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Bermudo Fuenmayor S, Serrano Castro PJ, Quiroga Subirana P, López Palmero S, Requena Mullor M, Parrón Carreño T. Environmental exposure to pesticides and Amyotrophic Lateral Sclerosis in the South of Spain. Neurologia 2023; 38:447-452. [PMID: 37659835 DOI: 10.1016/j.nrleng.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 01/01/2021] [Indexed: 09/04/2023] Open
Abstract
OBJECTIVE To determine if there is a relationship between environmental exposure to pesticides and the prevalence of Amyotrophic Lateral Sclerosis (ALS) in Andalusia. METHOD We carried out a case-control study using the logistic regression method to verify the relationship between the prevalence of ALS in the area exposed to pesticides versus the unexposed area, through the Odds Ratio statistical test. RESULTS The study population consisted of 519 individuals diagnosed with ALS between January 2016 and December 2018 according to the CMBD (Minimum Basic Data Set) as cases. In the control group, we have 8,384,083 individuals obtained from data from the National Institute of Statistics (INE). The Odds Ratio (OR) was used as a measure of association between cases and controls, obtaining an OR between 0.76 and 1.08 for the confidence interval of the CI (95%). CONCLUSIONS Despite the existence of various studies that suggest a possible association between environmental exposure to pesticides and the risk of Amyotrophic Lateral Sclerosis, our analysis of the Andalusian population did not find significant evidence of this association.
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Affiliation(s)
| | | | | | - S López Palmero
- Servicio de Medicina Interna en Complejo Hospitalario Torrecárdenas, Spain
| | | | - T Parrón Carreño
- Unidad de Delegación Territorial para la igualdad, salud y políticas sociales, Almería, Spain
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Boyle J, Wheeler DC, Naum R, Burke Brockenbrough P, Gebhardt M, Smith L, Harrell T, Stewart D, Gwathmey K. Analysis of the spatial distribution of amyotrophic lateral sclerosis in Virginia. Amyotroph Lateral Scler Frontotemporal Degener 2023:1-9. [PMID: 37452450 DOI: 10.1080/21678421.2023.2236653] [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: 03/20/2023] [Revised: 06/21/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
Objective: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder that is usually fatal. Environmental exposures have been posited in the etiology of ALS, but few studies have modeled the spatial risk of ALS over large geographic areas. In this paper, our goal was to analyze the spatial distribution of ALS in Virginia and identify any areas with significantly elevated risk using Virginia ALS Association administrative data. Methods: We used Bayesian hierarchical spatial regression models to estimate the relative risk for ALS in Virginia census tracts, adjusting for several covariates posited to be associated with the disease. We used an intrinsic conditional autoregressive prior to allow for spatial correlation in the risk estimates and stabilize estimates over space. Results: Considerable variation in ALS risk existed across Virginia, with greater relative risk found in the central and western parts of the state. We identified significantly elevated relative risk in a number of census tracts. In particular, Henrico, Albemarle, and Botetourt counties all contained at least four census tracts with significantly elevated risk. Conclusions: We identified several areas with significantly elevated ALS risk across Virginia census tracts. These results can inform future studies of potential environmental triggers for the disease, whose etiology is still being understood.
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Affiliation(s)
- Joseph Boyle
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - David C Wheeler
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Ryan Naum
- Department of Neurology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA, and
| | - Paula Burke Brockenbrough
- Department of Neurology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA, and
| | - Michelle Gebhardt
- Department of Neurology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA, and
| | - LaVon Smith
- Department of Neurology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA, and
| | | | | | - Kelly Gwathmey
- Department of Neurology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA, and
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Spencer PS, Palmer VS, Kisby GE, Lagrange E, Horowitz BZ, Valdes Angues R, Reis J, Vernoux JP, Raoul C, Camu W. Early-onset, conjugal, twin-discordant, and clusters of sporadic ALS: Pathway to discovery of etiology via lifetime exposome research. Front Neurosci 2023; 17:1005096. [PMID: 36860617 PMCID: PMC9969898 DOI: 10.3389/fnins.2023.1005096] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 01/09/2023] [Indexed: 02/17/2023] Open
Abstract
The identity and role of environmental factors in the etiology of sporadic amyotrophic lateral sclerosis (sALS) is poorly understood outside of three former high-incidence foci of Western Pacific ALS and a hotspot of sALS in the French Alps. In both instances, there is a strong association with exposure to DNA-damaging (genotoxic) chemicals years or decades prior to clinical onset of motor neuron disease. In light of this recent understanding, we discuss published geographic clusters of ALS, conjugal cases, single-affected twins, and young-onset cases in relation to their demographic, geographic and environmental associations but also whether, in theory, there was the possibility of exposure to genotoxic chemicals of natural or synthetic origin. Special opportunities to test for such exposures in sALS exist in southeast France, northwest Italy, Finland, the U.S. East North Central States, and in the U.S. Air Force and Space Force. Given the degree and timing of exposure to an environmental trigger of ALS may be related to the age at which the disease is expressed, research should focus on the lifetime exposome (from conception to clinical onset) of young sALS cases. Multidisciplinary research of this type may lead to the identification of ALS causation, mechanism, and primary prevention, as well as to early detection of impending ALS and pre-clinical treatment to slow development of this fatal neurological disease.
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Affiliation(s)
- Peter S. Spencer
- Department of Neurology, School of Medicine, Oregon Health and Science University, Portland, OR, United States,Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, OR, United States,*Correspondence: Peter S. Spencer,
| | - Valerie S. Palmer
- Department of Neurology, School of Medicine, Oregon Health and Science University, Portland, OR, United States
| | - Glen E. Kisby
- College of Osteopathic Medicine of the Pacific Northwest, Western University of Health Sciences, Lebanon, OR, United States
| | - Emmeline Lagrange
- Department of Neurology, Reference Center of Neuromuscular Disease and ALS Consultations, Grenoble University Hospital, Grenoble, France
| | - B. Zane Horowitz
- Department of Emergency Medicine, Oregon-Alaska Poison Center, Oregon Health and Science University, Portland, OR, United States
| | - Raquel Valdes Angues
- Department of Neurology, School of Medicine, Oregon Health and Science University, Portland, OR, United States
| | - Jacques Reis
- University of Strasbourg, Faculté de Médecine, Strasbourg, France
| | - Jean-Paul Vernoux
- Normandie Université, UNICAEN, Unité de Recherche Aliments Bioprocédés Toxicologie Environnements, Caen, France
| | - Cédric Raoul
- INM, University of Montpellier, INSERM, Montpellier, France
| | - William Camu
- ALS Reference Center, Montpellier University Hospital and University of Montpellier, INSERM, Montpellier, France
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Saucier D, Registe PPW, Bélanger M, O'Connell C. Urbanization, air pollution, and water pollution: Identification of potential environmental risk factors associated with amyotrophic lateral sclerosis using systematic reviews. Front Neurol 2023; 14:1108383. [PMID: 36970522 PMCID: PMC10030603 DOI: 10.3389/fneur.2023.1108383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 02/13/2023] [Indexed: 03/29/2023] Open
Abstract
Introduction Despite decades of research, causes of ALS remain unclear. To evaluate recent hypotheses of plausible environmental factors, the aim of this study was to synthesize and appraise literature on the potential associations between the surrounding environment, including urbanization, air pollution and water pollution, and ALS. Methods We conducted a series (n = 3) of systematic reviews in PubMed and Scopus to identify epidemiological studies assessing relationships between urbanization, air pollution and water pollution with the development of ALS. Results The combined search strategy led to the inclusion of 44 articles pertaining to at least one exposure of interest. Of the 25 included urbanization studies, four of nine studies on living in rural areas and three of seven studies on living in more highly urbanized/dense areas found positive associations to ALS. There were also three of five studies for exposure to electromagnetic fields and/or proximity to powerlines that found positive associations to ALS. Three case-control studies for each of diesel exhaust and nitrogen dioxide found positive associations with the development of ALS, with the latter showing a dose-response in one study. Three studies for each of high selenium content in drinking water and proximity to lakes prone to cyanobacterial blooms also found positive associations to ALS. Conclusion Whereas markers of air and water pollution appear as potential risk factors for ALS, results are mixed for the role of urbanization.
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Affiliation(s)
- Daniel Saucier
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
- Center de formation médicale du Nouveau-Brunswick, Moncton, NB, Canada
- *Correspondence: Daniel Saucier
| | - Pierre Philippe Wilson Registe
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
- Center de formation médicale du Nouveau-Brunswick, Moncton, NB, Canada
| | - Mathieu Bélanger
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
- Center de formation médicale du Nouveau-Brunswick, Moncton, NB, Canada
| | - Colleen O'Connell
- Stan Cassidy Center for Rehabilitation, Fredericton, NB, Canada
- Department of Medicine, Dalhousie Medicine New Brunswick, Saint John, NB, Canada
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Kip E, Parr-Brownlie LC. Healthy lifestyles and wellbeing reduce neuroinflammation and prevent neurodegenerative and psychiatric disorders. Front Neurosci 2023; 17:1092537. [PMID: 36875655 PMCID: PMC9975355 DOI: 10.3389/fnins.2023.1092537] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/23/2023] [Indexed: 02/17/2023] Open
Abstract
Since the mid-20th century, Western societies have considered productivity and economic outcomes are more important than focusing on people's health and wellbeing. This focus has created lifestyles with high stress levels, associated with overconsumption of unhealthy foods and little exercise, which negatively affect people's lives, and subsequently lead to the development of pathologies, including neurodegenerative and psychiatric disorders. Prioritizing a healthy lifestyle to maintain wellbeing may slow the onset or reduce the severity of pathologies. It is a win-win for everyone; for societies and for individuals. A balanced lifestyle is increasingly being adopted globally, with many doctors encouraging meditation and prescribing non-pharmaceutical interventions to treat depression. In psychiatric and neurodegenerative disorders, the inflammatory response system of the brain (neuroinflammation) is activated. Many risks factors are now known to be linked to neuroinflammation such as stress, pollution, and a high saturated and trans fat diet. On the other hand, many studies have linked healthy habits and anti-inflammatory products with lower levels of neuroinflammation and a reduced risk of neurodegenerative and psychiatric disorders. Sharing risk and protective factors is critical so that individuals can make informed choices that promote positive aging throughout their lifespan. Most strategies to manage neurodegenerative diseases are palliative because neurodegeneration has been progressing silently for decades before symptoms appear. Here, we focus on preventing neurodegenerative diseases by adopting an integrated "healthy" lifestyle approach. This review summarizes the role of neuroinflammation on risk and protective factors of neurodegenerative and psychiatric disorders.
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Affiliation(s)
- Elodie Kip
- Department of Anatomy, School of Biomedical Sciences, Brain Health Research Centre, Brain Research New Zealand, University of Otago, Dunedin, New Zealand
| | - Louise C Parr-Brownlie
- Department of Anatomy, School of Biomedical Sciences, Brain Health Research Centre, Brain Research New Zealand, University of Otago, Dunedin, New Zealand
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Arab A, Mostafalou S. Neurotoxicity of pesticides in the context of CNS chronic diseases. INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 2022; 32:2718-2755. [PMID: 34663153 DOI: 10.1080/09603123.2021.1987396] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/26/2021] [Indexed: 06/13/2023]
Abstract
Following the introduction and application of pesticides in human life, they have always been along with health concerns both in acute poisoning and chronic toxicities. Neurotoxicity of pesticides in chronic exposures has been known as one of the most important human health problems, as most of these chemicals act through interacting with some elements of nervous system. Pesticide-induced neurotoxicity can be defined in different categories of neurological disorders including neurodegenerative (Alzheimer, Parkinson, amyotrophic lateral sclerosis, multiple sclerosis), neurodevelopmental (attention deficit hyperactivity disorder, autism spectrum disorders, developmental delay, and intellectual disability), neurobehavioral and neuropsychiatric (depression/suicide attempt, anxiety/insomnia, and cognitive impairment) disorders some of which are among the most debilitating human health problems. In this review, neurotoxicity of pesticides in the mentioned categories and sub-categories of neurological diseases have been systematically presented in relation to different route of exposures including general, occupational, environmental, prenatal, postnatal, and paternal.
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Affiliation(s)
- Ali Arab
- Department of Pharmacology and Toxicology, School of Pharmacy, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Sara Mostafalou
- Department of Pharmacology and Toxicology, School of Pharmacy, Ardabil University of Medical Sciences, Ardabil, Iran
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Parks RM, Nunez Y, Balalian AA, Gibson EA, Hansen J, Raaschou-Nielsen O, Ketzel M, Khan J, Brandt J, Vermeulen R, Peters S, Goldsmith J, Re DB, Weisskopf MG, Kioumourtzoglou MA. Long-term Traffic-related Air Pollutant Exposure and Amyotrophic Lateral Sclerosis Diagnosis in Denmark: A Bayesian Hierarchical Analysis. Epidemiology 2022; 33:757-766. [PMID: 35944145 PMCID: PMC9560992 DOI: 10.1097/ede.0000000000001536] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease. Limited evidence suggests ALS diagnosis may be associated with air pollution exposure and specifically traffic-related pollutants. METHODS In this population-based case-control study, we used 3,937 ALS cases from the Danish National Patient Register diagnosed during 1989-2013 and matched on age, sex, year of birth, and vital status to 19,333 population-based controls free of ALS at index date. We used validated predictions of elemental carbon (EC), nitrogen oxides (NO x ), carbon monoxide (CO), and fine particles (PM 2.5 ) to assign 1-, 5-, and 10-year average exposures pre-ALS diagnosis at study participants' present and historical residential addresses. We used an adjusted Bayesian hierarchical conditional logistic model to estimate individual pollutant associations and joint and average associations for traffic-related pollutants (EC, NO x , CO). RESULTS For a standard deviation (SD) increase in 5-year average concentrations, EC (SD = 0.42 µg/m 3 ) had a high probability of individual association with increased odds of ALS (11.5%; 95% credible interval [CrI] = -1.0%, 25.6%; 96.3% posterior probability of positive association), with negative associations for NO x (SD = 20 µg/m 3 ) (-4.6%; 95% CrI = 18.1%, 8.9%; 27.8% posterior probability of positive association), CO (SD = 106 µg/m 3 ) (-3.2%; 95% CrI = 14.4%, 10.0%; 26.7% posterior probability of positive association), and a null association for nonelemental carbon fine particles (non-EC PM 2.5 ) (SD = 2.37 µg/m 3 ) (0.7%; 95% CrI = 9.2%, 12.4%). We found no association between ALS and joint or average traffic pollution concentrations. CONCLUSIONS This study found high probability of a positive association between ALS diagnosis and EC concentration. Further work is needed to understand the role of traffic-related air pollution in ALS pathogenesis.
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Affiliation(s)
- Robbie M Parks
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, New York, USA
- The Earth Institute, Columbia University, New York, New York, USA
| | - Yanelli Nunez
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Arin A Balalian
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Elizabeth A Gibson
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, New York, USA
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Johnni Hansen
- Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Ole Raaschou-Nielsen
- Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Environmental Science, Aarhus University, Roskilde, Denmark
| | - Matthias Ketzel
- Department of Environmental Science, Aarhus University, Roskilde, Denmark
- Global Centre for Clean Air Research (GCARE), University of Surrey, Guildford, United Kingdom
| | - Jibran Khan
- Department of Environmental Science, Aarhus University, Roskilde, Denmark
| | - Jørgen Brandt
- Department of Environmental Science, Aarhus University, Roskilde, Denmark
- iClimate – interdisciplinary Center for Climate Change, Aarhus University, Denmark
| | - Roel Vermeulen
- Institute for Risk Assessment Sciences, Utrecht University, Utrecht, the Netherlands
| | - Susan Peters
- Institute for Risk Assessment Sciences, Utrecht University, Utrecht, the Netherlands
| | - Jeff Goldsmith
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Diane B. Re
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Marc G. Weisskopf
- Departments of Environmental Health and Epidemiology, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Marianthi-Anna Kioumourtzoglou
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, New York, USA
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Andrew A, Zhou J, Gui J, Harrison A, Shi X, Li M, Guetti B, Nathan R, Tischbein M, Pioro E, Stommel E, Bradley W. Airborne lead and polychlorinated biphenyls (PCBs) are associated with amyotrophic lateral sclerosis (ALS) risk in the U.S. THE SCIENCE OF THE TOTAL ENVIRONMENT 2022; 819:153096. [PMID: 35041949 PMCID: PMC10752436 DOI: 10.1016/j.scitotenv.2022.153096] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 01/09/2022] [Accepted: 01/09/2022] [Indexed: 06/14/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) risk is linked to environmental exposures. The National Emissions Inventory (NEI) database compiles mandatory reports of levels of airborne contaminants from a variety of stationary and mobile pollution sources across the U.S. The objective of this study was to identify airborne contaminants that may be associated with ALS etiology for future study. We geospatially estimated exposure to airborne contaminants as risk factors for ALS in a nationwide large de-identified medical claims database, the SYMPHONY Integrated Dataverse®. We extracted zip3 of residence at diagnosis of ~26,000 nationally distributed ALS patients and n = 3 non-ALS controls matched per case for age and sex. We individually aggregated the median levels of each of 268 airborne contaminants recorded in the NEI database for 2008 to estimate local residential exposure. We randomly broke the dataset into two independent groups to form independent discovery and validation cohorts. Contaminants associated with increased ALS risk in both the discovery and validation studies included airborne lead (false discovery rate (FDR) = 0.00077), and polychlorinated biphenyls (PCBs), such as heptachlorobiphenyl (FDR = 3.60E-05). Small aircraft were the largest source of airborne lead, while the PCB emissions came from certain power plants burning biomass, and from industrial boilers. Associations with residential history of lead exposure were confirmed in two additional cohorts (10 year top quartile in New Hampshire/Vermont OR 2.46 95% CI 1.46-2.80, and in Ohio OR 1.60 95% CI 1.28-1.98). The results of our geospatial analysis support neurotoxic airborne metals and PCBs as risk factors for ALS.
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Affiliation(s)
- Angeline Andrew
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America.
| | - Jie Zhou
- Dartmouth College, Hanover, NH, United States of America
| | - Jiang Gui
- Dartmouth College, Hanover, NH, United States of America
| | - Antoinette Harrison
- Mitsubishi Tanabe Pharma America, Inc., Jersey City, NJ, United States of America
| | - Xun Shi
- Dartmouth College, Hanover, NH, United States of America
| | - Meifang Li
- Dartmouth College, Hanover, NH, United States of America
| | - Bart Guetti
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America
| | | | - Maeve Tischbein
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America
| | - Erik Pioro
- Cleveland Clinic, Cleveland, OH, United States of America
| | - Elijah Stommel
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America
| | - Walter Bradley
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, United States of America
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Residential exposure to electromagnetic fields and risk of amyotrophic lateral sclerosis: a dose-response meta-analysis. Sci Rep 2021; 11:11939. [PMID: 34099747 PMCID: PMC8185090 DOI: 10.1038/s41598-021-91349-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/25/2021] [Indexed: 11/08/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is neurodegenerative disease characterized by a fatal prognosis and still unknown etiology. Some environmental risk factors have been suggested, including exposure to magnetic fields. Studies have suggested positive associations in occupationally-exposed populations, but the link with residential exposure is still debated as is the shape of such relation. Due to recent availability of advanced biostatistical tools for dose–response meta-analysis, we carried out a systematic review in order to assess the dose–response association between ALS and residential exposure to magnetic fields. We performed an online literature searching through April 30, 2021. Studies were included if they assessed residential exposure to electromagnetic fields, based either on distance from overhead power lines or on magnetic field modelling techniques, and if they reported risk estimates for ALS. We identified six eligible studies, four using distance-based and one modelling-based exposure assessment, and one both methods. Both distance-based and particularly modelling-based exposure estimates appeared to be associated with a decreased ALS risk in the highest exposure category, although estimates were very imprecise (summary RRs 0.87, 95% CI 0.63–1.20, and 0.27, 95% CI 0.05–1.36). Dose–response meta-analysis also showed little association between distance from power lines and ALS, with no evidence of any threshold. Overall, we found scant evidence of a positive association between residential magnetic fields exposure and ALS, although the available data were too limited to conduct a dose–response analysis for the modelled magnetic field estimates or to perform stratified analyses.
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Muscle Function Differences between Patients with Bulbar and Spinal Onset Amyotrophic Lateral Sclerosis. Does It Depend on Peripheral Glucose? J Clin Med 2021; 10:jcm10081582. [PMID: 33918552 PMCID: PMC8069029 DOI: 10.3390/jcm10081582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/17/2021] [Accepted: 04/02/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND One of the pathogenic mechanisms of ALS disease is perturbed energy metabolism particularly glucose metabolism. Given the substantial difference in the severity and the prognosis of the disease, depending on whether it has a bulbar or spinal onset, the aim of the study was to determine metabolic differences between both types of ALS, as well as the possible relationship with muscle function. MATERIALS AND METHODS A descriptive, analytical, quantitative, and transversal study was carried out in hospitals and Primary Care centers in the region of Valencia, Spain. Fasting glucose and alkaline phosphatase (AP) levels in venous blood, muscle percentage, fat percentage, muscle strength (MRC scale), and functional capacity (Barthel Index) were measured in 31 patients diagnosed with ALS (20 with spinal onset ALS and 11 with bulbar onset ALS). A healthy control of 29 people was included. RESULTS No significant differences were observed in blood AP and glucose levels between spinal onset and bulbar onset ALS patients. However, a significant positive correlation was observed between the mean values of both substances in patients with spinal onset ALS. Moreover, a lower percentage of muscle mass and a higher percentage of fat mass were also seen in spinal ALS patients, who also presented lower muscle strength and lower functional capacity. CONCLUSION The results of this study seem to point to a possible difference in the peripheral use of glucose between patients with bulbar onset ALS and spinal onset ALS, who appear to have possible insulin resistance. These metabolic differences could explain the lower muscle percentage and lower muscular function in spinal onset ALS patients, although further studies are required.
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11
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Bermudo Fuenmayor S, Serrano Castro PJ, Quiroga Subirana P, López Palmero S, Requena Mullor M, Parrón Carreño T. Environmental exposure to pesticides and Amyotrophic Lateral Sclerosis in the South of Spain. Neurologia 2021; 38:S0213-4853(21)00030-X. [PMID: 33771383 DOI: 10.1016/j.nrl.2021.01.013] [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: 12/19/2020] [Accepted: 01/01/2021] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE To determine if there is a relationship between environmental exposure to pesticides and the prevalence of Amyotrophic Lateral Sclerosis (ALS) in Andalusia. METHOD We carried out a case-control study using the logistic regression method to verify the relationship between the prevalence of ALS in the area exposed to pesticides versus the unexposed area, through the Odds Ratio statistical test. RESULTS The study population consisted of 519 individuals diagnosed with ALS between January 2016 and December 2018 according to the CMBD (Minimum Basic Data Set) as cases. In the control group, we have 8,384,083 individuals obtained from data from the National Institute of Statistics (INE). The Odds Ratio (OR) was used as a measure of association between cases and controls, obtaining an OR between 0.76 and 1.08 for the confidence interval of the CI (95%). CONCLUSIONS Despite the existence of various studies that suggest a possible association between environmental exposure to pesticides and the risk of Amyotrophic Lateral Sclerosis, our analysis of the Andalusian population did not find significant evidence of this association.
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Affiliation(s)
| | | | | | - S López Palmero
- Servicio de Medicina Interna en Complejo Hospitalario Torrecárdenas, Spain
| | | | - T Parrón Carreño
- Unidad de Delegación Territorial para la igualdad, salud y políticas sociales, Almería, Spain
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12
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Filippini T, Mandrioli J, Malagoli C, Costanzini S, Cherubini A, Maffeis G, Vinceti M. Risk of Amyotrophic Lateral Sclerosis and Exposure to Particulate Matter from Vehicular Traffic: A Case-Control Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18030973. [PMID: 33499343 PMCID: PMC7908475 DOI: 10.3390/ijerph18030973] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 12/26/2022]
Abstract
(1) Background: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease with still unknown etiology. Some occupational and environmental risk factors have been suggested, including long-term air pollutant exposure. We carried out a pilot case-control study in order to evaluate ALS risk due to particulate matter with a diameter of ≤10 µm (PM10) as a proxy of vehicular traffic exposure. (2) Methods: We recruited ALS patients and controls referred to the Modena Neurology ALS Care Center between 1994 and 2015. Using a geographical information system, we modeled PM10 concentrations due to traffic emissions at the geocoded residence address at the date of case diagnosis. We computed the odds ratio (OR) and 95% confidence interval (CI) of ALS according to increasing PM10 exposure, using an unconditional logistic regression model adjusted for age and sex. (3) Results: For the 132 study participants (52 cases and 80 controls), the average of annual median and maximum PM10 concentrations were 5.2 and 38.6 µg/m3, respectively. Using fixed cutpoints at 5, 10, and 20 of the annual median PM10 levels, and compared with exposure <5 µg/m3, we found no excess ALS risk at 5-10 µg/m3 (OR 0.87, 95% CI 0.39-1.96), 10-20 µg/m3 (0.94, 95% CI 0.24-3.70), and ≥20 µg/m3 (0.87, 95% CI 0.05-15.01). Based on maximum PM10 concentrations, we found a statistically unstable excess ALS risk for subjects exposed at 10-20 µg/m3 (OR 4.27, 95% CI 0.69-26.51) compared with those exposed <10 µg/m3. However, risk decreased at 20-50 µg/m3 (OR 1.49, 95% CI 0.39-5.75) and ≥50 µg/m3 (1.16, 95% CI 0.28-4.82). ALS risk in increasing tertiles of exposure showed a similar null association, while comparison between the highest and the three lowest quartiles lumped together showed little evidence for an excess risk at PM10 concentrations (OR 1.13, 95% CI 0.50-2.55). After restricting the analysis to subjects with stable residence, we found substantially similar results. (4) Conclusions: In this pilot study, we found limited evidence of an increased ALS risk due to long-term exposure at high PM10 concentration, though the high statistical imprecision of the risk estimates, due to the small sample size, particularly in some exposure categories, limited our capacity to detect small increases in risk, and further larger studies are needed to assess this relation.
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Affiliation(s)
- Tommaso Filippini
- Department of Biomedical, Metabolic and Neural Sciences, CREAGEN Environmental, Genetic and Nutritional Epidemiology Research Center, University of Modena and Reggio Emilia, 41125 Modena, Italy; (T.F.); (C.M.)
| | - Jessica Mandrioli
- Neurology Unit, Department of Neuroscience, S. Agostino Estense Hospital, Azienda Ospedaliero Universitaria di Modena, 41126 Modena, Italy;
| | - Carlotta Malagoli
- Department of Biomedical, Metabolic and Neural Sciences, CREAGEN Environmental, Genetic and Nutritional Epidemiology Research Center, University of Modena and Reggio Emilia, 41125 Modena, Italy; (T.F.); (C.M.)
| | - Sofia Costanzini
- DIEF Department of Engineering “Enzo Ferrari,” University of Modena and Reggio Emilia, 41125 Modena, Italy;
| | | | | | - Marco Vinceti
- Department of Biomedical, Metabolic and Neural Sciences, CREAGEN Environmental, Genetic and Nutritional Epidemiology Research Center, University of Modena and Reggio Emilia, 41125 Modena, Italy; (T.F.); (C.M.)
- Department of Epidemiology, Boston University School of Public Health, Boston, MA 02118, USA
- Correspondence:
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Oggiano R, Pisano A, Sabalic A, Farace C, Fenu G, Lintas S, Forte G, Bocca B, Madeddu R. An overview on amyotrophic lateral sclerosis and cadmium. Neurol Sci 2020; 42:531-537. [PMID: 33280067 PMCID: PMC7843544 DOI: 10.1007/s10072-020-04957-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/01/2020] [Indexed: 12/11/2022]
Abstract
The present review represents an update about the knowledge of the possible role of Cadmium (Cd) in amyotrophic lateral sclerosis (ALS) initiation and its progression. ALS is a neurodegenerative disease that occurs in adulthood; its etiology is unknown and leads to death within a few years from its appearance. Among the various possible causes that can favor the development of the disease, heavy metals cannot be excluded. Cadmium is a heavy metal that does not play a biological role, but its neurotoxicity is well known. Numerous in vitro studies on cell and animal models confirm the toxicity of the metal on the nervous system, but these data are not accompanied by an epidemiological evidence, and, thus, an unclear correlation between Cd and the onset of the disease can be pointed out. On the other hand, a possible multifactorial and synergic mechanism in which Cd may have a role can explain the ALS onset. More efforts in new clinical, biochemical, and epidemiological studies are necessary to better elucidate the involvement of Cd in this lethal disease.
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Affiliation(s)
- Riccardo Oggiano
- Department of Biomedical Science - Histology, University of Sassari, Sassari, Italy
| | - Andrea Pisano
- Department of Biomedical Science - Histology, University of Sassari, Sassari, Italy
| | - Angela Sabalic
- Department of Biomedical Science - Histology, University of Sassari, Sassari, Italy
| | - Cristiano Farace
- Department of Biomedical Science - Histology, University of Sassari, Sassari, Italy.,National Institute of Biostructures and Biosystems, Rome, Italy
| | - Grazia Fenu
- Department of Biomedical Science - Histology, University of Sassari, Sassari, Italy
| | - Simone Lintas
- Department of Biomedical Science - Histology, University of Sassari, Sassari, Italy
| | - Giovanni Forte
- Department of Environment and Health, Istituto Superiore di Sanità, Rome, Italy
| | - Beatrice Bocca
- Department of Environment and Health, Istituto Superiore di Sanità, Rome, Italy
| | - Roberto Madeddu
- Department of Biomedical Science - Histology, University of Sassari, Sassari, Italy. .,National Institute of Biostructures and Biosystems, Rome, Italy.
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Oliveira M, Padrão A, Ramalho A, Lobo M, Teodoro AC, Gonçalves H, Freitas A. Geospatial Analysis of Environmental Atmospheric Risk Factors in Neurodegenerative Diseases: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228414. [PMID: 33202965 PMCID: PMC7697835 DOI: 10.3390/ijerph17228414] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/12/2022]
Abstract
Despite the vast evidence on the environmental influence in neurodegenerative diseases, those considering a geospatial approach are scarce. We conducted a systematic review to identify studies concerning environmental atmospheric risk factors for neurodegenerative diseases that have used geospatial analysis/tools. PubMed, Web of Science, and Scopus were searched for all scientific studies that included a neurodegenerative disease, an environmental atmospheric factor, and a geographical analysis. Of the 34 included papers, approximately 60% were related to multiple sclerosis (MS), hence being the most studied neurodegenerative disease in the context of this study. Sun exposure (n = 13) followed by the most common exhaustion gases (n = 10 for nitrogen dioxide (NO2) and n = 5 for carbon monoxide (CO)) were the most studied atmospheric factors. Only one study used a geospatial interpolation model, although 13 studies used remote sensing data to compute atmospheric factors. In 20% of papers, we found an inverse correlation between sun exposure and multiple sclerosis. No consensus was reached in the analysis of nitrogen dioxide and Parkinson’s disease, but it was related to dementia and amyotrophic lateral sclerosis. This systematic review (number CRD42020196188 in PROSPERO’s database) provides an insight into the available evidence regarding the geospatial influence of environmental factors on neurodegenerative diseases.
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Affiliation(s)
- Mariana Oliveira
- CINTESIS—Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal; (A.R.); (M.L.); (H.G.); (A.F.)
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal
- Correspondence:
| | - André Padrão
- Faculty of Arts and Humanities, University of Porto, Via Panorâmica, s/n, 4150-564 Porto, Portugal;
| | - André Ramalho
- CINTESIS—Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal; (A.R.); (M.L.); (H.G.); (A.F.)
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal
| | - Mariana Lobo
- CINTESIS—Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal; (A.R.); (M.L.); (H.G.); (A.F.)
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal
| | - Ana Cláudia Teodoro
- Department of Geosciences, Environment and Land Planning, Faculty of Sciences, University of Porto, Rua do Campo Alegre 687, 4169-007 Porto, Portugal;
- Earth Sciences Institute (ICT), Pole of the FCUP, University of Porto, 4169-007 Porto, Portugal
| | - Hernâni Gonçalves
- CINTESIS—Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal; (A.R.); (M.L.); (H.G.); (A.F.)
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal
| | - Alberto Freitas
- CINTESIS—Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal; (A.R.); (M.L.); (H.G.); (A.F.)
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal
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Amyotrophic lateral sclerosis and lead: A systematic update. Neurotoxicology 2020; 81:80-88. [PMID: 32941938 DOI: 10.1016/j.neuro.2020.09.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/22/2020] [Accepted: 09/08/2020] [Indexed: 12/12/2022]
Abstract
Heavy metals are considered to be among the leading environmental factors that trigger amyotrophic lateral sclerosis (ALS). However, no convincing biopathological mechanism and therapeutic clinical implication of such metals in ALS pathogenesis have been established. This is partly attributable to the technical and scientific difficulties in demonstrating a direct and causative role of heavy metals in the onset of ALS in patients. However, a body of epidemiological, clinical and experimental evidences suggest that lead (Pb), more than other metals, could actually play a major role in the onset and progression of ALS. Here, to clarify the nature of the association and the causative role of Pb in ALS, we comprehensively reviewed the scientific literature of the last decade with objective database searches and the methods typically adopted in systematic reviews, critically analysing and summarising the various scientifically sound evidence on the relationship between ALS and Pb. From these tasks, we noted a number of multidisciplinary associations between ALS and Pb, and specifically the importance of occupational exposure to Pb in ALS development and/or progression. We also report the possible involvement of TAR DNA binding protein (TDP-43)-based molecular mechanism in Pb-mediated ALS, although these data rely on a single study, which included both in vitro experiments and an animal model, and are therefore still preliminary. Finally, we briefly examined whether this knowledge could inspire new targeted therapies and policies in the fight against ALS.
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Joseph AC, Fuentes M, Wheeler DC. The impact of population mobility on estimates of environmental exposure effects in a case-control study. Stat Med 2020; 39:1610-1622. [PMID: 32059071 DOI: 10.1002/sim.8501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 09/20/2019] [Accepted: 10/28/2019] [Indexed: 12/12/2022]
Abstract
In many studies of environmental risk factors for disease, researchers use the location at diagnosis as a geographic reference for environmental exposures. However, many environmental pollutants change continuously over space and time. The dynamic characteristics of these pollutants coupled with population mobility in the United States suggest that for diseases with long latencies like cancer, historic exposures may be more relevant than exposure at the time of diagnosis. In this article, we evaluated to what extent the commonly used assumption of no population mobility results in increased bias in the estimates of the relationship between environmental exposures and long-latency health outcomes disease in a case-control study. We conducted a simulation study using the residential histories of a random sample from the National Institutes of Health-AARP (formerly American Association of Retired Persons) Diet and Health Study. We simulated case-control status based on subject exposure and true exposure effects that varied temporally. We compared estimates from models using only subject location at diagnosis to estimates where subjects were assumed to be mobile. Ignoring population mobility resulted in underestimates of subject exposure, with largest deviations observed at time points further away from study enrollment. In general, the effect of population mobility on the bias of the estimates of the relationship between the exposure and the outcome was more prominent with exposures that showed substantial spatial and temporal variability. Based on our results, we recommend using residential histories when environmental exposures and disease latencies span a long enough time period that mobility is important.
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Affiliation(s)
- Anny-Claude Joseph
- Department of Mathematical Sciences, United States Military Academy, West Point, NY
| | - Montserrat Fuentes
- Office of the Executive Vice President and Provost, University of Iowa, Iowa City, IA
| | - David C Wheeler
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
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Chen GX, ’t Mannetje AM, Douwes J, van den Berg L, Pearce N, Kromhout H, D’Souza W, McConnell M, Glass B, Brewer N, McLean DJ. Occupation and motor neuron disease: a New Zealand case–control study. Occup Environ Med 2019; 76:309-316. [DOI: 10.1136/oemed-2018-105605] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 02/15/2019] [Accepted: 02/25/2019] [Indexed: 12/12/2022]
Abstract
ObjectivesTo assess associations between occupation and motor neuron disease (MND).MethodsWe conducted a population-based case–control study with cases (n=321) recruited through the New Zealand Motor Neurone Disease Association and hospital discharge data. Controls (n=605) were recruited from the Electoral Roll. Information on personal and demographic details, lifestyle factors and a full occupational history was collected using questionnaires and interviews. Associations with ever/never employed and employment duration were estimated using logistic regression stratified by sex and adjusted for age, ethnicity, socioeconomic deprivation, education and smoking.ResultsElevated risks were observed for field crop and vegetable growers (OR 2.93, 95% CI 1.10 to 7.77); fruit growers (OR 2.03, 95% CI 1.09 to 3.78); gardeners and nursery growers (OR 1.96, 95% CI 1.01 to 3.82); crop and livestock producers (OR 3.61, 95% CI 1.44 to 9.02); fishery workers, hunters and trappers (OR 5.62, 95% CI 1.27 to 24.97); builders (OR 2.90, 95% CI 1.41 to 5.96); electricians (OR 3.61, 95% CI 1.34 to 9.74); caregivers (OR 2.65, 95% CI 1.04 to 6.79); forecourt attendants (OR 8.31, 95% CI 1.79 to 38.54); plant and machine operators and assemblers (OR 1.42, 95% CI 1.01 to 2.01); telecommunications technicians (OR 4.2, 95% CI 1.20 to 14.64); and draughting technicians (OR 3.02, 95% CI 1.07 to 8.53). Industries with increased risks were agriculture (particularly horticulture and fruit growing), construction, non-residential care services, motor vehicle retailing, and sport and recreation. Positive associations between employment duration and MND were shown for the occupations fruit growers, gardeners and nursery growers, and crop and livestock producers, and for the horticulture and fruit growing industry.ConclusionsThis study suggests associations between MND and occupations in agriculture and several other occupations.
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Sánchez-Díaz G, Escobar F, Badland H, Arias-Merino G, Posada de la Paz M, Alonso-Ferreira V. Geographic Analysis of Motor Neuron Disease Mortality and Heavy Metals Released to Rivers in Spain. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E2522. [PMID: 30423874 PMCID: PMC6266970 DOI: 10.3390/ijerph15112522] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 12/12/2022]
Abstract
The etiology of motor neuron disease (MND) is still unknown. The aims of this study were to: (1) analyze MND mortality at a fine-grained level; and (2) explore associations of MND and heavy metals released into Spanish river basins. MND deaths were extracted from the Spanish nationwide mortality registry (2007⁻2016). Standardized mortality ratios (SMRs) for MND were estimated at a municipal level. Sites that emitted quantities of heavy metals above the regulatory thresholds were obtained from the European Pollutant Release and Transfer Register database (2007⁻2015). The relative risks for non-exposed and exposed municipalities (considering a downstream 20 km river section) by type of heavy metal were analyzed using a log-linear model. SMRs were significantly higher in central and northern municipalities. SMRs were 1.14 (1.10⁻1.17) higher in areas exposed to heavy metals than in non-exposed areas: 0.95 (0.92⁻0.96). Considering the different metals, we found the following increased MND death risks in exposed areas: 20.9% higher risk for lead, 20.0% for zinc, 16.7% for arsenic, 15.7% for chromium, 15.4% for cadmium, 12.7% for copper, and 12.4% for mercury. This study provides associations between MND death risk and heavy metals in exposed municipalities. Further studies investigating heavy metal exposure are needed to progress in MND understanding.
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Affiliation(s)
- Germán Sánchez-Díaz
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, Madrid 28029, Spain.
- Department of Geology, Geography and Environmental Sciences, University of Alcala, Alcalá de Henares 28801, Spain.
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Madrid 28029, Spain.
| | - Francisco Escobar
- Department of Geology, Geography and Environmental Sciences, University of Alcala, Alcalá de Henares 28801, Spain.
| | - Hannah Badland
- Healthy Liveable Cities Group, Centre for Urban Research, RMIT University, Melbourne VIC 3001, Australia.
| | - Greta Arias-Merino
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, Madrid 28029, Spain.
| | - Manuel Posada de la Paz
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, Madrid 28029, Spain.
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Madrid 28029, Spain.
| | - Verónica Alonso-Ferreira
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, Madrid 28029, Spain.
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Madrid 28029, Spain.
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