghio and Weidong Wu.

A Cross-Sectional Study of the Cardiovascular Effects of Welding Fumes

Objectives

Occupational exposure to particulate air pollution has been associated with an increased risk of cardiovascular disease. However, the risk to welders working today remains unclear. We aimed to elucidate the cardiovascular effects of exposure to welding fumes.

Methods

In a cross-sectional study, structured interviews and biological sampling were conducted for 101 welders and 127 controls (all non-smoking males) from southern Sweden. Personal breathing zone sampling of respirable dust was performed. Blood pressure (BP) and endothelial function (using peripheral arterial tonometry) were measured. Plasma and serum samples were collected from peripheral blood for measurement of C-reactive protein, low-density lipoprotein, homocysteine, serum amyloid A, and cytokines.

Results

Welders were exposed to 10-fold higher levels of particles than controls. Welders had significantly higher BP compared to controls, an average of 5 mm Hg higher systolic and diastolic BP (P≤0.001). IL-8 was 3.4 ng/L higher in welders (P=0.010). Years working as a welder were significantly associated with increased BP (β=0.35, 95%CI 0.13 – 0.58, P=0.0024 for systolic BP; β=0.32, 95%CI 0.16 – 0.48, P<0.001 for diastolic BP, adjusted for BMI) but exposure to respirable dust was not associated with BP. No clear associations occurred between welding and endothelial function, or other effect markers.

Conclusions

A modest increase in BP was found among welders compared to controls suggesting that low-to-moderate exposure to welding fumes remains a risk factor for cardiovascular disease.