Field survey of health perception and complaints of Pennsylvania residents in the Marcellus Shale region

Pennsylvania Marcellus Shale region residents have reported medical symptoms they believe are related to nearby Unconventional Natural Gas Development (UNGD). Associations between medical symptoms and UNGD have been minimally explored. The objective of this descriptive study is to explore whether shale region Pennsylvania residents perceive UNGD as a health concern and whether they attribute health symptoms to UNGD exposures. A questionnaire was administered to adult volunteers with medical complaints in a primary-care medical office in a county where UNGD was present. Participants were asked whether they were concerned about health effects from UNGD, and whether they attributed current symptoms to UNGD or to some other environmental exposure. There were 72 respondents; 22% perceived UNGD as a health concern and 13% attributed medical symptoms to UNGD exposures. Overall, 42% attributed one or more of their medical symptoms to environmental causes, of which UNGD was the most frequent. A medical record review conducted on six participants who attributed their medical symptoms to UNGD revealed that only one of these records documented both the symptoms in question and the attribution to UNGD. The results of this pilot study suggest that there is substantial concern about adverse health effects of UNGD among Pennsylvania Marcellus Shale residents, and that these concerns may not be adequately represented in medical records. Further efforts to determine the relationship between UNGD and health are recommended in order to address community concerns.

Chemosensory loss: functional consequences of the world trade center disaster

BACKGROUND

Individuals involved in rescue, recovery, demolition, and cleanup at the World Trade Center (WTC) site were exposed to a complex mixture of airborne smoke, dust, combustion gases, acid mists, and metal fumes. Such exposures have the potential to impair nasal chemosensory (olfactory and trigeminal) function.

OBJECTIVE

The goal of this study was to evaluate the prevalence of chemosensory dysfunction and nasal inflammation among these individuals.

METHODS

We studied 102 individuals who worked or volunteered at the WTC site in the days and weeks during and after 11 September 2001 (9/11) and a comparison group with no WTC exposure matched to each participant on age, sex, and job title. Participants were comprehensively evaluated for chemosensory function and nasal inflammation in a single session. Individual exposure history was obtained from self-reported questionnaires.

RESULTS

The prevalence of olfactory and trigeminal nerve sensitivity loss was significantly greater in the WTC-exposed group relative to the comparison group [prevalence ratios (95% confidence intervals) = 1.96 (1.2-3.3) and 3.28 (2.7-3.9) for odor and irritation thresholds, respectively]. Among the WTC responders, however, individuals caught in the dust cloud from the collapse on 9/11 exhibited the most profound trigeminal loss. Analysis of the nasal lavage samples supported the clinical findings of chronic nasal inflammation among the WTC-exposed cohort.

CONCLUSIONS

The prevalence of significant chemosensory impairment in the WTC-exposed group more than 2 years after their exposure raises concerns for these individuals when the ability to detect airborne odors or irritants is a critical safety factor.

RELEVANCE TO CLINICAL PRACTICE

This outcome highlights the need for chemosensory evaluations among individuals with exposure to acute high or chronic levels of airborne pollutants.

Olfactory function in workers exposed to styrene in the reinforced-plastics industry

BACKGROUND

Impairment of olfactory function in humans has been associated with occupational exposure to volatile chemicals. To investigate whether exposure to styrene was associated with olfactory impairment, olfactory function was examined in workers with a minimum of 4 years exposure to styrene in the reinforced-plastics industry (current mean exposure: 26 ppm, range: 10-60 ppm; historic mean dose: 156 ppm-years, range: 13.8-328 ppm-years) and in a group of age- and gender-matched, unexposed controls.

METHODS

Olfactory function was assessed using a standardized battery that included tests of threshold sensitivity for phenylethyl alcohol (PEA), odor identification ability, and retronasal odor perception. Odor detection thresholds for styrene were also obtained as a measure of specific adaptation to the work environment.

RESULTS

No differences were observed between exposed workers and controls on tests of olfactory function. Elevation of styrene odor detection thresholds among exposed workers indicated exposure-induced adaptation.

CONCLUSIONS

The present study found no evidence among a cross-section of reinforced-plastics industry workers that current or historical exposure to styrene was associated with impairment of olfactory function. Taken together with anatomical differences between rodent and human airways and the lack of evidence for styrene metabolism in human nasal tissue, the results strongly suggest that at these concentrations, styrene is not an olfactory toxicant in humans.

The effect of a health care management initiative on reducing workers' compensation costs

The effect of both a cost control and health care management initiative (HCMI) on Workers' Compensation costs at a self-insured University Hospital was assessed. Seven cohorts of injured workers were studied. Cost control measures started in 1993 included early return to work and injury prevention programs, internal administration of legal cases, and utilization of modified duty assignments. The health care management initiative fully in place in 1997 included aggressive case management and preferred provider panel utilization. Workers' Compensation indemnity costs and lost workdays incurred by each cohort were compared. A 41 to 59% reduction in indemnity payments and 46 to 67% reduction in lost time cases were realized after the health care management initiative was fully in place. During this time, accepted claims were reduced by 10 to 15%. The quality of the provider panel, as measured by academic credentials, experience and board certification, did not change. Cost control measures, without comprehensive case management, did not decrease these parameters significantly. The health care management initiative realized reductions in lost time cases and Workers' Compensation indemnity costs.

A phase I trial of docetaxel and gemcitabine in patients with advanced cancer

BACKGROUND

Docetaxel and gemcitabine are active in a broad range of malignancies. The objective of this phase I trial was to determine the maximally tolerated doses of the combination of docetaxel and gemcitabine.

PATIENTS AND METHODS

Patients with advanced cancer, WHO performance status 0-2, who had received up to one prior chemotherapy regimen were treated with gemcitabine on days 1 and 8 and docetaxel on day 8 repeated every 21 days. Prophylactic ciprofloxacin was commenced on day 11 of each cycle and continued until the neutrophil count reached 1.0 x 10(9)/l. G-CSF was not administered. Dose levels studied were docetaxel/gemcitabine: 60/800, 60/1000, 75/1000, 75/1200, 85/1200 and 100/1200 mg/m2.

RESULTS

Thirty-nine patients were entered and all were assessable for toxicity. The highest administered dose level was 100 mg/m2 docetaxel and 1200 mg/m2 gemcitabine with dose limiting toxicities of febrile neutropenia, grade 4 neutropenia > or = 7 days, grade 4 thrombocytopenia, grade 3 stomatitis and/or grade 3 fatigue in three out of six patients. Treatment was well tolerated (40 cycles) in the 10 patients treated at the recommended dose level (85/1200) with only a single episode of febrile neutropenia and grade 3 or 4 non-hematologic toxicity was infrequent. There was no significant pulmonary toxicity. Responses were seen in a range of malignancies including non-small-cell lung cancer.

CONCLUSIONS

The recommended dose level of 85 mg/m2 docetaxel and 1200 mg/m2 gemcitabine has a favourable toxicity profile and is suitable for further investigation in phase II trials. This non-platinum containing regimen warrants further investigation as a potential alternative to platinum containing regimens in non-small-cell lung cancer and other malignancies.

Treatment of T-cell prolymphocytic leukemia with human CD52 antibody

PURPOSE

T-prolymphocytic leukemia (T-PLL) is an aggressive malignancy of mature T cells refractory to conventional chemotherapy, with a median survival duration of 7.5 months. We report here promising results with the use of a genetically reshaped human CD52 antibody, CAMPATH-1H.

PATIENTS AND METHODS

Fifteen patients with T-PLL, most of whom had received the purine analog deoxycoformycin (DCF), were treated with CAMPATH-1H. Results were compared with those of 25 patients treated with DCF.

RESULTS

Major responses occurred in 11 patients (73%) treated with CAMPATH-1H compared with 40% with DCF. Complete remissions (CRs) were documented in nine (60%) of the CAMPATH-1H cases and only three (12%) were obtained with DCF. CRs with CAMPATH-1H were durable, and re-treatment with the antibody resulted in second CRs in three relapsed patients. Two of them were successfully autografted with peripheral-blood and bone marrow stem cells collected during the first CR. Apart from first-dose reactions, infusions of CAMPATH-1H were well tolerated. However, two responding patients developed severe bone marrow aplasia that was fatal in one; the second remained moderately pancytopenic 21 weeks after stopping CAMPATH-1H therapy. The cause of this adverse effect is unknown.

CONCLUSION

CAMPATH-1H is an effective agent in T-PLL and represents a significant improvement over other types of therapy. However, CAMPATH-1H alone is not sufficient for long-term remissions, and the role of autologous stem-cell transplantation needs further investigation.

In vivo 'purging' of residual disease in CLL with Campath-1H

We assessed the role of human CD52 antibody (Campath-1H) in six patients with chronic lymphocytic leukaemia (CLL) treated to maximal response with purine analogues (fludarabine/deoxycoformycin) in whom persistent leukaemic infiltration of blood and bone marrow had precluded autologous stem cell transplantation. Five patients achieved haematological and histological complete remission following Campath-1H and one had minimal focal residual CLL in a trephine biopsy. Autologous transplantation was performed in two patients without complications and with rapid haemopoietic engraftment. Treatment with Campath-1H may be of value in eradicating residual disease in CLL and may facilitate high-dose therapy in young patients.

Subcutaneous CAMPATH-1H in fludarabine-resistant/relapsed chronic lymphocytic and B-prolymphocytic leukaemia

Seven patients with B-cell leukaemia - six with chronic lymphocytic leukaemia (CLL) and one with B-prolymphocytic leukaemia (B-PLL) - were treated with CAMPATH-1H*, a genetically reshaped CD52 monoclonal antibody, administered subcutaneously (s.c.) three times a week for 6-12 weeks. Four were resistant to, and three had had a short partial remission (PR) following, fludarabine chemotherapy. The patient with B-PLL achieved complete remission and three patients with CLL attained PR; two of the latter were retreated. The three remaining patients were non-responders. Three patients were transfusion-dependent before CAMPATH and all three became transfusion-independent after treatment. The overall median survival from starting CAMPATH-1H was 11 months. Three patients reactivated cytomegalovirus (CMV) during the course of treatment, and two were treated with, and responded to, ganciclovir.

2-Chlorodeoxyadenosine in the treatment of hairy cell leukaemia: differences in response in patients with and without abdominal lymphadenopathy

We treated 26 patients with hairy cell leukaemia (HCL) with 2-chlorodeoxyadenosine, including nine with abdominal lymphadenopathy and of whom two had HCL-variant; 18 were previously treated. The overall response in 23 evaluable HCL patients was 100% with 87% complete remission (CR). The CR rate was 57% in patients with abdominal lymphadenopathy. Neither of the patients with HCL-variant achieved CR. Of four patients who had become refractory to 2'-deoxycoformycin, two achieved CR and one partial remission (PR). The lower response in HCL with abdominal lymphadenopathy supports the view that this represents a more resistant form of the disease.

Fludarabine in lymphoproliferative disorders: the Royal Marsden Hospital experience

Fludarabine 25 mg/m2 was given on five consecutive days every four weeks to 85 patients with B- and T-cell malignancies. The median number of courses given was five. All patients except one had received previous chemotherapy. The overall response rate in non-Hodgkin's lymphoma (NHL) was 50% (five complete responses (CR) and 19 partial responses (PR)). The response rate in chronic lymphocytic leukemia (CLL) was 43% (four CR and 12 PR). Responses were seen in all groups of B-cell malignancies, but no T-cell malignancies (n = 4) responded. The median duration of CR has not been reached and the median duration of PR was 14 months for NHL and 16 months for CLL. The median survival from starting fludarabine for patients who achieved a CR or PR in NHL has not been reached and the median duration of PR in CLL was 23 months. The median duration of survival in non-responders was five months. Fludarabine was well tolerated and the main toxicity was myelosuppression. Our results suggest that even in patients who have never responded to any chemotherapy, regardless of the number of treatment regimens previously given, there is a 36% chance of response. In addition, this is the first report of fludarabine activity in Franklin's disease.

Medical monitoring of dioxin clean-up workers

The effectiveness of the safety measures established to protect clean-up workers from 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD) exposure during clean-up operations of the most highly TCDD-contaminated area following the Seveso accident was evaluated. Clean-up workers (N = 36) and referent subjects (N = 36) underwent a 2-yr prospective controlled study aimed at detecting whether specific clinical and biochemical outcomes differed between the two groups. No cases of overt TCDD-related clinical disease occurred (i.e., chloracne, liver disease, peripheral neuropathy, porphyria cutanea tarda), and no clear-cut differences in biochemical outcomes between clean-up and reference workers were detected. The safety measures that were taken together with worker's compliance during clean-up operations were effective in preventing acute health effects. The safety, industrial hygiene, and health monitoring programs which were established following the Seveso accident should be applied as a minimum in similar situations.

The effects of protective equipment on styrene exposure in workers in the reinforced plastics industry

This study was designed to determine whether styrene absorption through the skin results in measurable changes in biologic indicators of styrene exposure using a group of workers engaged in hand lay-up operations during which extensive styrene skin contact occurs. Serial measurements of expired breath and blood styrene and urinary excretion of mandelic and phenylglyoxylic acid were made in eight female workers during 4 consecutive days using different experimental conditions including either (1) gloves/protective clothing alone, (2) respirator alone, (3) both gloves/protective clothing and respirator, or (4) neither respirator nor gloves/protective clothing. A two-by-two factorial design imbedded in a Latin square design allowed estimation of the effects of the two types of protection (i.e., gloves/clothing and respiratory) and any interaction. Levels of styrene in venous blood and expired breath and urine mandelic and phenylglyoxylic acid excretion were no different when gloves/clothes were used as protection compared to no protection at all. Significant reduction in all biologic indices occurred when respiratory protection was used. The results of the study suggest that percutaneous absorption of styrene is not a significant exposure source and does not significantly contribute to the body burden of styrene of workers in the reinforced plastic industry engaged in hand lay-up operations. Respiratory protective devices were the most effective means for reducing styrene absorption. Even though skin absorption of styrene is limited, skin protection is necessary because of the risk of dermatitis.