The environmental history in pediatric practice: a study of pediatricians' attitudes, beliefs, and practices

Environmental health in medical schools in France: A call from medical students

OBJECTIVE

Environmental factors contribute to more than 25% of all global disease but as medical student, we consider that environmental health is insufficiently taught. We are not armed for facing patient's questions, prevent diseases linked to environmental exposure and adapt care in susceptible population.

MATERIAL AND METHODS

We conducted a national French survey, using a web-based questionnaire from October to November 2021. All medical students were interrogated to assess their knowledge on environmental health and their desire to obtain a specific curriculum on this topic.

RESULTS

Two hundred and thirty-two students responded to the survey and most (62.7%) had never had any teaching on environmental health during their medical studies. The majority claimed to have no knowledge on environmental health (63.6%), and most had never been read or seen media content about it (59.2%). Those who had knowledge on environmental health, had been informed through social media, questioning the reliability of this content. Most (87.3%) were ready to take a specific course on environmental health issues during their medical studies in order to better inform their patients with evidence-based medicine and identify at risk population.

CONCLUSION

Through a survey, we identified the need and the emergency of implanting a curriculum on environmental medicine in our medical education.

An Update on Pediatric Environmental Health Specialty Units: Activities and Impacts, 2015-19

OBJECTIVE

Pediatric Environmental Health Specialty Units (PEHSUs) address health concerns impacting children and their families related to environmental hazards by providing consultation and education to families, communities, and health care professionals. This analysis evaluated the productivity of the national PEHSU program.

METHODS

PEHSUs reported data on services provided to US communities between October 1, 2014 and September 30, 2019. Descriptive statistics and qualitative analysis are presented.

RESULTS

During this period, 6102 consultations and 4644 educational outreach activities were recorded. PEHSU faculty and staff published 462 articles, reviews, book chapters, fact sheets, commentaries, short informational pieces, and other materials between 2014 and 2019. These included 190 articles in scientific peer-reviewed journals and 29 textbook chapters to increase professional capacity in pediatric and reproductive environmental health. Lead, other metals, substances of abuse, pesticides, mold, and air pollution were frequently reported as agents of concern and educational topics. Requests for an overview of pediatric environmental health and outdoor pollutants were other frequently reported topics.

CONCLUSIONS

PEHSUs work to decrease harmful exposures and improve children's health. They serve as expert resources for families, health care professionals, and communities on health effects related to environmental exposures. Data show the breadth and depth of concerns addressed and demonstrate the productivity and impact of this national program.

Environmental contaminants and child development: Developmentally-informed opportunities and recommendations for integrating and informing child environmental health science

Child environmental health (CEH) science has identified numerous effects of early life exposures to common, ubiquitous environmental toxicants. CEH scientists have documented the costs not only to individual children but also to population-level health effects of such exposures. Importantly, such risks are unequally distributed in the population, with historically marginalized communities and the children living in these communities receiving the most damaging exposures. Developmental science offers a lens and set of methodologies to identify nuanced biological and behavioral processes that drive child development across physical, cognitive, and socioemotional domains. Developmental scientists are also experts in considering the multiple, hierarchically-layered contexts that shape development alongside toxicant exposure. Such contexts and the individuals acting within them make up an overarching "child serving ecosystem" spanning systems and sectors that serve children directly and indirectly. Articulating how biobehavioral mechanisms and social-ecological contexts unfold from a developmental perspective are needed in order to inform CEH translation and intervention efforts across this child-serving ecosystem. Developmentalists can also benefit from integrating CEH science findings in their work by considering the role of the physical environment, and environmental toxicants specifically, on child health and development. Building on themes that were laid out by Trentacosta and Mulligan in 2020, this commentary presents recommendations for connecting developmental and CEH science and for translating such work so that it can be used to promote child development in an equitable manner across this child-serving ecosystem. These opportunities include (1) Using Developmentally-Informed Conceptual Models; (2) Applying Creative, Sophisticated, and Rigorous Methods; (3) Integrating Developmentally-Sensitive Intervention Considerations; and (4) Establishing Interdisciplinary Collaborations and Cross-Sector Partnerships.

Developing and implementing core competencies in children's environmental health for students, trainees and healthcare providers: a narrative review

Knowledge of the health impacts of environmental exposures (such as pollution disasters, poor air quality, water contamination, climate change) on children's health has dramatically increased in the past 40 years. The World Health Organization (WHO) estimated that 23% of all deaths worldwide were attributable to the environment, and 26% of deaths in children less than 5 years old could be prevented with removal of environmental risks factors. Yet, little has permeated medical education, leaving pediatric providers ill equipped to address these issues. To address this gap, members from the Pediatric Environmental Health Specialty Units, a United States nationwide network of academically affiliated experts who have created numerous environmental health educational materials and programs, have identified fifteen core environmental health (EH) competencies needed by health care providers to enable them to effectively address environmental health concerns. These competencies can serve as the foundation for the development and implementation of relevant educational programs. The core EH competencies are based upon these foundational elements: 1) Definition of "children's environmental health" that describes how environmental exposures (positive and negative) in early life influence the health and development in childhood and across the entire human life span 2) Children are not "little adults" and so have unique vulnerabilities to environmental hazards; 3) Environmental health inequities exist, causing some children to have a disproportionate amount of unhealthy exposures and consequently a greater risk of adverse effects; 4) Climate change will translate to numerous adverse health effects that will particularly affect children worldwide. In this article, the authors describe the core environmental health competencies and provide resources, online tools, strategies, and examples targeted to all levels of training and practice to better enable leaders and educators to bring this important content to the forefront.

Physician Training Related to Environmental Hazards near Ash Superfund Sites

Physicians do not receive formal environmental health training in medical schools. The objectives of this study were to provide health care providers with basic environmental medicine training to better advise, treat or refer patients in the community and to observe any differences in the environmental medicine learning gains pre/post- test assessment. To rectify the problem of the lack of physicians' training related to environmental hazards, we conducted an environmental health workshop which targeted physicians living near Health Zone 1, Superfund ash sites. Fifty health care providers from both St. Vincent Family Medicine and Department of Health, Duval County Health Department (DOH-Duval) participated in a pre-test survey before the training and a post-test survey following the training. We used a non-parametric Wilcoxon Signed-Rank test to compare pre- and post- knowledge of training participants. At the 10% level of significance, the number of incorrect answers significantly declined in the post-training survey compared to the pre-training survey for all participants from both facilities combined (p=0.083). Site-specific analysis show, while a significant difference was found for participants from the St. Vincent's site (p=0.084), the difference for participants from the DOH-Duval site was not significant (p = 0.102), although the number of incorrect answers declined. The training resulted in learning gains for the 50 participants and the evaluations were very positive with 100% of physicians recommending this training to other health care providers. Additionally, training participants gave a high mark for the environmental medicine pocket guide. In 2019, the ash sites are 90% remediated and cleanup is expected to be completed in 2022. There is still a need for additional training for physicians due to other active sites (i.e., Kerr-McGee) in the community. This study highlights the importance of providing environmental hazards training to physicians and the approach by which it could be delivered effectively.

Family medicine residents' knowledge of, attitudes toward, and clinical practices related to environmental health: Multi-program survey

OBJECTIVE

To assess family medicine residents' knowledge of, attitudes toward, and clinical practices related to environmental health (EH).

DESIGN

Two-part study with questionnaire construction using a modified Delphi method, and a Web-based questionnaire administered to family medicine residents between November 2015 and January 2016.

SETTING

All Canadian family medicine programs (for questionnaire construction) and 4 Ontario family medicine training programs (for questionnaire administration).

PARTICIPANTS

First- to third-year family medicine residents (for questionnaire administration).

MAIN OUTCOME MEASURES

Responses to 93 survey items that measured family medicine residents' knowledge of, attitudes toward, and clinical practices related to EH.

RESULTS

For the final administered questionnaire, 203 of 887 (22.9%) family medicine residents responded. Although 92.0% of respondents somewhat or strongly believed that taking an environmental exposure history was important, only 18.1% of them had specific training in taking environmental exposure history, and 48.4% believed that taking an exposure history takes up too much time in office practice. While 82.9% of residents correctly identified recreational water use as a cause of gastroenteritis, only 60.2% correctly identified radon as a cause of lung cancer and 37.6% knew that elevated ground-level ozone is associated with asthma. Only 10.8% believed their supervisors had a good understanding of environmental exposures. Residents who believed their supervisors understood environmental exposures were more likely to take exposure histories for patients with uncontrolled asthma (P < .05), and those who discussed EH exposure with supervisors frequently, or thought environmental exposure histories were very important, were more likely to provide patients with EH education materials (P < .01).

CONCLUSION

Although family medicine residents are aware of the importance of assessing patients' environmental exposures, they lack training and mentorship in EH. As a health determinant of critical importance, EH should be a high priority for inclusion in postgraduate family medicine education.

Drivers of Physicians' Engagement in Addressing Eco-health Problems

Physicians are in a unique position to be first-hand observers of the effects of environmental factors on population health. As a source of information which is highly trusted, they are also well-suited to raise awareness about the linkages between ecosystem and population health. Yet, current clinical practice in many parts of the world rarely includes environmental health assessments and patient education. The empirical evidence on the reasons for this lack of engagement is limited by the small number of studies published, its narrow geographical scope and the dearth of multivariate statistical analysis. This study used a mixed-methods approach to investigate the determinants of whether physicians at selected hospitals in Thailand assess the environmental history of their patients and provide environmental health advice. Using an ordered logistic regression model, it was found that physicians' engagement was associated with their knowledge, personal motivation, perception of being supported by senior staff and ability to discuss with colleagues. According to key informants, possible remedies for the observed lack of physicians' engagement include revisions of the medical school curriculum, clear strategies for addressing eco-health linkages in the clinical context at the national and hospital level, and better cooperation between relevant government institutions in Thailand.

A Framework for Integrating Environmental and Occupational Health and Primary Care in a Postdisaster Context

CONTEXT

Integration of environmental and occupational health (EOH) into primary care settings is a critical step to addressing the EOH concerns of a community, particularly in a postdisaster context. Several barriers to EOH integration exist at the physician, patient, and health care system levels.

PROGRAM

This article presents a framework for improving the health system's capacity to address EOH after the Deepwater Horizon oil spill and illustrates its application in the Environmental and Occupational Health Education and Referral (EOHER) program. This program worked with 11 Federally Qualified Health Center systems in the Gulf Coast region to try to address the EOH concerns of community members and to assist primary care providers to better understand the impact of EOH factors on their patients' health.

IMPLEMENTATION

The framework uses a 3-pronged approach to (1) foster coordination between primary care and EOH facilities through a referral network and peer consultations, (2) increase physician capacity in EOH issues through continuing education and training, and (3) conduct outreach to community members about EOH issues.

EVALUATION

The EOHER program highlighted the importance of building strong partnerships with community members and other relevant organizations, as well as high organizational capacity and effective leadership to enable EOH integration into primary care settings. Physicians in the EOHER program were constrained in their ability to engage with EOH issues due to competing patient needs and time constraints, indicating the need to improve physicians' ability to assess which patients are at high risk for EOH exposures and to efficiently take environmental and occupational histories.

DISCUSSION

This article highlights the importance of addressing EOH barriers at multiple levels and provides a model that can be applied to promote community health, particularly in the context of future natural or technological disasters.

Expert clinician's perspectives on environmental medicine and toxicant assessment in clinical practice

Background

Most clinicians feel ill-equipped to assess or educate patients about toxicant exposures, and it is unclear how expert environmental medicine clinicians assess these exposures or treat exposure-related conditions. We aimed to explore expert clinicians’ perspectives on their practice of environmental medicine to determine the populations and toxicants that receive the most attention, identify how they deal with toxicant exposures and identify the challenges they face and where they obtain their knowledge.

Methods

A qualitative study involving semi-structured interviews with expert environmental clinicians in Australia and New Zealand was conducted. Interviews were recorded and transcribed, and themes were identified and collated until no new themes emerged.

Results

Five dominant themes emerged from 16 interviews: (1) environmental medicine is a divided profession based on type of practice, patient cohort seen and attitudes towards nutrition and exposure sources; (2) clinical assessment of toxicant exposures is challenging; (3) the environmental exposure history is the most important clinical tool; (4) patients with environmental sensitivities are increasing, have unique phenotypes, are complex to treat and rarely regain full health; and (5) educational and clinical resources on environmental medicine are lacking.

Conclusions

Environmental medicine is divided between integrative clinicians and occupational and environmental physicians based on their practice dynamics. All clinicians face challenges in assessing toxicant loads, and an exposure history is seen as the most useful tool. Standardised exposure assessment tools have the potential to significantly advance the clinical practice of environmental medicine and expand its reach across other clinical disciplines.

Childhood Leukemia and Primary Prevention

Leukemia is the most common pediatric cancer, affecting 3800 children per year in the United States. Its annual incidence has increased over the last decades, especially among Latinos. Although most children diagnosed with leukemia are now cured, many suffer long-term complications, and primary prevention efforts are urgently needed. The early onset of leukemia-usually before 5 years of age-and the presence at birth of "pre-leukemic" genetic signatures indicate that pre- and postnatal events are critical to the development of the disease. In contrast to most pediatric cancers, there is a growing body of literature-in the United States and internationally-that has implicated several environmental, infectious, and dietary risk factors in the etiology of childhood leukemia, mainly for acute lymphoblastic leukemia, the most common subtype. For example, exposures to pesticides, tobacco smoke, solvents, and traffic emissions have consistently demonstrated positive associations with the risk of developing childhood leukemia. In contrast, intake of vitamins and folate supplementation during the preconception period or pregnancy, breastfeeding, and exposure to routine childhood infections have been shown to reduce the risk of childhood leukemia. Some children may be especially vulnerable to these risk factors, as demonstrated by a disproportionate burden of childhood leukemia in the Latino population of California. The evidence supporting the associations between childhood leukemia and its risk factors-including pooled analyses from around the world and systematic reviews-is strong; however, the dissemination of this knowledge to clinicians has been limited. To protect children's health, it is prudent to initiate programs designed to alter exposure to well-established leukemia risk factors rather than to suspend judgment until no uncertainty remains. Primary prevention programs for childhood leukemia would also result in the significant co-benefits of reductions in other adverse health outcomes that are common in children, such as detriments to neurocognitive development.

Pediatric Environmental Health Specialty Units: An Analysis of Operations

BACKGROUND

In 1998 the Agency for Toxic Substances and Disease Registry (ATSDR) secured the first federal funding to develop an innovative network of public health-oriented entities: Pediatric Environmental Health Specialty Units (PEHSUs). PEHSU goals were to provide pediatric and environmental health education to health care providers and health profession students, to offer consultation to health care professionals, parents, and others regarding environmental health exposures, and to provide referrals to specialized medical resources when necessary. This report analyzes the productivity of US PEHSUs from 1999 to 2014.

METHODS

This was a retrospective analysis of federally mandated quarterly reports filed by each PEHSU. These reports document specific goal-related deliverables outlined under cooperative agreements awarded to the Association of Occupational and Environmental Clinics (AOEC) with funding from the Environmental Protection Agency (EPA) and ATSDR. Costs were obtained from grant budget information available from the administrator of the grants, AOEC.

RESULTS

Total EPA/ATSDR funding for PEHSUs paid to AOEC during 1999-2014 was $23,847,452. The average cost to the EPA/ATSDR of running each PEHSU in 2014 was $169,256. Through over 8000 consultations and educational activities, PEHSUs reached 702,506 people: 298,936 health professionals, 61,947 health professional trainees, 323,817 members of the public, and 17,806 public health officials and others.

CONCLUSIONS

PEHSUs have grown into an established, productive network of clinical and educational centers whose expertise and activities have benefited both the public and health care professionals alike. The federal contributions to the cost of operating these centers have been more than offset by the benefits PEHSUs have conferred on the communities they serve.

A Scoping Review of Maternal and Child Health Clinicians Attitudes, Beliefs, Practice, Training and Perceived Self-Competence in Environmental Health

Clinicians regularly assess, diagnose and manage illnesses which are directly or indirectly linked to environmental exposures. Yet, various studies have identified gaps in environmental assessment in routine clinical practice. This review assessed clinicians' environmental health practices, attitudes and beliefs, and competencies and training. Relevant articles were sought using a systematic search strategy using five databases, grey literature and a hand search. Search strategies and protocols were developed using tailored mesh terms and keywords. 43 out of 11,291 articles were eligible for inclusion. Clinicians' attitudes and beliefs towards environmental health and routine clinical practice were generally positive, with most clinicians believing that environmental hazards affect human health. However, with the exception of tobacco smoke exposure, environmental health assessment was infrequently part of routine clinical practice. Clinicians' self-competence in environmental assessment was reported to be inadequate. Major challenges were the time required to complete an assessment, inadequate training and concerns about negative patients' responses. Clinicians have strong positive attitudes and beliefs about the importance of environmental health assessments. However, more concerted and robust strategies will be needed to support clinicians in assuming their assessment and counselling roles related to a wider range of environmental hazards.

Children's Cancer and Environmental Exposures: Professional Attitudes and Practices

BACKGROUND

Epidemiologic studies worldwide have provided substantial evidence of the contributions of environmental exposures to the development of childhood cancer, yet this knowledge has not been integrated into the routine practice of clinicians who care for children with this disease. To identify the basis of this deficit, we sought to assess the environmental history-taking behavior and perceptions of environmental health among pediatric hematologists and oncologists.

PROCEDURE

A web-based survey was sent from June to October 2012 to 427 pediatric oncologists, fellows, and nurse practitioners from 20 US institutions, with an overall response rate of 45%.

RESULTS

Survey responses indicated that environmental exposures are of concern to clinicians. The vast majority of respondents (88%) reported receiving questions from families about the relationship between certain environmental exposures and the cancers they regularly treat. However, a lack of comfort with these topics seems to have limited their discussions with families about the role of environmental exposures in childhood cancer pathogenesis. Although 77% of respondents suspected that some of the cases they saw had an environmental origin, their methods of taking environmental histories varied widely. Over 90% of respondents believed that more knowledge of the associations between environmental exposures and childhood cancer would be helpful in addressing these issues with patients.

CONCLUSIONS

Although limited in size and representativeness of participating institutions, the results of this survey indicate a need for increased training for hematology/oncology clinicians about environmental health exposures related to cancer and prompt translation of emerging research findings in biomedical journals that clinicians read.

The Environment and Children's Health Care in Northwest China

Background

Industrialization in the northwest provinces of the People’s Republic of China is accelerating rapid increases in early life environmental exposures, yet no publications have assessed health care provider capacity to manage common hazards.

Methods

To assess provider attitudes and beliefs regarding the environment in children’s health, determine self-efficacy in managing concerns, and identify common approaches to managing patients with significant exposures or environmentally-mediated conditions, a two-page survey was administered to pediatricians, child care specialists, and nurses in five provinces (Gansu, Shaanxi, Xinjiang, Qinghai, and Ningxia). Descriptive and multivariable analyses assessed predictors of strong self-efficacy, beliefs or attitudes.

Results

960 surveys were completed with <5% refusal; 695 (72.3%) were valid for statistical analyses. The role of environment in health was rated highly (mean 4.35 on a 1-5 scale). Self-efficacy reported with managing lead, pesticide, air pollution, mercury, mold and polychlorinated biphenyl exposures were generally modest (2.22-2.52 mean). 95.4% reported patients affected with 11.9% reporting seeing >20 affected patients. Only 12.0% reported specific training in environmental history taking, and 12.0% reported owning a text on children’s environmental health. Geographic disparities were most prominent in multivariable analyses, with stronger beliefs in environmental causation yet lower self-efficacy in managing exposures in the northwestern-most province.

Conclusions

Health care providers in Northwest China have strong beliefs regarding the role of environment in children’s health, and frequently identify affected children. Few are trained in environmental history taking or rate self-efficacy highly in managing common hazards. Enhancing provider capacity has promise for improving children’s health in the region.

Improving pediatrician knowledge about environmental triggers of asthma

BACKGROUND

Control of environmental triggers (ETs) greatly improves asthma outcomes in children. Disseminating these findings to general pediatricians has not been well established.

METHODS

After delivering a structured and standardized presentation on ET identification and control to pediatricians, we surveyed them about knowledge and practices of ET assessment and management. We analyzed matched responses for pre/post and 3- to 6-month follow-up using McNemar's χ(2) test.

RESULTS

Matched data were available for 367 participants, and 3- to 6-month follow-up data were available for 83. There was a significant posttraining increase in intention to ask about ETs and recommend ET management. After 3 to 6 months, all responses remained significantly higher than baseline, except "likely to refer to an asthma specialist."

CONCLUSION

Pediatricians reported a significant improvement in knowledge about ETs of asthma and a willingness to incorporate exposure history questions and remediation recommendations in their routine practice.

Pesticide exposure in children

Pesticides are a collective term for a wide array of chemicals intended to kill unwanted insects, plants, molds, and rodents. Food, water, and treatment in the home, yard, and school are all potential sources of children's exposure. Exposures to pesticides may be overt or subacute, and effects range from acute to chronic toxicity. In 2008, pesticides were the ninth most common substance reported to poison control centers, and approximately 45% of all reports of pesticide poisoning were for children. Organophosphate and carbamate poisoning are perhaps the most widely known acute poisoning syndromes, can be diagnosed by depressed red blood cell cholinesterase levels, and have available antidotal therapy. However, numerous other pesticides that may cause acute toxicity, such as pyrethroid and neonicotinoid insecticides, herbicides, fungicides, and rodenticides, also have specific toxic effects; recognition of these effects may help identify acute exposures. Evidence is increasingly emerging about chronic health implications from both acute and chronic exposure. A growing body of epidemiological evidence demonstrates associations between parental use of pesticides, particularly insecticides, with acute lymphocytic leukemia and brain tumors. Prenatal, household, and occupational exposures (maternal and paternal) appear to be the largest risks. Prospective cohort studies link early-life exposure to organophosphates and organochlorine pesticides (primarily DDT) with adverse effects on neurodevelopment and behavior. Among the findings associated with increased pesticide levels are poorer mental development by using the Bayley index and increased scores on measures assessing pervasive developmental disorder, inattention, and attention-deficit/hyperactivity disorder. Related animal toxicology studies provide supportive biological plausibility for these findings. Additional data suggest that there may also be an association between parental pesticide use and adverse birth outcomes including physical birth defects, low birth weight, and fetal death, although the data are less robust than for cancer and neurodevelopmental effects. Children's exposures to pesticides should be limited as much as possible.

Pesticide exposure in children

This statement presents the position of the American Academy of Pediatrics on pesticides. Pesticides are a collective term for chemicals intended to kill unwanted insects, plants, molds, and rodents. Children encounter pesticides daily and have unique susceptibilities to their potential toxicity. Acute poisoning risks are clear, and understanding of chronic health implications from both acute and chronic exposure are emerging. Epidemiologic evidence demonstrates associations between early life exposure to pesticides and pediatric cancers, decreased cognitive function, and behavioral problems. Related animal toxicology studies provide supportive biological plausibility for these findings. Recognizing and reducing problematic exposures will require attention to current inadequacies in medical training, public health tracking, and regulatory action on pesticides. Ongoing research describing toxicologic vulnerabilities and exposure factors across the life span are needed to inform regulatory needs and appropriate interventions. Policies that promote integrated pest management, comprehensive pesticide labeling, and marketing practices that incorporate child health considerations will enhance safe use.

Effect of an environmental health educational programme for paediatricians in an Egyptian University Hospital: before and after study

OBJECTIVES

To study the effect of an educational intervention on paediatricians' knowledge, attitudes and practices regarding children's environmental health and to identify the sources of information and common environmental history taking constrains.

DESIGN

Before and after study.

SETTING

Zagazig University Paediatric Hospital.

PARTICIPANTS

Practising paediatricians from all specialty units.

MAIN OUTCOME MEASURES

The outcome of a specifically designed educational programme about paediatric environmental health was assessed using structured pre- and post-test questionnaires.

RESULTS

Nearly half the participants were aware about most of the paediatric environmental health-related topics. Textbooks/guidelines (85.7%) and the Internet (64.3%) were the main sources of information. The participants demonstrated relatively strong positive attitudes towards the importance of children's environmental health. However, less than half of them (44.6%) reported environmental history taking as a routine practice; where lack of time (94.6%), wide range of hazardous exposures (91.1%) and lack of expertise and training (91.1%) were the main constrains. Significant improvement in participants' knowledge, attitudes and practices was revealed after the educational programme.

CONCLUSIONS

There is a demand for continuous medical education about environmental health in paediatric practice, particularly environmental and occupational history taking.

Metals and disease: a global primary health care perspective

Metals are an important and essential part of our daily lives. Their ubiquitous presence and use has not been without significant consequences. Both industrial and nonindustrial exposures to metals are characterized by a variety of acute and chronic ailments. Underreporting of illnesses related to occupational and environmental exposures to chemicals including metals is of concern and presents a serious challenge. Many primary care workers rarely consider occupational and environmental exposures to chemicals in their clinical evaluation. Their knowledge and training in the evaluation of health problems related to such exposures is inadequate. This paper presents documented research findings from various studies that have examined the relationship between metal exposures and their adverse health effects both in developing and developed countries. Further, it provides some guidance on essential elements of a basic occupational and environmental evaluation to health care workers in primary care situations.

Integrating environmental health into medical education

Although environmental factors contribute to more than 25% of all global disease, and toxic agents ranked fifth in underlying causes of U.S. deaths in 2000, environmental medicine education is largely omitted in the continuum of U.S. medical education. The paucity of specialists trained in environmental medicine (i.e., occupational medicine and other preventive medicine specialties and subspecialties), coupled with the lack of adequate general medical education on how to prevent, diagnose, refer, or treat patients exposed to hazardous substances in the environment, contributes to lost opportunities for primary prevention or early intervention to mitigate or minimize environmentally related disease burden. Survey findings of graduating medical students over the past few years have identified environmental health as a medical school topic area that can be improved. This article reflects a panel presentation on the challenge of including environmental health in general medical education. It was given at the 2010 "Patients and Populations: Public Health in Medical Education" conference cosponsored by the CDC and the American Association of Medical Colleges. A variety of educational strategies, models, and educational resources are presented that illustrate how recommended competency-based environmental health content can be integrated into medical education to better prepare medical students and physicians without specialized expertise in environmental medicine to provide or facilitate environmental preventive or curative patient care.

Resetting our priorities in environmental health: an example from the South-North partnership in Lake Chapala, Mexico

Lake Chapala is a major source of water for crop irrigation and subsistence fishing for a population of 300,000 people in central Mexico. Economic activities have created increasing pollution and pressure on the whole watershed resources. Previous reports of mercury concentrations detected in fish caught in Lake Chapala have raised concerns about health risks to local families who rely on fish for both their livelihood and traditional diet. Our own data has indicated that 27% of women of childbearing age have elevated hair mercury levels, and multivariable analysis indicated that frequent consumption of carp (i.e., once a week or more) was associated with significantly higher hair mercury concentrations. In this paper we describe a range of environmental health research projects. Our main priorities are to build the necessary capacities to identify sources of water pollution, enhance early detection of environmental hazardous exposures, and deliver feasible health protection measures targeting children and pregnant women. Our projects are led by the Children's Environmental Health Specialty Unit nested in the University of Guadalajara, in collaboration with the Department of Environmental Health of Harvard School of Public Health and Department of Pediatrics of the New York School of Medicine. Our partnership focuses on translation of knowledge, building capacity, advocacy and accountability. Communication will be enhanced among women's advocacy coalitions and the Ministries of Environment and Health. We see this initiative as an important pilot program with potential to be strengthened and replicated regionally and internationally.

Teaching home environmental health to resident physicians

Healthy Homes programs seek to integrate the evaluation and management of a multitude of health and safety risks in households. The education of physicians in the identification, evaluation, and management of these home health and safety issues continues to be deficient. Healthy Homes programs represent a unique opportunity to educate physicians in the home environment and stimulate ongoing, specific patient-physician discussions and more general learning about home environmental health. The Case Healthy Homes and Patients Program addresses these deficiencies in physician training while providing direct services to high-risk households. Pediatric and family practice resident physicians participate in healthy home inspections and interventions for their primary care patients and follow up on identified risks during health maintenance and acute illness visits.

Clinical services in environmental pediatrics

Pediatric healthcare providers are confronted with environmental health problems frequently: the child with asthma exacerbated by the odor of paint in school or mouse antigen at home, the family who wants to know the risks and benefits of using different types of sunblock, or the community that asks the provider for advice on the potential health impacts of building the new elementary school next to the on-ramp to the interstate highway. Pediatric providers have not been well trained to deal with these questions in medical or nursing schools, residency training, or continuing-education settings. This article provides guidance on history taking, the physical examination, laboratory evaluations of patients and the environment, and making an assessment about and managing environmental health problems. Pediatric Environmental Health Specialty Units are discussed as a source of consultation and referral. The identification and utilization of evidence-based resources are stressed and clinicians are cautioned about non-evidence-based assessments such as clinical ecology and hair analysis and non-evidence-based management strategies such as chelation for autism.

Integrating Environmental Health into Nurse Practitioner Training—Childhood Pesticide Exposure Risk Assessment, Prevention, and Management

The use of pesticides in agriculture, public places, and private homes and gardens is ubiquitous throughout the United States. Children are particularly vulnerable to pesticide exposure because of immature biological and developmental processes. Thus, it is important that primary health care providers identify clients at risk for pesticide exposure and poisoning and know how to respond effectively if clients experience exposure. However, many primary health care providers are not adequately trained or prepared to manage the health-related effects of pesticide exposure. Recent efforts, supported by the U.S. Environmental Protection Agency, have addressed this shortcoming in nursing and medical education. A primary initiative is to find ways to integrate basic environmental health content, specifically regarding pesticide exposure, into nursing and medical curricula. As one strategy to achieve this, a pilot case study was developed by revising and enhancing an existing pediatric case study used in a required course for nurse practitioner students. The aim was to raise students' awareness of risk assessment, prevention, and appropriate care strategies for pesticide exposure. Evaluation of students' experience with the pilot case study suggested it was a meaningful and valued addition to their training, as well as an efficient way to introduce environmental health content into primary health care provider curricula.

Integrating environmental health into nurse practitioner training-childhood pesticide exposure risk assessment, prevention, and management

The use of pesticides in agriculture, public places, and private homes and gardens is ubiquitous throughout the United States. Children are particularly vulnerable to pesticide exposure because of immature biological and developmental processes. Thus, it is important that primary health care providers identify clients at risk for pesticide exposure and poisoning and know how to respond effectively if clients experience exposure. However, many primary health care providers are not adequately trained or prepared to manage the health-related effects of pesticide exposure. Recent efforts, supported by the U.S. Environmental Protection Agency, have addressed this shortcoming in nursing and medical education. A primary initiative is to find ways to integrate basic environmental health content, specifically regarding pesticide exposure, into nursing and medical curricula. As one strategy to achieve this, a pilot case study was developed by revising and enhancing an existing pediatric case study used in a required course for nurse practitioner students. The aim was to raise students' awareness of risk assessment, prevention, and appropriate care strategies for pesticide exposure. Evaluation of students' experience with the pilot case study suggested it was a meaningful and valued addition to their training, as well as an efficient way to introduce environmental health content into primary health care provider curricula.

Translating knowledge about environmental health to practitioners: are we doing enough?

BACKGROUND

Practitioners see a large number of children affected by environmental exposures each year. A national network of pediatric environmental health specialty units has been established to strengthen prevention capacity, yet the effectiveness of that translational resource has not been assessed.

METHODS

We supplemented a qualitative systematic review of previous assessments of healthcare provider capacity with a self-administered survey sent to the membership of the Michigan chapter of the American Academy of Pediatrics. We mailed surveys twice between October 2007 and January 2008 and obtained a 39.4% response rate.

RESULTS

Our systematic review identified 8 relevant studies, all of which relied on self-report questionnaires and surveys. Recognizing this methodological weakness, we found that national and state samples consistently identified significant gaps in self-efficacy and knowledge about environmental hazards across a broad range of child care providers. In the Michigan survey, respondents voiced high self-efficacy in dealing with lead and second-hand smoke, but confidence in managing pesticide, mercury, mold, polychlorinated biphenyl, and air pollution exposures was much lower (P < 0.0001). Pediatricians routinely referred affected patients to lead/toxicology clinics and allergist/immunologists but not to the regional pediatric environmental health specialty unit.

CONCLUSIONS

Gaps persist in practitioner knowledge about environmental health nationwide and across disciplines. Despite methodological weaknesses, educational opportunities and other efforts should be studied to determine best practices for enhancing the evaluation of environmental health concerns in children.

Children's Environmental Health Faculty Champions Initiative: a successful model for integrating environmental health into pediatric health care

BACKGROUND

Pediatric medical and nursing education lack the environmental health content needed to properly prepare health care professionals to prevent, recognize, manage, and treat environmental exposure-related diseases. The need for improvements in health care professionals' environmental health knowledge has been expressed by leading institutions. However, few studies have evaluated the effectiveness of programs that incorporate pediatric environmental health (PEH) into curricula and practice.

OBJECTIVE

We evaluated the effectiveness of the National Environmental Education Foundation's (NEEF) Children's Environmental Health Faculty Champions Initiative, which is designed to build environmental health capacity among pediatric health care professionals.

METHODS

Twenty-eight pediatric health care professionals participated in a train-the-trainer workshop, in which they were educated to train other health care professionals in PEH and integrate identified PEH competencies into medical and nursing practice and curricula. We evaluated the program using a workshop evaluation tool, action plan, pre- and posttests, baseline and progress assessments, and telephone interviews.

RESULTS

During the 12 months following the workshop, the faculty champions' average pretest score of 52% was significantly elevated (p < 0.0001) to 65.5% on the first posttest and to 71.5% on the second posttest, showing an increase and retention of environmental health knowledge. Faculty champions trained 1,559 health care professionals in PEH, exceeding the goal of 280 health care professionals trained. Ninety percent of faculty champions reported that PEH had been integrated into the curricula at their institution.

CONCLUSION

The initiative was highly effective in achieving its goal of building environmental health capacity among health care professionals. The faculty champions model is a successful method and can be replicated in other arenas.

Pacific Northwest health professionals survey on pesticides and children

The Pacific Northwest includes several regions of pesticide-intensive agriculture, and the health risks of pesticides to children have become a focus of scientific inquiry and public health concern. To prepare a curriculum for regional health care providers on pesticides and child health, we sought to review the experience, attitudes and needs in this subject from the intended target audience. Forty-nine key informants serving high volumes of farmworkers and farm families in agricultural areas of the region were identified: 23 physicians, nine physician assistants, five nurse practitioners, and 12 community health workers completed telephone surveys (98% response rate). These informants serve a high-risk group of children, yet only 49% had any pesticide related health training and only 22% had received child specific information. Regardless of previous training, 55% affirmed the statement, "I use pesticide information in my profession or practice." However, 61% were not comfortable responding to patient/client questions based on their training, background, and experience. Ninety-two percent of the informants endorsed that more pesticide information would be useful in their work, particularly information specific to child health. Format preferences for future training varied. Physicians most frequently mentioned Web-based training materials while mid-level clinicians' most highly requested format was written summaries. The option of a conference/workshop was particularly popular among community health workers. This key informant survey indicates an important pesticide training gap among health care workers serving children at high risk of pesticide exposure.

Using mixed methods to evaluate the Pediatric Lead Assessment Network Education Training Program (PLANET)

The Pediatric Lead Assessment Network Education Training Program (PLANET) is a peer-to-peer in-person 1-hr lead poisoning prevention educational program for health professionals. This evaluation was designed to determine the impact of the PLANET program. Evaluation methods included analyzing data from PLANET sign-in sheets, evaluation forms, pre/postknowledge tests, claims data, and focus groups (FGs) and interviews (IVs) with PLANET attendees and nonattendees. Claims data were used to compare blood lead testing rates for physicians attending and those not attending a PLANET program. Over 2,000 health professionals attended the 192 PLANET presentations delivered between June 2001 and December 2006; most were registered nurses or physicians. Written evaluations were overwhelmingly positive. Posttests indicated increased provider knowledge about childhood lead poisoning prevention, and assessment of blood lead testing rates showed higher testing rates for PLANET attendees. FG and IV participants suggesting improvements including using alternative delivery modes.

Our genes are not our destiny: incorporating molecular medicine into clinical practice

In many developed nations, the state of publicly administered health care is increasingly precarious as a result of escalating numbers of chronically ill patients, inadequate medical personnel and hospital facilities, as well as sparse funding for ongoing upgrades to state-of-the-art diagnostic and therapeutic technology - an increased emphasis on aetiology-centred medicine should be considered in order to achieve improved health for patients and populations. Medical practice patterns which are designed to provide quick and effective amelioration of signs and symptoms are frequently not an enduring solution to many health afflictions and chronic disease states. Recent scientific discovery has rendered the drug-oriented algorithmic paradigm commonly found in contemporary evidence-based medicine to be a reductionist approach to clinical practice. Unfolding evidence appears to support a genetic predisposition model of health and illness rather than a fatalistic predestination construct - modifiable epigenetic and environmental factors have enormous potential to influence clinical outcomes. By understanding and applying fundamental clinical principles relating to the emerging fields of molecular medicine, nutrigenomics and human exposure assessment, doctors will be empowered to address causality of affliction when possible and achieve sustained reprieve for many suffering patients.

Paediatric environmental health speciality units in Europe: Integrating a missing element into medical care

Paediatricians are in an excellent position to identify children with environmental risk, to advise their parents about the best way of reducing or preventing such risks, and to recommend actions to the responsible politicians involved. Paediatric environmental health speciality units (PEHSU) can help to qualify and support paediatricians in this task. PEHSU is defined as a unit within a paediatric hospital or clinic that is able to recognize, assess, and prevent environment-related health risks, to help other paediatric specialists in the management of such diseases in children, as well as to provide education, training, and research, putting emphasis on thorough and adequate establishment of paediatric environmental histories (PEHis) and to the application of the precautionary principle. Although activities and services provided by each PEHSU would differ depending on the centre or community where it is located, all should include training, research, medical care and community and school health.

The ambulatory pediatric association fellowship in pediatric environmental health: a 5-year assessment

BACKGROUND

Evidence is mounting that environmental exposures contribute to causation of disease in children. Yet few pediatricians are trained to diagnose, treat, or prevent disease of environmental origin.

OBJECTIVES

To develop a cadre of future leaders in pediatric environmental health (PEH), the Ambulatory Pediatric Association (APA) launched a new 3-year fellowship in 2001-the world's first formal training program in PEH. Sites were established at Boston Children's Hospital, Mount Sinai School of Medicine, George Washington University, University of Cincinnati, and University of Washington. Fellows are trained in epidemiology, biostatistics, toxicology, risk assessment, and preventive medicine. They gain clinical experience in environmental pediatrics and mentored training in clinical research, policy development, and evidence-based advocacy. Thirteen fellows have graduated. Two sites have secured follow-on federal funding to enable them to continue PEH training.

DISCUSSION

To assess objectively the program's success in preparing fellows for leadership careers in PEH, we conducted a mailed survey in 2006 with follow-up in 2007.

CONCLUSIONS

Fifteen (88%) of 17 fellows and graduates participated; program directors provided information on the remaining two. Nine graduates are pursuing full-time academic careers, and two have leadership positions in governmental and environmental organizations. Ten have published one or more first-authored papers. Seven graduates are principal investigators on federal or foundation grants. The strongest predictors of academic success are remaining affiliated with the fellowship training site and devoting < 20% of fellowship time to clinical practice.

CONCLUSION

The APA fellowship program is proving successful in preparing pediatricians for leadership careers in PEH.

A model for physician education and consultation in pediatric environmental health--the Pediatric Environmental Health Specialty Units (PEHSU) program

The unique biologic characteristics and behaviors of children make them vulnerable to environmental toxicants. Physicians and other health professionals are challenged in addressing pediatric environmental health care needs in part because of deficient knowledge and skills in pediatric environmental health. This deficiency seems to stem from inadequate exposure to the field of pediatric environmental health during clinical training. The foundational goal of the PEHSU program is to address the gap in pediatric environmental health knowledge by enhancing the fundamental knowledge and skills of pediatricians, primary care physicians, and other health professionals.

The National Children's Study: a 21-year prospective study of 100,000 American children

Prospective, multiyear epidemiologic studies have proven to be highly effective in discovering preventable risk factors for chronic disease. Investigations such as the Framingham Heart Study have produced blueprints for disease prevention and saved millions of lives and billions of dollars. To discover preventable environmental risk factors for disease in children, the US Congress directed the National Institute of Child Health and Human Development, through the Children's Health Act of 2000, to conduct the National Children's Study. The National Children's Study is hypothesis-driven and will seek information on environmental risks and individual susceptibility factors for asthma, birth defects, dyslexia, attention-deficit/hyperactivity disorder, autism, schizophrenia, and obesity, as well as for adverse birth outcomes. It will be conducted in a nationally representative, prospective cohort of 100,000 US-born children. Children will be followed from conception to 21 years of age. Environmental exposures (chemical, physical, biological, and psychosocial) will be assessed repeatedly during pregnancy and throughout childhood in children's homes, schools, and communities. Chemical assays will be performed by the Centers for Disease Control and Prevention, and banks of biological and environmental samples will be established for future analyses. Genetic material will be collected on each mother and child and banked to permit study of gene-environment interactions. Recruitment is scheduled to begin in 2007 at 7 Vanguard Sites and will extend to 105 sites across the United States. The National Children's Study will generate multiple satellite studies that explore methodologic issues, etiologic questions, and potential interventions. It will provide training for the next generation of researchers and practitioners in environmental pediatrics and will link to planned and ongoing prospective birth cohort studies in other nations. Data from the National Children's Study will guide development of a comprehensive blueprint for disease prevention in children.

The chemical erosion of human health: adverse environmental exposure and in-utero pollution - determinants of congenital disorders and chronic disease

Epidemiological research designed to explore causality of illness has produced increasing evidence to verify that exposure to toxic agents is contributing to the escalating burden of chronic affliction, including congenital disorders. While endeavoring to facilitate optimal health and well-being for patients, the medical profession is currently challenged by the consequences of environmental factors unique to the modern era. In the last half century, there have been profound shifts in health-related habits of individuals and population groups, and recent research suggests that changes in the home and workplace environment are responsible for many common health problems including various congenital anomalies. As a result of increasing concern about environmental influences on health, 'Human Exposure Assessment,' the investigation and study of specific patient exposures and related health concerns, is a rapidly expanding area of scientific research. Practitioners of clinical medicine, including providers of maternity care, should acquire the skills to elicit a proper environmental exposure history and the necessary tools to implement proactive patient education relating to precautionary avoidance.

Educational needs assessment for pediatric health care providers on pesticide toxicity

PURPOSE

This pilot project, carried out under the National Strategies for Health Care Providers: Pesticides Initiative, assessed the attitudes, beliefs and practices of pediatricians, nurse practitioners, physicians assistants, and nurses in the metropolitan Washington, D.C., area and the surrounding rural counties regarding health effects of pesticide toxicity and continuing education on pesticide toxicity in the years 2001-2002.

METHODS

Data were collected from practitioners (physicians, physician assistants, and nurse practitioners) and nurses using questionnaires as well as from practitioners using focus groups. Sites for questionnaire distribution and focus groups were selected to represent a variety of practice types and geographic settings. One-hundred-sixty questionnaires from practitioners and 43 from nurses were analyzed. These issues were probed further in six focus groups with 29 participants.

RESULTS

Most respondents in both groups did not frequently diagnose or ask questions about pesticide toxicity on patient histories. Most focus group participants were more comfortable answering questions about acute pesticide toxicity, and many relied on poison control centers for assistance with management of acute cases. They expressed less understanding and more uncertainties about chronic toxicity. When asked questions by patients, 64% of practitioners and 69% of nurses felt poorly prepared to answer them. Forty percent of practitioners but only 26% of nurses felt it was important to obtain more information on pesticides. There were divergent preferences on ways to obtain continuing medical education (CME) in general, but a recurrent theme was the need to make CME on pesticide toxicity clinically relevant and one topic among several in a CME conference. Lectures and short courses were the most commonly preferred modes of education among both practitioners and nurses.

CONCLUSION

Educational materials to reach this population of pediatric clinicians on pesticides, as well as other environmental health topics, should make the case justifying the importance of the topics, highlight information of clinical relevance, and use a variety of media. These results should be confirmed before being generalized to a broader group of clinicians, although the consistency of findings between focus groups suggests they are robust, at least for this geographic area.

The environment in pediatric practice: a study of New York pediatricians' attitudes, beliefs, and practices towards children's environmental health

Chronic diseases of environmental origin are a significant and increasing public health problem among the children of New York State, yet few resources exist to address this growing burden. To assess New York State pediatricians self-perceived competency in dealing with common environmental exposures and diseases of environmental origin in children, we assessed their attitudes and beliefs about the role of the environment in children's health. A four-page survey was sent to 1,500 randomly selected members of the New York State American Academy of Pediatrics in February 2004. We obtained a 20.3% response rate after one follow-up mailing; respondents and nonrespondents did not differ in years of licensure or county of residence. Respondents agreed that the role of environment in children's health is significant (mean 4.44 +/- 0.72 on 1-5 Likert scale). They voiced high self-efficacy in dealing with lead exposure (mean 4.16-4.24 +/- 0.90-1.05), but their confidence in their skills for addressing pesticides, mercury and mold was much lower (means 2.51-3.21 +/- 0.90-1.23; p < 0.001). About 93.8% would send patients to a clinic "where pediatricians could refer patients for clinical evaluation and treatment of their environmental health concerns." These findings indicate that New York pediatricians agree that children are suffering preventable illnesses of environmental origin but feel ill-equipped to educate families about common exposures. Significant demand exists for specialized centers of excellence that can evaluate environmental health concerns, and for educational opportunities.

Environmental History-Taking in Clinical Practice: Knowledge, Attitudes, and Practice of Primary Care Physicians in Italy

OBJECTIVE

We investigated knowledge and attitudes of the PCPs about environmental risks and behaviours in regarding environmental history taking of the patients.

METHODS

This study was designed as a cross-sectional mail survey and target population were 500 PCPs practicing in Calabria (Italy). Questions of the questionnaire focused on PCPs demographics and practice characteristics, knowledge of the major environmental risk factors and related health effects, attitudes about role of environment on human health and about performing an accurate environmental exposures history.

RESULTS

94% of PCPs correctly indicated noise exposures as a possible cause of irreversible hearing loss and more than half indoor radon exposure for lung cancer, but only 27.8% correctly recognized all health effects related to environmental exposures. PCPs who assign an important role to the environment were significantly more likely to have knowledge of environmental risk factors related to respiratory disease. A vast majority of PCPs reported to take a patient history on occupational exposures, but less than one third of PCPs reported to provide education material about environment and public health to their patients. PCPs who ask their patients about environmental exposures were significantly more likely to consider environmental health history a helpful tool to prevent exposures to environmental threats.

CONCLUSIONS

Physicians are supposed to learn and then educate patients about the importance of preventing environment related diseases.

Exploring the continuum: medical information to effective clinical practice. Paper II. Towards aetiology-centred clinical practice

Contemporary clinical practice increasingly functions within a disease management paradigm aimed at finding and implementing therapeutic interventions that demonstrate efficacy in clinical trials. Disease prevention, elucidation of illness aetiology and proactive health promotion have taken a back seat. Current clinical care often includes a 'fast-food' type of medical encounter, which frequently neglects disease causality. The medical community is presently challenged by unique administrative and professional adversities as well as undue commercial influence; these factors contribute to a lethargic response to escalating rates of chronic illness and to mainstream medicine's relative inattention to emerging research about disease aetiology. Individual medical practitioners and the medical establishment must strategically seek to advance patient health and maintain professional relevancy by a renewed emphasis on the following principles: patient-based clinical care, aetiology-centred medicine, and proactive health promotion.

Incorporating environmental health into pediatric medical and nursing education

Pediatric medical and nursing education currently lacks the environmental health content necessary to appropriately prepare pediatric health care professionals to prevent, recognize, manage, and treat environmental-exposure-related disease. Leading health institutions have recognized the need for improvements in health professionals' environmental health education. Parents are seeking answers about the impact of environmental toxicants on their children. Given the biologic, psychological, and social differences between children and adults, there is a need for environmental health education specific to children. The National Environmental Education and Training Foundation, in partnership with the Children's Environmental Health Network, created two working groups, one with expertise in medical education and one with expertise in nursing education. The working groups reviewed the transition from undergraduate student to professional to assess where in those processes pediatric environmental health could be emphasized. The medical education working group recommended increasing education about children's environmental health in the medical school curricula, in residency training, and in continuing medical education. The group also recommended the expansion of fellowship training in children's environmental health. Similarly, the nursing working group recommended increasing children's environmental health content at the undergraduate, graduate, and continuing nursing education levels. Working groups also identified the key medical and nursing organizations that would be important in leveraging these changes. A concerted effort to prioritize pediatric environmental health by governmental organizations and foundations is essential in providing the resources and expertise to set policy and provide the tools for teaching pediatric environmental health to health care providers.

Medio ambiente y cáncer pediátrico

BACKGROUND

Cancer is the final result of the variable combination of two determinants: endogenous or constitutional factors and exogenous or environmental factors. Between 85 % and 96 % of pediatric cancers (PC) are probably associated with environmental risk factors (RF), most of which have not been identified. The spectacular progress made in survival in PC contrasts with the lack of knowledge of the RF implicated in its etiopathogenesis.

OBJECTIVE

1) To analyze up-to-date knowledge of the interaction among environmental RF in the etiopathogenesis of PC, and 2) to inform pediatricians of the "Environment and Pediatric Cancer" research project directed by the Pediatric Environmental Health Specialty Unit of the Hospital Infantil Universitari La Fe in Valencia (Spain).

MATERIAL AND METHODS

Current medical records focus almost exclusively on the diagnosis and treatment of cancer. The Pediatric Environmental Medical Record will contain the validated items required to document and presence or absence of endogenous and exogenous RF associated with PC described in the literature, as well as the main human cancerogenic agents identified by the International Agency for Research on Cancer and the US National Toxicology Program.

RESULTS

The project aims to determine the frequency of endogenous and exogenous RF associated with PC in Spain. This project will enable hypotheses to be formulated for future epidemiologic case-control and cohort studies in Spain and other European countries, thus stimulating the introduction of educational and preventive policies in the Spanish population.

CONCLUSIONS

The project requires the aid of all hospital and non-hospital pediatricians involved in pediatric cancer in informing parents and offering them the possibility of voluntarily collaborating in the "Environment and Pediatric Cancer" project by contacting the Pediatric Health Specialty Unit (Unidad de Salud Medioambiental del Hospital Infantil La Fe de Valencia [www.pehsu.org]). The collaboration of our colleagues will be essential in gaining greater insight into the RF associated with PC and in achieving prevention in the medium and long term.

Human plasminogen is highly susceptible to peroxynitrite inactivation

It has been shown that diabetic patients have up to three-fold increases in plasma nitrated tyrosine. We hypothesize that nitration of plasminogen could impair its catalytic properties and be a factor in diabetic thrombogenicity. To test this hypothesis, in this study we addressed the effects of the peroxynitrite donor 3-morpholinosydnonimine (SIN-1) on human streptokinase-induced plasmin activity. Given the link between glycation and oxidation we also explored whether peroxynitrite enhances the effect of fructose (1-5 mmol/l) and glucose (5-50 mmol/l) on plasminogen. We provide evidence that plasminogen, but not antithrombin III, is quickly inactivated by exogenously generated peroxynitrite (0-20 mmol/l SIN-1), in a time-and dose-dependent manner. The effect occurs even when the molar ratio of other plasma proteins and key antioxidants is respected. In our system, peroxynitrite did not enhance the effect of the sugars. Preincubation of the sugars with peroxynitrite also failed to produce any effect. This suggests that in conditions and times approaching the in vivo situation, plasminogen is more susceptible to peroxynitrite damage than to carbonyl damage. Plausibly, nitration of tyrosine should play a critical role in either conformational or functional changes. If proven in ulterior in vivo studies, this factor would provide another mechanism by which nitrosative stress participates in diabetic complications.