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Veltkamp M. Clinical trials in pulmonary sarcoidosis; what is needed, what is happening and what is next? Curr Opin Pulm Med 2024; 30:576-582. [PMID: 38963156 DOI: 10.1097/mcp.0000000000001098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
PURPOSE OF REVIEW There is a clinical unmet need to improve treatment for patients with pulmonary sarcoidosis. Both retrospective and prospective drug trials are hampered by the fact that patients with sarcoidosis are characterized by a heterogeneous presentation and disease course. In this review, an overview is given of different drug trials in pulmonary sarcoidosis with an emphasis on different primary endpoints and the problems related to them. RECENT FINDINGS In recent years, using significant input from patients with sarcoidosis, different task-forces/studies tried to develop a core set of most important outcomes to measure in future studies on treatment of sarcoidosis. Furthermore, at present, three major clinical trials are being conducted on new drugs for treatment of pulmonary sarcoidosis. SUMMARY Progress has been made to develop a core set of outcomes measures that can be used in making a combined primary endpoint in future drug trials in sarcoidosis.
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Affiliation(s)
- Marcel Veltkamp
- ILD Center of Excellence, member of European Reference Network-Lung, St Antonius Hospital, Nieuwegein, The Netherlands
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2
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Bhargava M, Crouser ED. Application of laboratory models for sarcoidosis research. J Autoimmun 2024:103184. [PMID: 38443221 DOI: 10.1016/j.jaut.2024.103184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
This manuscript will review the implications and applications of sarcoidosis models towards advancing our understanding of sarcoidosis disease mechanisms, identification of biomarkers, and preclinical testing of novel therapies. Emerging disease models and innovative research tools will also be considered.
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Affiliation(s)
- Maneesh Bhargava
- University of Minnesota Medical Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, 420 Delaware Street SE, MMC 276. Minneapolis, MN 55455, USA
| | - Elliott D Crouser
- Ohio State University Wexner Medicine Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, 241 W. 11th Street, Suite 5000, Columbus, OH 43201, USA.
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3
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Cozier YC, Arkema EV. Epidemiology of Sarcoidosis. Clin Chest Med 2024; 45:1-13. [PMID: 38245359 DOI: 10.1016/j.ccm.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
Sarcoidosis is a systemic, granulomatous disease with variable presentation earning it the term "the great mimicker." The current epidemiology confirms that the disease occurs worldwide, affecting both sexes, and all races, ethnicities, and ages. To date, no causal exposure or agent has been identified. The organ systems most frequently affected by sarcoidosis are also those with greatest exposure to the natural world suggesting environmental and lifestyle contributions to the disease. These include particulate matter, microorganisms, nicotine, and obesity. In this article, we review the epidemiology of sarcoidosis and discuss these non-genetic risk factors in the hope of providing important insight into sarcoidosis and stimulating future research.
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Affiliation(s)
- Yvette C Cozier
- Department of Epidemiology, Boston University School of Public Health, 715 Albany Street, Talbot 3-East, Boston, MA 02118-2526, USA.
| | - Elizabeth V Arkema
- Department of Medicine Solna, Division of Clinical Epidemiology, Karolinska Institutet, T2, Stockholm 17176, Sweden
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Baughman RP, Lower E. D. Geraint James Lecture: The sarcoidosis saga: what insights from the past will guide us in the future. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2023; 40:e2023057. [PMID: 38126494 DOI: 10.36141/svdld.v40i4.15282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023]
Abstract
The sarcoidosis community in general and the World Association of Sarcoidosis and Other Granulomatous diseases (WASOG) in particular have led efforts to improve sarcoidosis diagnosis and care. Evidence based guidelines regarding the diagnosis and treatment have recently been published. In addition, several clinical trials examining existing and new treatments for sarcoidosis have been completed and published. In addition, WASOG has developed criteria and identified Centers of Excellence for sarcoidosis care around the world. In discussing what insights from the past will guide us in the future, this paper focuses on three specific topics: updating the diagnosis of sarcoidosis, using placebo-controlled trials to illuminate the natural course of pulmonary sarcoidosis; and exploring multidisciplinary sarcoidosis clinic care using Centers of Excellence. New approaches for diagnosis of sarcoidosis and steroid tapering are proposed based on current literature.
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5
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Arkema EV, Rossides M, Cozier YC. Sarcoidosis and its relation to other immune-mediated diseases: Epidemiological insights. J Autoimmun 2023:103127. [PMID: 37816661 DOI: 10.1016/j.jaut.2023.103127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/27/2023] [Accepted: 10/04/2023] [Indexed: 10/12/2023]
Abstract
Several epidemiological studies show a co-occurrence of sarcoidosis with other immune-mediated diseases (IMD). There are many similarities between sarcoidosis and IMDs in their geographical distribution and risk factors. Understanding these similarities and identifying the differences can help us to better understand sarcoidosis and put it into context with other IMDs. In this review, we present the current knowledge about the overlap between sarcoidosis and other IMDs derived from epidemiological studies. Epidemiologic methods utilize study design and statistical analysis to describe the patterns in data and, ideally, identify causal relationships between an exposure and a health outcome. We discuss how study design and analysis may affect the interpretation of epidemiological studies on this topic and highlight some theories that attempt to explain the relation between sarcoidosis and other IMDs.
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Affiliation(s)
- Elizabeth V Arkema
- Karolinska Institutet, Department of Medicine Solna, Clinical Epidemiology Division, Stockholm, Sweden.
| | - Marios Rossides
- Department of Respiratory Medicine and Allergy, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden; Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Yvette C Cozier
- Boston University School of Public Health, Department of Epidemiology, Boston, MA, USA; Slone Epidemiology Center, Boston University School of Medicine, Boston, MA, USA
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Levin AM, She R, Chen Y, Adrianto I, Datta I, Loveless IM, Garman L, Montgomery CG, Li J, Iannuzzi MC, Rybicki BA. Identification of Environmental Exposures Associated with Risk of Sarcoidosis in African Americans. Ann Am Thorac Soc 2023; 20:1274-1282. [PMID: 37209419 PMCID: PMC10502890 DOI: 10.1513/annalsats.202208-722oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 05/19/2023] [Indexed: 05/22/2023] Open
Abstract
Rationale: Sarcoidosis is a racially disparate granulomatous disease likely caused by environmental exposures, genes, and their interactions. Despite increased risk in African Americans, few environmental risk factor studies in this susceptible population exist. Objectives: To identify environmental exposures associated with the risk of sarcoidosis in African Americans and those that differ in effect by self-identified race and genetic ancestry. Methods: The study sample comprised 2,096 African Americans (1,205 with and 891 without sarcoidosis) compiled from three component studies. Unsupervised clustering and multiple correspondence analyses were used to identify underlying clusters of environmental exposures. Mixed-effects logistic regression was used to evaluate the association of these exposure clusters and the 51 single-component exposures with risk of sarcoidosis. A comparison case-control sample of 762 European Americans (388 with and 374 without sarcoidosis) was used to assess heterogeneity in exposure risk by race. Results: Seven exposure clusters were identified, five of which were associated with risk. The exposure cluster with the strongest risk association was composed of metals (P < 0.001), and within this cluster, exposure to aluminum had the highest risk (odds ratio, 3.30; 95% confidence interval [95% CI], 2.23-4.09; P < 0.001). This effect also differed by race (P < 0.001), with European Americans having no significant association with exposure (odds ratio, 0.86; 95% CI, 0.56-1.33). Within African Americans, the increased risk was dependent on genetic African ancestry (P = 0.047). Conclusions: Our findings support African Americans having sarcoidosis environmental exposure risk profiles that differ from those of European Americans. These differences may underlie racially disparate incidence rates that are partially explained by genetic variation differing by African ancestry.
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Affiliation(s)
- Albert M. Levin
- Department of Public Health Science and
- Center for Bioinformatics, Henry Ford Health System, Detroit, Michigan
| | - Ruicong She
- Department of Public Health Science and
- Center for Bioinformatics, Henry Ford Health System, Detroit, Michigan
| | - Yalei Chen
- Department of Public Health Science and
- Center for Bioinformatics, Henry Ford Health System, Detroit, Michigan
| | - Indra Adrianto
- Department of Public Health Science and
- Center for Bioinformatics, Henry Ford Health System, Detroit, Michigan
| | - Indrani Datta
- Department of Public Health Science and
- Center for Bioinformatics, Henry Ford Health System, Detroit, Michigan
| | - Ian M. Loveless
- Department of Public Health Science and
- Center for Bioinformatics, Henry Ford Health System, Detroit, Michigan
| | - Lori Garman
- Arthritis and Clinical Immunology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma; and
| | - Courtney G. Montgomery
- Arthritis and Clinical Immunology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma; and
| | - Jia Li
- Department of Public Health Science and
- Center for Bioinformatics, Henry Ford Health System, Detroit, Michigan
| | - Michael C. Iannuzzi
- Department of Medical Education, School of Medicine, City University of New York, New York, New York
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Hena KM, Patterson KC. Making Progress in Clinical Trials in Sarcoidosis. Chest 2023; 164:682-685. [PMID: 37019354 DOI: 10.1016/j.chest.2023.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/05/2023] Open
Affiliation(s)
- Kerry M Hena
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, New York University, New York, NY
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Abstract
Sarcoidosis is characterized by noncaseating granulomas which form in almost any part of the body, primarily in the lungs and/or thoracic lymph nodes. Environmental exposures in genetically susceptible individuals are believed to cause sarcoidosis. There is variation in incidence and prevalence by region and race. Males and females are almost equally affected, although disease peaks at a later age in females than in males. The heterogeneity of presentation and disease course can make diagnosis and treatment challenging. Diagnosis is suggestive in a patient if one or more of the following is present: radiologic signs of sarcoidosis, evidence of systemic involvement, histologically confirmed noncaseating granulomas, sarcoidosis signs in bronchoalveolar lavage fluid (BALF), and low probability or exclusion of other causes of granulomatous inflammation. No sensitive or specific biomarkers for diagnosis and prognosis exist, but there are several that can be used to support clinical decisions, such as serum angiotensin-converting enzyme levels, human leukocyte antigen types, and CD4 Vα2.3+ T cells in BALF. Corticosteroids remain the mainstay of treatment for symptomatic patients with severely affected or declining organ function. Sarcoidosis is associated with a range of adverse long-term outcomes and complications, and with great variation in prognosis between populations. New data and technologies have moved sarcoidosis research forward, increasing our understanding of the disease. However, there is still much left to be discovered. The pervading challenge is how to account for patient variability. Future studies should focus on how to optimize current tools and develop new approaches so that treatment and follow-up can be targeted to individuals with more precision.
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Affiliation(s)
- Marios Rossides
- Department of Respiratory Medicine and Allergy, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden.,Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Pernilla Darlington
- Department of Clinical Science and Education, Södersjukhuset and Karolinska Institutet, Stockholm, Sweden.,Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
| | - Susanna Kullberg
- Department of Respiratory Medicine and Allergy, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Solna, Respiratory Medicine Division & Center for Molecular Medicine (CMM), Karolinska Institutet, Stockholm, Sweden
| | - Elizabeth V Arkema
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
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Management of Sarcoidosis: When to Treat, How to Treat and for How Long? CURRENT PULMONOLOGY REPORTS 2022. [DOI: 10.1007/s13665-022-00298-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Abstract
Purpose of Review
This review draws together recent publications, consensus statements on sarcoidosis and our 25-year collective experience in managing this disease. We focus on pulmonary sarcoidosis, highlighting recent and established concepts in disease mechanisms, the diversity of the clinical course, including possible ‘subtypes’ of sarcoidosis, and how to measure disease activity. We discuss the principles guiding therapeutic intervention and summarise the more recent clinical trials in sarcoidosis.
Recent Findings
These include recent progress in understanding the mechanisms of disease using new scientific tools, measurements of disease activity using CT and MRI scans, and the potential role of anti-fibrotic treatment for patients with progressive fibrotic sarcoidosis.
Summary
Sarcoidosis is a heterogeneous disease with variable organ involvement, disease course, and response to treatment. We offer an angle on when and how to treat, and provide an overall roadmap for managing sarcoidosis.
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Obi ON, Saketkoo LA, Russell AM, Baughman RP. Sarcoidosis: Updates on therapeutic drug trials and novel treatment approaches. Front Med (Lausanne) 2022; 9:991783. [PMID: 36314034 PMCID: PMC9596775 DOI: 10.3389/fmed.2022.991783] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/17/2022] [Indexed: 12/04/2022] Open
Abstract
Sarcoidosis is a systemic granulomatous inflammatory disease of unknown etiology. It affects the lungs in over 90% of patients yet extra-pulmonary and multi-organ involvement is common. Spontaneous remission of disease occurs commonly, nonetheless, over 50% of patients will require treatment and up to 30% of patients will develop a chronic progressive non-remitting disease with marked pulmonary fibrosis leading to significant morbidity and death. Guidelines outlining an immunosuppressive treatment approach to sarcoidosis were recently published, however, the strength of evidence behind many of the guideline recommended drugs is weak. None of the drugs currently used for the treatment of sarcoidosis have been rigorously studied and prescription of these drugs is often based on off-label” indications informed by experience with other diseases. Indeed, only two medications [prednisone and repository corticotropin (RCI) injection] currently used in the treatment of sarcoidosis are approved by the United States Food and Drug Administration. This situation results in significant reimbursement challenges especially for the more advanced (and often more effective) drugs that are favored for severe and refractory forms of disease causing an over-reliance on corticosteroids known to be associated with significant dose and duration dependent toxicities. This past decade has seen a renewed interest in developing new drugs and exploring novel therapeutic pathways for the treatment of sarcoidosis. Several of these trials are active randomized controlled trials (RCTs) designed to recruit relatively large numbers of patients with a goal to determine the safety, efficacy, and tolerability of these new molecules and therapeutic approaches. While it is an exciting time, it is also necessary to exercise caution. Resources including research dollars and most importantly, patient populations available for trials are limited and thus necessitate that several of the challenges facing drug trials and drug development in sarcoidosis are addressed. This will ensure that currently available resources are judiciously utilized. Our paper reviews the ongoing and anticipated drug trials in sarcoidosis and addresses the challenges facing these and future trials. We also review several recently completed trials and draw lessons that should be applied in future.
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Affiliation(s)
- Ogugua Ndili Obi
- Division of Pulmonary Critical Care and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, United States,*Correspondence: Ogugua Ndili Obi,
| | - Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, LA, United States,University Medical Center—Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, New Orleans, LA, United States,Section of Pulmonary Medicine, Louisiana State University School of Medicine, New Orleans, LA, United States,Department of Undergraduate Honors, Tulane University School of Medicine, New Orleans, LA, United States
| | - Anne-Marie Russell
- Exeter Respiratory Institute University of Exeter, Exeter, United Kingdom,Royal Devon and Exeter NHS Foundation Trust, Devon, United Kingdom,Faculty of Medicine, Imperial College and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Robert P. Baughman
- Department of Medicine, University of Cincinnati, Cincinnati, OH, United States
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Xu C, Nery PB, Wiefels C, Beanlands RS, Spence SD, Juneau D, Promislow S, Boczar K, deKemp RA, Birnie DH. Negative Association of Smoking History With Clinically Manifest Cardiac Sarcoidosis: A Case-Control Study. CJC Open 2022; 4:756-762. [PMID: 36148253 PMCID: PMC9486855 DOI: 10.1016/j.cjco.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/05/2022] [Indexed: 11/26/2022] Open
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12
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Editorial: Sarcoidosis: now and into the future. Curr Opin Pulm Med 2022; 28:448-450. [PMID: 35938202 DOI: 10.1097/mcp.0000000000000899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Ye X, Zhang Y, Song X, Liu Q. Research Progress in the Pharmacological Effects and Synthesis of Nicotine. ChemistrySelect 2022. [DOI: 10.1002/slct.202104425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Xiaoping Ye
- Department of Pharmaceutical Engineering College of Chemical Engineering Northwest University Taibai North Road 229 Xi'an 710069 Shaanxi P.R. China
| | - Yanxin Zhang
- Department of Pharmaceutical Engineering College of Chemical Engineering Northwest University Taibai North Road 229 Xi'an 710069 Shaanxi P.R. China
- Glycobiology and Glycotechnology Research center College of Food Science and Technology Northwest University Taibai North Road 229 Xi'an 710069 Shaanxi P.R. China
- College of Life Sciences Northwest University Taibai North Road 229 Xi'an 710069 Shaanxi P.R. China
| | - Xiaoping Song
- Department of Pharmaceutical Engineering College of Chemical Engineering Northwest University Taibai North Road 229 Xi'an 710069 Shaanxi P.R. China
- Shaanxi Key Laboratory of Degradable Biomedical Materials College of Chemical Engineering Northwest University Taibai North Road 229 Xi'an 710069 Shaanxi P.R. China
- Shaanxi R&D Center of Biomaterials and Fermentation Engineering College of Chemical Engineering Northwest University Taibai North Road 229 Xi'an 710069 Shaanxi P.R. China
| | - Qingchao Liu
- Department of Pharmaceutical Engineering College of Chemical Engineering Northwest University Taibai North Road 229 Xi'an 710069 Shaanxi P.R. China
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Nienhuis WA, Grutters JC. Potential therapeutic targets to prevent organ damage in chronic pulmonary sarcoidosis. Expert Opin Ther Targets 2021; 26:41-55. [PMID: 34949145 DOI: 10.1080/14728222.2022.2022123] [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: 11/04/2022]
Abstract
INTRODUCTION Sarcoidosis is a granulomatous inflammatory disease with high chances of reduced quality of life, irreversible organ damage, and reduced life expectancy when vital organs are involved. Any organ system can be affected, and the lungs are most often affected. There is no preventive strategy as the exact etiology is unknown, and complex immunogenetic and environmental factors determine disease susceptibility and phenotype. Present-day treatment options originated from clinical practice and are effective in many patients. However, a substantial percentage of patients suffer from unacceptable side effects or still develop refractory, threatening pulmonary or extrapulmonary disease. AREAS COVERED As non-caseating granulomas, the pathological hallmark of disease, are assigned to divergent activation and regulation of the immune system, targets in relation to the possible triggers of granuloma formation and their sequelae were searched and reviewed. EXPERT OPINION :The immunopathogenesis underlying sarcoidosis has been a dynamic field of study. Several recent new insights give way to promising new therapeutic targets, such as certain antigenic triggers (e.g. from Aspergillus nidulans), mTOR, JAK-STAT and PPARγ pathways, the NRP2 receptor and MMP-12, which await further exploration. Clinical and trigger related phenotyping, and molecular endotyping in sarcoidosis will likely hold the key for precision medicine in the future.
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Affiliation(s)
- W A Nienhuis
- ILD Center of Excellence, Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - J C Grutters
- ILD Center of Excellence, Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands.,Division of Hearth and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
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Bhargava M, Mroz MM, Maier LA. Smoke Signals: Promise of Nicotine as a Treatment for Pulmonary Sarcoidosis. Chest 2021; 160:1169-1170. [PMID: 34625164 DOI: 10.1016/j.chest.2021.06.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Maneesh Bhargava
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep, University of Minnesota, Minneapolis, MN
| | - Margaret M Mroz
- Division of Environmental and Occupational Health Sciences, National Jewish Health, Denver, CO
| | - Lisa A Maier
- Division of Environmental and Occupational Health Sciences, National Jewish Health, Denver, CO; Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Department of Environmental and Occupational Health, Colorado School of Public Health, Aurora, CO.
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